Nursing Assessment Exam 1 Questions and Answers (Get an A) 2025 Version.

Nursing Assessment Exam 1 Questions and Answers (Get an A) 2025 Version. What are the 6 steps of the nursing process? ADOPIE Assessment Diagnosis Outcome Identification Planning Implementation Evaluation What are the types of Health Assessment? 1) Comprehensive assessment 2)Problem-based/Focused assessment 3) Episodic/follow-up assessment 4)Shift Assessment 5) Screening Assessment What are the 3 primary components of Health Assessment? History (subjective data) Physical examination (objective data) Documentation of data Why do we document all of our data? Improves plan of care It is a legal document of patient's health Draws a baseline for future evaluations It must be accurate, concise, and without bias T/F If it is not documented you did not do it. True What is context of care? it refers to circumstance or situation related to health care delivery. 1) may be related to setting or environment 2) may be related to physical, psychological, or SES circumstances involving the pt. What is a comprehensive assessment? A detailed H&P exam performed at the onset of care in a primary care setting or on admission to a hospital or long-term facility. What is a Problem-based/focused assessment? the problem-based or focused assessment involves a history and examination that are limited to a specific problem or complaint. This type of assessment is most commonly used in a walk-in clinic or emergency department, but it may also be applied in other outpatient setting. What is a Episodic/follow-up assessment? This type of assessment is usually done when a patient is following up with a health care provider for a previously identified problem. For example, a patient treated by a health care provider for pneumonia might be asked to return for a follow-up visit after completion of anti0abiotics. What is Shift assessment? When individuals are hospitalized, nurses conduct assessments each shift. The purpose is is to identify changes in a patients' condition from baseline. What is a screening assessment? a short examination focused on disease detection. usually conducted in health fairs. What is Health promotion? Behavior motivated by desire to increase well-being and actualize health potential. What is Health protection? Behavior motivated by desire to avoid illness, detect illnesses early, and maintain functioning when ill. What are the 3 levels of health promotion? Primary= preventing disease from developing through promoting a healthy lifestyle. Secondary= Screening efforts to promote early detection of disease. Tertiary= minimizing disability from acute or cronic illness or injury and allowing for most productive life within lilmitations. What are examples for the 3 levels of health promotion? Primary= Immunizations Secondary= Mammogram Tertiary = The disease is already present: Hypertension management. A mother of three is being seen for a screening assessment. While planning the initial part of the visit with this patient, the nurse needs to ensure that: a)The patient receives a refill for her thyroid medication. b)The patient is instructed on preventive measures for hypertension. C)Other family members are present during the interview. D)Information about the patient's lifestyle habits is gathered. Correct Answer: D Rationale: There are multiple types of health assessments. If a patient receives a refill, this is an episodic or follow-up assessment. If a patient is instructed in preventive measures, this is more along the lines of a comprehensive assessment. A screening assessment would require the nurse to have data about lifestyle habits. The medical-surgical nurse is reviewing the practice related to a patient who acquired pneumonia while recovering from a hip replacement. The unit documents this event as failure to rescue and would like the nurse to develop a personal professional action plan. This plan will most likely include: A)Reflection on action B)Reflection in action C)Tertiary prevention of health care-associated infections D)Reasoning patterns Correct Answer: A Rationale: Reflection on action represents the contribution of an experience to a nurse's collective experiences. Reflection in action specifically relates to evaluating outcomes of interventions. The nurse needs to look at his practice to identify whether something can change. A nurse is assessing a female teenager. The nurse asks the young woman to bend over and touch her toes. The nurse assesses the curvature of the spine as a means of detecting scoliosis. Assessing the curvature of the spine is an example of: A)Health education B)Primary prevention C)Secondary prevention D)Tertiary prevention Correct Answer: C Rationale: Primary prevention is preventing the disease before it begins. Secondary prevention means that the nurse is trying to detect disease as early as possible to improve outcomes. What are the two primary components of health assessment? Health history Physical examination Is a health history subjective or objective data? Subjective Single-most important factor for successful interviewing is the ______ skill of the nurse. communication What are some factors that affect a nurses therapeutic communication? Physical setting, nurse behaviors, type of questions asked, how questions are asked. Behavior