SLCC Health Assessment Exam 1 Questions and Answers Fully Solved 100%

- Person assumes opposing roles with incompatible expectations o Sports vs household chores o Stay home vs working to support family - Role Conflict - signifies the conscious awareness of a painful sensation - Phase 3- Perception - The entire universe is seen to have supernatural forces at work, which affect all humans as well as the world in general. Spirits and various other entities are thought to affect the status of both physical and mental health. - Magicoreligious -Americans expect people to maintain a fairly high level of eye contact -Those that look away or not giving "good eye contact" are considered rude or inattentive -Eastern Countries and Native Americans- look down to show respect while talking -African Americans look away when being talked to, but very high level of contact when speaking. -deeply engaged in conversation. However, perceived as rude in other cultures. - EYE CONTACT AND FACE POSITIONING -Causes anxiety or concern • Can be short- or long-term • Is perceived as outside of our coping abilities. • Feels unpleasant. • Decreases performance. • Can lead to mental and physical problems. - Distress (negative stress) -Lower socioeconomic status (SES), making nutritious foods unaffordable -Lifestyle of long work hours and obtaining one or more meals from a fast-food chain or vending machine-Poor food choices by children, teens, and adults, including fatty or fried meats, sugary foods, and few fruits and vegetables -Chronic dieting, particularly with fad diets, to meet perceived societal norms for weight and appearance -Chronic diseases (e.g., Crohn disease, cirrhosis, or cancer) that may interfere with absorption or use of nutrients -Dental and other factors such as difficulty chewing, loss of taste sensation, depression -Limited access to sufficient food regardless of SES such as being physically unable to shop, cook, or feed one's self -Disorders whereby food is self-limited or refused (e.g., anorexia nervosa, bulimia, depression, dementia, or other psychiatric disorders) -Illness or trauma that increases client's nutritional n - RISK FACTORS FOR NUTRITION DISORDERS AND DISEASE -Motivates, focuses energy. • Is short term • Is perceived as within our coping abilities • Feels exciting • Improves performance - Eustress (positive stress) "any act including confinement, isolation, verbal assault, humiliation, intimidation, infantilization, or any other treatment which may diminish the sense of identity, dignity, and self-worth" - emotional abuse #5 of nursing process is - evaluation -evaluate everything that has been done so far. Is the plan working or not working? • Exposure to excessively high environmental temperatures • Inability to access adequate fluids, especially water • Excess intake alcohol or other diuretic fluids • Taking diuretic medications • Impaired thirst mechanisms• High fevers - FACTORS AFFECTING HYDRATION • has holistic aspects, as it is based on a concept of whole person versus sum of the parts, and seeks a balance of all aspects of a person. • Balance is maintained by adding or subtracting substances that regulate the body's temperature, moisture, and dryness. Diet and medications are thought to have varying characteristics of hot/cold and wet/dry, and interact with diseases that are thought to be hot or cold. - Hot/Cold Theory • Hot/Cold TheoryThere are perceived to be: Four "humors" of the body that work together to regulate the bodily functions - Blood Phlegm black bile yellow bile • Infants cannot verbalize or understand pain -TRUE • pain is not a normal process of aging- TRUE • Very young patients do not feel pain- FALSE • Pain is not an indication of pathology or injury. TRUE • Confused or demented patients do not feel pain - FALSE - AGE related facts • Sex • Age • Depression • Previous attempt • Ethanol abuse • Rational thinking loss • Social supports lacking • Organized Plan • No spouse • Availability of lethal means• Sickness - SAD PERSONAS SUICIDE RISK TOOL this assessment guide can be used to assess the likelihood of a suicide attempt • Sweat (palms, pits, etc.) • increase blood pressure • increase heart rate • increase breathing rate • "Butterflies in stomach" • Nausea • Shaking • Bladder overdrive • Headache/muscle tension • Change is sleeping patterns (insomnia) • Change in appetite • Moody • Forgetful - Common Symptoms of Stress • Weight • Intake and output • Skin turgor • Pitting edema • Skin for moisture • Venous filling • Neck veins in supine position with head elevated 45 degrees • Tongue furrows • Eyeball palpation • Eye position • Lung sounds• Blood pressure - HYDRATION ASSESSMENT •Anxious clients- simple, concise questions •Angry clients- be calm, avoid arguing, don't allow client between you and the door •Depressed clients- express interest and understanding, avoid upbeat, encouraging stance. •Manipulative client- structure, limits, •Seductive clients- Don't interact without witness •Sensitive issues- sexuality, dying, spirituality •Self-aware •Ask simple questions in non-judgmental manner •Referral to pastoral counselor or specialist Special considerations of - Emotional variations •Direct eye contact may be considered rude or aggressive •Lack of eye contact may be considered evasive, insecure, or inattentive •Use an interpreter or culture broker- not family Special considerations of - Cultural variations •don't assume health problem •Assess hearing acuity- position self appropriately •Do not yell at the client •Establish and maintain trust, privacy, and partnership •Avoid medical jargon Special considerations of - Gerontological Variations •PROVIDING INFORMATION- PAMPLETE, DISCHARGE PAPERWORK •VOICE- TONE, VOLUME, RATE, PITCH & PAUSES - verbal communication12 oz beer/cooler at 5% alcohol • 8-9 oz malt liquor at 7% alcohol • 5 oz white wine at 12% alcohol • 3-4 oz of red wine at 17% alcohol • 1.5 oz of spirits at 40% alcohol • 3 oz martini = 2 standard drinks @ 40% alcohol - standard drink 4. Evaluate outcomes - Where the interventions put in place affective or not. 93% of all communication is - non verbal A - delta - primary afferent fibers A good health assessment is (1-4) 1. ____and ___. examples? 2. - 1) -ongoing and -continuous examples: call light close to patient, bed railing up or down, any distractors, anything to cause fall risk. 2)Analyze and synthesize data. A good health assessment is also 3. make judgements about effectiveness of nursing interventions meaning? - if we discover patient has a fall risk. As a nurse intervention will be making sure patient doesn't go to bathroom alone. Has call light close in case they need to get up, nothing on the floor that may cause potential fall a list of questions, arranged by organ system, designed to uncover dysfunction and disease. It can be applied in several ways: As a screening tool asked of every patient that the nurse/clinician encounters. - Review of SystemsA nurse collects data. Subjective (what the patient tells you) and objective (data/facts we can observe) A good nursing judgement is when data collection is ___ - Adequate and accurate -able to know and pick up on signs patient may have to be able to diagnose correctly. Will then be able to educate patient. a representation of a special characteristics of a particular society - culture a result of activation and sensitization of the nociceptive pain pathway by a variety of mediators released at a site of tissue inflammation - inflammatory pain