-open-ended question correct answer which can be used to begin the interview
and is a broadly stated question encourages a free-flowing, open response. The
intent is to elicit responses that are more than one word ex how are you feeling?
-Process of clinical judgement include 4 components (Tanner): correct answer
Noticing
Interpreting
responding
reflecting
-reflecting- is correct answer a critical component reflection-in-action (reflecting
on past experiences while in the midst of another situation). Reflection-on-action
(thinking about a situation that has occurred and developing a better
understanding of what happened and the appropriateness of the patient
outcomes)
-responding correct answer appropriate actions and interventions
(Q) Describe seizure movement that u observed.did u notice any other sign such
as change in color of the face or lips; loss of consciousness? Did the patient
urinate or have a BM? After seizure how long did it take patient to return to pre
seizure level of consciousness? correct answer response to these questions help
identify the areas of the brain involved in seizure activity
can follow the path of when a patient has a seizure of excessive discharge along
the motor cortex. this is an ex of simple seizure in which the patient maintains
consciousness.
,(Q) How have the seizures affected your life? Your occupation? identification?
correct answer because seizure may be chronic disease that may affect, the
patients driving, employment, personal relationships, nurse need to know how
this is affecting the patient's life and how they are managing
carrying identification about seizures helps those who may assist a patein who is
seizing
(Q) prob w/ coordination ? diff bal or walk? lean on side or fall? which dir? Do legs
suddenly give way? correct answer CVA
but dysfunction of cerebellum or inner should be considered when bal impair
MS, Parkinson's, or brain tumor also causes
fall on right side may be impair on left side of ?the brain
(Q) weakness in or diff swallowing or moving body parts? is it confined or
generalized? associated? how weakness affect activities? correct answer decrease
circ to brain can cause these symptoms
some type of transient ischemic attack (TIA) or CVa may have occurred
4 basic assessment techniques used to collect data for physical assessment:
correct answer inspect
palpate
percuss
auscultate
4 foundational health measures that are used as indicators of progress toward
goals are: correct answer 1) general health status
2) health-related quality of life and well being
,3) determinants of health
4) disparities
According to Tanner, clinical judgement is influenced by correct answer nursing
experiences, knowledge, attitude, and perspective rather than data. ex; of 50
male that check in to walk in clinic
Active listening- involves correct answer listening w/ purpose to spoken words as
well as noticing nonverbal behaviors
Age- Related Variation correct answer Infants, children, and adolescents
pediatric health history is similar to that of the adult
additional question include:
pregancy
prenatal care
growth and development
behavioral
school status
Nurse makes the decision to interview the adolescent w/ the parent or alone
Pregnancy
comprehensive health history is obtained at the first prenatal visit to establish
baseline data
health history is similar to what was covered in the chapter
Older Adults
primary difference is various age related questions and functional status
, more time may be needed to conduct health history because they have multiple
symptoms, meds, long past health history
AGE-RELATED VARIATIONS NS
Infants and Children correct answer infants sensation and cranial nerves are
assessed by observation
unique reflexes are assessed in infants
child motor dev is compared w/ standardize table
AGE-RELATED VARIATIONS NS
Older Adults correct answer usually follows the same procedure for younger child
tests for gait of older adults are often assessed to identify fall risks
Alternative Health History Formats correct answer Alternative formats are based
on a health status approach
2 ex:
North American Nursing Diagnosis Association Taxonomy II
Gordon's Functional Health Patterns (Appendix A)
Alzheimer's Disease correct answer incurable degenerative neurologic disorder
that begins w/ a decline of memory
most common cause of dementia in western countries
cause is unknown
clinical findings:
3 stages