of pt. How the pt. feels during the interview, nature of information being discussed or problem being confronted Begin interviews with what type of questions? open-ended. encourage a free-flowing open response. If want more precise data from your patients what type of question should you ask? Close-ended What do directive questions do? lead patient to focus on one set of thoughts. Most often used in reviewing systems and evaluation functional status. Use _____ listening to help concentrate on pt. responses and subtleties. listening _______ uses verbal and nonverbal phrases to encrourage patinets to continue to talk further. Facilitation _____ is used to gather more information. Clarification. _______ is repeating what patient says ini different words to confirm interpretation. Restatement _____ reflection is repeating what the patient said and encourages elaboration or more information. Reflection ______ is used when inconsistencies are noted between patient report and nurse's observations. Confrontation _______ is used to share conclusions drawn from data. Pt. may then confirm, deny, or revise Interpretations _______ condenses and orders data to clarify sequence of events for that pt. It emphasizes data related to health promotion, disease protection, and resolving health problems Summary What are the components of a comprehensive health history? Biographic data Reason for seeking care Present health status Past medical history Family history Personal and psychosocial history Review of all body systems Health histories can provide nurses with data needed for appropriate care. Nurses obtaining a health history should: A) Help the patient identify personal beliefs about health. B) Assess vital signs. C) Inquire about activities that can affect financial stability. D) Explain patient rights and responsibilities. Correct Answer: A Rationale: The nurse is to help the patient define health. This will allow the nurse to better understand comments made as the health history data are collected. Vital signs are not part of the health history. Financial issues may be a part of the concerns but usually are not as important as understanding the patient's health beliefs. Patient rights and responsibilities are not part of the health history Because a nurse seeks to create a patient-centered interview process, the nurse will: A) Ask the patient, "Do you suffer from any arthralgias?" B) Give the patient as little information as possible to avoid fear. C)Ask the patient, "Can you please tell me more about your spells?" D) Inform the patient, "You don't have to share anything with me that makes you uncomfortable." Correct Answer: C Rationale: The word "arthralgia" may be a word that many patients do not understand. The nurse needs to be careful when withholding information related to not wanting to "scare" the patient. It is best if the nurse works with the patient on identifying what information the patient wants to receive. There could be an age-appropriate component to this (i.e., children), in which case the nurse will work with caregivers to ensure that all required information is given. In option "C," the patient has used the word "spells." The nurse should not discourage this but should investigate further. In option "D," the nurse should not say this; often there is sensitive material that must be covered or addressed to provide adequate care. Preparation for an interview with a patient requires thoughtful consideration of the physical environment. As the physical space is arranged: A) Desks should not be used because they bestow too much "power" on the interviewer. B) Desks are usable as long as they are not a barrier between interviewer and interviewee. C) Interviewer eye level should be six inches lower than interviewee eye level. D) Interviewer eye level should be six inches higher than interviewee eye level. Correct Answer: B Rationale: Desks are appropriate as long as they are not barriers between the nurse and the patient. The nurse and the patient should be at the same eye level because this conveys a sense of equality and team work. What is the single-most important component to reduce infection transmission? Hand hygiene. T/F health care professionals are not at risk of a latex allergy is they don't already have it. False; latex allergies can develop because of frequent exposure. Physical Exams being with _____. What do we achieve from this data? Inspection. It happens right when you walk into the room. visual exam of the body, including movement and posture. Also you obtain by smell. What is Palpation? Use of hands to feel texture, size shape, consistency, location of certain parts, and identify painful or tender areas. With palpation what does the nurse want to make sure they have? A gentile touch, warm hands, and short nails to prevent discomfort or injury. What do we use percussion for? Evaluate size, borders, and consistency of internal organs, also to detect tenderness, and determine extent of fluid in a body cavity. What is direct percussion? when you strike finger or hand directly against patient's body, evaluate adult sinus by direcly taping finger on sinus. elicit tenderness over kidney by striking costovertebral angle directly with fist. What is indirect percussion? it requires both hands, methods can vary by ststem being assessed. What does percussion help with? tapping produces a vibration deep in body tissue, with subsequent sound waves. Peruss tow or three times in one location before moving to another. Stronger percussion is needed for obese or muscular pt. What are the five percussion tones you can hear? What do they sound like? 1) Tympany is loud, high-piched sound heard over abdomen 2) Resonance is heard over normal lung tissue. 3)Hyperresonance is heard in overinflated lungs, as in emphysema. 4) Dullness is heard over liver 5) Flatness is heard over bones and muscle. What is auscultation? listening to sounds within body; nurse commonly uses stethoscope to facilitate auscultation. T/F the way a stethoscope works is by magnifying the sounds when you press it against the skin. False; it blocks out extraneous sounds when evaluating the patient and allows you to focus on a specific aream. What are the 3 different types of thermometers? 1)Electric: which calculates and displays temperature on digital screen within 15 to 30 seconds. 2)Tympanic: Temperatures are obtained by playing a probe into ear; studies have shown widely varing results. 3) temporal artery: utilizes infrared technology; studies demonstrate a high level of accuracy. What are the 4 types of stethoscopes? 1) Acoustic- most common 2) Magnetic 3) Electric 4) Stereophonic What are the 4 components of a acoustic stethoscope. Ear piece, binaurals, tubing, head (diaphragm and bell) On a stethoscope what is the diaphragm usually used for? used to hear high-pitched sounds such as breath sounds, bowel sounds, and normal heart sounds. Structure screens out low-pitched sounds. On a stethoscope what is the bell normally used for? Used to hear soft, low-pitched sounds like extra heart wounds. press lightly to body. What is a fetoscope? A special type of acoustic stethoscope. it is used to auscultate fetal heart. What is a sphygmomanometer? A blood pressure cuff, What is a pulse oximetry? How does it work? consists of LED probe emitting light waves deoxygenated hemoglobin molecules circulating the blood. What is pulse oximety measured in? Where do we put the sensors? % of estimate of oxygen saturation in arterial blood and pulse rate. Sensor taped to ear, finger, or toe What chart is used to measure visual acuity and screening? Snellen chart. place pt. 20 ft from the chart. 11 letters decreasing in size. Test one eye at a time. Top number= distance from chart. Bottom number= distance person with normal vision should be able to read line. What visual acuity chart is used for kids or people who don't speak English? E chart. What chart is used to measure near vision? Jaeger and Rosenbaum. 14in. away from head. What instrument contain a series of lenses, mirrors, and light apertures to inspect internal eye? Ophthtalmoscope- postitive and negative lenses compensate for myopina or hyperopia. We have an expert-written solution to this problem! How does the ophthalmoscope work? If patient's pupils have been dilated, the large light may be used for internal eye examination. Small light may be used if patient's pupils are very small or if pupils have not been dilated. Red-free filter shines green beam and facilitates identification of pallor of disc; hemorrhages appear black. Slit light permits exam of anterior of eye and elevation or depression of a lesion. Grid light facilitates an estimate of size, location, and pattern of fundal lesion What is an otoscope? Otoscope consists of magnification lens, light source, and speculum inserted into auditory canal to inspect external auditory canal and tympanic membrane. Choose largest size speculum that fits into patient's ear canal. Pneumatic attachment produces small puffs of air against tympanic membrane to evaluate fluctuation of tympanic membrane in children. What is a penlight used for? Used to illuminate inside of mouth or nose, highlight a lesion, or evaluate pupillary constriction. Light transmitted from otoscope may be substituted as a focused light source. What is a nasal speculum? Spreads opening of nares to inspect internal surfaces of nose. Two instruments may be used as a nasal speculum: Simple nasal speculum is used in conjunction with penlight to inspect lower and middle turbinates of the nose. Gently squeezing handle of speculum causes blades of speculum to open and spread nares. Second type is broad-tipped, cone-shaped device that is placed on the end of an otoscope. What is a tuning fork used for? Auditory screening and assessment of vibratory sensation. What is a reflex hammer? Used to test deep tendon reflexes. Percussion (reflex) hammer consists of a triangular rubber component on end of a metal handle: Flat surface commonly used when striking tendon directly. Pointed surface used to strike tendon directly or to strike a finger, which is placed on a small tendon such as patient's biceps tendon. Neurologic hammer can also be used to test deep tendon reflexes; similar to percussion hammer, but the rubber striking end is rounded on both sides. What is a Doppler? Doppler uses ultrasonic waves to detect and amplify difficult-to-hear vascular sounds such as fetal heart tones or peripheral pulses. Coupling gel is applied to patient's skin; then transducer is slid over skin surface until blood flow is heard in earpieces. As blood in vessels ebbs and flows, Doppler picks up and amplifies subtle changes in pitch; the resulting sound that the nurse hears is a swishing, pulsating sound. Volume control may further amplify sound. What is a goniometer? Determines degree of flexion or extension of joint. Two-piece ruler jointed in middle with a protractor-type measuring device. Placed over joint; as individual extends or flexes joint, degrees of flexion and extension are measured on protractor What is a caliper for skinfold thickness? Measure thickness of subcutaneous tissue to estimate amount of body fat. Different models may be used for different points on body. Most frequent location is posterior aspect of triceps. What is vaginal speculum? Spreads walls of vaginal canal to inspect vaginal tissue and cervix. Three types with two blades and handle: Graves' has variety of sizes and blade lengths. Pedersen has blades as long as Graves' but narrower and flatter to aid inspection. Pediatric, or virginal, is smaller in all dimensions. Patient should be forewarned about clicking and snapping sounds of opening speculum. What is a audioscope? Basic screening for hearing acuity. Fast, simple test to detect problems. Tones created at different frequencies (1000 to 5000 Hz). Patient responds to hearing of tone by raising finger. Light indicates tone sound, and patient should respond at the same time. What is a monofilament? Used to test lower extremity sensation. Small, flexible wire-like device attached to handle and bends at 10 g of pressure. Used to assess sensation on various parts of foot, to touch intact skin only. Inability to feel suggests reduced peripheral sensation. What is a transilluminator? Used to differentiate characteristics of tissue, fluid, and air in specific body cavity. Strong light source with narrow beam at distal section of light. Room darkened, light placed against skin over body cavity: Light is transmitted differently through air, fluid, or tissue with different glowing red hues. Character of glowing light hues determines if area under surface is filled with air, fluid, or tissue What is a wood's lamp? Used to detect fungal infection of skin; used with fluorescent dye to detect corneal abrasions. Black light effect: Fungal infections exhibit fluorescent yellow-green or blue-green color. Darkened room enhances clinical interpretation of lesion colors The nurse is preparing the room for the dermatologist. The nurse knows that the patient may have a fungal infection on the left leg. Which tool is not part of the setup for this assessment? A)Wood's lamp B)Magnifier C)Monofilament D)Ruler Correct Answer: C Rationale: Wood's lamp may be used to identify fungi with a fluorescent glow. The magnifier may be used to assess the wound more closely, and the ruler will help to identify wound size. The monofilament is used to assess sensation and would not be part of this assessment. Collection of objective data from a patient with a swollen left elbow includes which piece of equipment? A)Magnifier B)Blood pressure cuff C)Snellen chart D)Goniometer Correct Answer: D Rationale: The goniometer is used to measure extension or flexion of joints. The magnifier is not used (unless there is a lesion that needs to be assessed). The blood pressure cuff may be indicated if that is a regular part of intake. The Snellen chart is used for visual acuity. When does general inspection begin? The moment nurse meets the patient. Body temperature is regulated by the ______. Expected temperature ranges from 96.4 to 99.1. Hypothalamus T/F Temperature during menstrual cycle increases .5-1.0 F. At ovulation and remains elevated until menses cease because of progesterone secretion. True If taking a oral temperature delay ____ if patient ingested hot or cold, liquids or smoked 10 minutes. Why do we put oral electronic thermometer under the tongue in the sublingual pocket? This location receives blood supply from carotid artery; thus indirectly reflects core temperature. T/F Tympanic temperature is the most reliable mode to retrieve a temperature. False. It has questionable accuracy. _____ artery is most frequently used to measure heart rate because accessible and easily palpated. Radial What arteries are common alternative sites to assess pulse rate? Brachial, and carotid Where do you auscultate the heart? Located over the fifth intercostal space at the mid clavicular line. What does respiratory rate involve? counting number of ventilator cycles and inhalation and exhalation, each minute. When counting the respiratory rate of men and women how do they differ in where to look? Men usually breath diaphramatically, increasing movement of abdomen Women tend to be thoracic breathers, noted with movement of chest What are some factors that increase respiratory rate? fever, anxiety, exercise, depth, and high altitude What are some ways to describe the respiratory rate? regular or irregular. Depth by observing excursion or movement of chest wall. Depth described as deep, normal, or shallow. What is cardiac output? the volume of blood ejected from heart each minute. What is Peripheral resistance? force that opposes flow of blood through vessels; when arteries are narrow, peripheral resistance to blood flow is high, and reflected in elevated blood pressure. How is Blood pressure measured? in millimeters of mercury (mm Hg) What is the systolic blood pressure? maximum exerted on arteries when ventricles eject blood from heart What is diastolic blood pressure? represents minimum amount of pressure exerted on vessels when ventricles of heart relax. What physiologic factors affect blood pressure. Age: From childhood to adulthood there is gradual rise. Gender: After puberty, women usually have a lower blood pressure than men; however, after menopause, women's blood pressure may be higher than men's. Race: Incidence of hypertension is twice as high in black Americans as in whites. Diurnal variations: Pressure is lower in early morning and peaks in late afternoon or early evening. Emotions: Anxiety, anger, or stress may increase blood pressure. Pain: Acute pain may increase blood pressure. Personal habits: Caffeine or smoking within 30 minutes before measurement may increase reading. Weight: Obese patients tend to have higher blood pressures than nonobese patients. The nurse is working in a primary care clinic. She walks into the room, and the general inspection begins. What is not part of the general inspection? A) Patient's facial expressions are consistent with verbalized emotions. B) Patient is wearing clothes that are normally worn by whites. C) Patient is staring down at the floor through most of the interview. D)Patient's gait is strong and symmetrical. Rationale: Cultural assessment is important. However, nurses must be careful to make assumptions, generalizations, or both. In America, the common dress of people of many cultures is the same. The nurse collects patient data through assessment of vital signs. Many nurses will delegate the performance of temperature data collection to unlicensed assistive personnel. As the nurse talks to the assistant, the nurse knows to teach that: A) Tympanic thermometers touch the tympanic membrane. B) Axillary temperatures are taken with the red probe on the electronic thermometer. C) Axillary temperatures are usually most accurate because of the local blood supply. D) Rectal thermometers are placed 2.8 cm to 3.5 cm into the rectum. Correct Answer: D Rationale: Tympanic thermometers need to seal the ear canal but do not touch the tympanic membrane. Red tipped probes indicate rectal temperatures only. Axillary temperatures are considered the least accurate. A woman in labor suffers from preeclampsia. Nurses in the labor and delivery unit need to assess her blood pressure. The nurse explains to the patient that: A) Using a cuff that is too narrow will give a reading that is inaccurate and high. B) Deflating the cuff too quickly will make the reading inaccurate and high. C) Deflating the cuff 5 mm Hg per second will make the reading inaccurate and high. D) Waiting 3 minutes before repeating the blood pressure measurement will result in a false-high blood pressure measurement. Correct Answer: A Rationale: Cuff width should be 40% of the circumference of the limb to be used to assess blood pressure. Quick deflation (faster than 2 mm Hg to 3 mm Hg per second) makes the blood pressure measurement inaccurate and low. Waiting 3 minutes between repeat blood pressure measurements will help ensure an accurate second reading. The nurse (is/isn't) responsible for asking about beliefs-- this is essential for individualized care. is What is culture? All the socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, lifeways, and characteristics that influence a worldview What is Ethnicity? Social groups within a culture and social system that shares common cultural and social heritage that includes: language, history, lifestyle, religion, or all of these. What is race? genetic in origin and includes physical characteristics: skin color, bone structure, eye color, and hair color. T/F individuals from the same racial group are also from the same culture False. Individuals from the same racial group are not necessarily from the same culture. What is religion? an organized system of beliefs, rituals, and practices in which an individual participates. What is spirituality? Its a broader concept than religion and may include: Prayer, Meditation, Walking in the woods, Listening to music, Intentional appreciation of beauty, Being present in the world with others How many national standards for the importance of culturally and linguistically appropriate care (CLAS) are there? How many do nurses use? There are 14 national standarts to ensure euitable and effective treatment. Which part of the CLAS are we suppose to know? Standard 1 directly affects nurses. Healthcare organizations should ensure that patients receive: Effective, understandable, and respectful care. Care provided in a manner compatible with cultural health beliefs and practices and preferred language. Furthermore, The Joint Commission requires that a spiritual history be taken from every patient admitted to hospital. To ensure you don't sterotype what must a nurse do? Recognize the uniqueness of each individual. Cultural heritage equals "roots." This helps explain activities and beliefs. Differences exist within cultures and groups. Beliefs and attitudes in the United States have been shaped by stereotypical images and misinformation. Each patient deserves personalized assessment. When dealing with cultural diversity remember... Be sensitive. Ask questions. Gather specific information. Do not stereotype. Do not assume care for one individual of a culture is appropriate for another individual of same or similar culture. Regardless of culture or race, each patient is unique—take time to know each patient Staff development educators are responsible for assisting staff nurses in being adequately prepared to perform their duties as they care for patients from many different cultures and backgrounds. As the educator works with a new nurse from the Philippines, the educator will include: A) Training on American food choices. B) Assistance with competency in skin lesions on dark skin. C) Practice in assessing patients' personal beliefs and practices. D) Information on immigration and privacy laws. Correct Answer: C Rationale: Training on a specific population is of value. However, it is more important for a nurse to understand how to assess each individual patient related to cultural background and beliefs. The reason for this is twofold. First, Western society is becoming so heterogeneous that it is difficult for nurses to know about all cultures. Secondly, individual patients may experience their culture differently than other members of that social group. What is the primary responsibility of all health care providers? Pain relief Pain assessment is also known as the ____ vital sign fifth T/F The nurse can judge a persons perception of the pain and can make their own score. False only the patient can perceive their own pain. What effect can pain have on your patient? Reduce mobility Impair sleep Contribute to loss of appetite The perception ofo pain is influenced by ______ and ______ factors. Cognitive and cultural factors. Patient's previous experiences with pain and current physical and mental status affect pain perception and response. What are some cognitive factors that influence pain perception? Attention people give to the pain. Expectation or anticipation of pain. Appraisal or expression of pain. T/F Culture does not play a role in a persons perception of pain? False Cultural influences may affect how pain is communicated. What is the difference between acute pain, and chronic pain? Acute: has recent onset and results from tissue damage, is usually self-limiting, and ends when tissue heals. May cause physiologic signs associated with pain. Chronic: may be intermittent or continuous pain lasting more than 6 months. Clinical manifestations of chronic pain are not those of physiologic stress because patient adapts to pain, but often reports symptoms of irritability, depression, withdrawal, or insomnia. What is nociceptive pain? Arises from somatic structures such as bone, joint, or muscle. Results from activation of normal neural systems. What is Neuropathic pain? Occurs because of abnormal processing of sensory input. What is Referred pain? Pain felt in a location away from the injury. Often visceral pain, as many abdominal organs have no pain receptors. What is Phantom pain? Pain felt in an amputated extremity. What is pain threshold? point at which a stimulus is perceived as pain. This threshold does not vary significantly among people or in same person over time. What is pain tolerance? is duration or intensity of pain a person will endure before outwardly responding. Pain tolerance decreases with repeated exposure to pain, fatigue, anger, boredom, and sleep deprivation. Tolerance increases after alcohol consumption, medications, hypnosis, warmth, distracting activities, and strong faith-related beliefs. When collecting data from patients you follow the mnemonic OLD CARTS. What does it stand for? O- Onset L- Location D- Duration C- Characteristics A- Aggravating factors R- Related symptoms T- Treatment by patient S- Severity Will everyone show there pain physically the same way? No, while others are crying some are smiling even though in the same pain. Some are Stoic, some over express What are some descripting factors of pain? Location: Where the pain is.' Quality: Describe what the pain feels like. (burning, sharp) Quantity: Rate of pain What are some problem-based descriptive of pain? Onset: When did it start Does it start gradually or suddenly What the pt. thinks is causing the pain. What are some examination techniques a nurse can use to try to perceive that patients pain? Observe patient for posture and behavior that helps relieve pain. Observe facial expressions. Listen for sounds made by patient. Inspect skin for color, temperature, moisture. Measure blood pressure and pulse. Assess respiratory rate and pattern. Observe pupillary size and reaction to light. Initiation of intravenous access can be a painful experience for the patient. As the needle is inserted into skin, the patient is calm. However, when the needle pierces the vein, the patient pulls the hand away. The time that the person endured the pain before outwardly responding is known as: A) Pain tolerance. B) Pain intolerance. C) Pain perception. D) Pain threshold. Correct Answer: A Rationale: Pain tolerance is the duration or intensity of pain that can be endured before an outward response is noted. The pain threshold is the point at which pain is perceived. Assessment of circulation, motion, and sensation is done every 8 hours in a patient recovering from a laminectomy 3 days after surgery. The patient had the surgery for consistent low back pain. Now on day 3, the patient has a burning sensation on the lateral edge of the right foot. This is best described as: A) Cellulitis. B) Nociceptive pain. C) Fasciitis. D) Neuropathic pain. Correct Answer: D Rationale: Cellulitis is an interstitial infection. Nociceptive pain is usually associated with tissue destruction or damage. Neuropathy is connected to nerve-related pain. It would appear that a nerve is being disturbed as a result of the surgery or the initial disease process. Burning sensation is a classic presentation or complaint related to nerve pain. What is the definition of Mental Health? State of well-being-- ability to realize one's own abilities. Can cope with normal stressors of life. Able to contribute to community. What is the definition of mental status? The degree of competence that a person shows. Intellectual, emotional, psychological, and personality. What type of abusive experiences may influence a person's mental health? Alcohol abuse, drug abuse, and personal abuse. Interpersonal violence is not an illness, but it is a ____ and ______ _______ _____ crime, and human rights violation. When taking a personal and psychosocial history of a person what questions do you want to ask them? Interpersonal relationship questions. (about people that they live with and are close to them.) Stressors (Things that can cause stress like life changes) Anger (feelings towards thing, have they felt angry often?) Why is it important to ask every patient about alcohol and drug use? It is used to help determine if it is a health problem. What is major depression? an abnormal mood state characterized by sense of sadness, hopelessness, helplessness, worthlessness, or despair from loss or tragedy. What can symptoms of major depression interfere with? patient's ability to work, study, sleep, eat, and enjoy pleasurable activities What clinical findings must the nurse find to help diagnosis major depression? Must have a depressed mood for at least two weeks, also have signification distress, and have five of classic manifestations for diagnosis of major depression. What are some (clinical manifestations) or examples of how a major depressed person expresses his disorder? Clinical manifestations include sad, anxious, or "empty" mood; hopelessness, guilt, worthlessness, and helplessness; changed appetite with weight loss or gain; insomnia; fatigue; difficulty concentrating and making decisions; and suicidal thoughts. What is Bipolar disorder? Bipolar disorder characterized by episodes of mania, depression, or mixed moods. Mood switches may be rapid or gradual. What are clinical findings about bipolar disorder? Manic phase exhibits excessive emotional displays, excitement, or hyperactivity accompanied by elation or delusions of grandeur. Depressive phase marked by apathy and feelings of profound sadness, loneliness, guilt, and lowered self-esteem. What is Schizophrenia? Severe disturbance of thought and associative looseness Impaired reality testing (hallucinations, delusions). Limited socialization What are clinical findings about schizophrenia? Flat, blunted, or bizarre emotions Disorganized thinking Jumbled or illogical speech Impaired reasoning Autistic thinking: Delusions and hallucinations Severe ambivalence What is Anxiety? Anxiety is a feeling of uneasiness or discomfort from mild anxiety to panic. Unlike fear, anxiety is the response to no specific source or actual object. Energy that anxiety provides may mobilize a person to take constructive action such as solving a major problem or filling an unmet need. Used destructively, it may immobilize a person. What are the four levels of anxiety? Mild, moderate, severe, and panic. What are some characteristics mild anxiety? Person has broad perceptual field because anxiety heightens awareness to sensory stimuli. Person sees and hears more and thinks more logically. Learning occurs in mild anxiety. Moderately anxious person has narrower field of perception and uses selective inattention to ignore stimuli in environment to focus on a specific concern. (good for studying for test) What are some characteristics of moderate anxiety? Anxious person has narrower field of perception. Uses selective inattention to ignore stimuli in environment to focus on a specific concern. Severe anxiety: Person has reduced perception. Develops compulsive mechanisms to avoid anxiety-provoking object or situation. What are some characteristics of panic anxiety? Complete disruption of perceptual field. Person experiences terror. Unable to think logically or make decisions. What is OCD? Obsessive-compulsive disorder is classified as an anxiety disorder because anxiety symptoms develop when patient tries to resist an obsession or compulsion. Obsessions are defined as unwanted, intrusive thoughts or impulses that cause anxiety or distress. (Not wanting Germs) Compulsions are unwanted, repetitive behavior patterns or mental acts intended to reduce anxiety. (Washing hands because doesn't want germs) What are some clinical findings about OCD? Common obsessions include repeated thoughts about contamination, repeated doubts, need to have everything in a particular order, and sexual imagery What is AWS? and what are the two phases of it? alcohol withdrawal syndrome: Alcohol withdrawal Alcohol withdrawal delirium or delirium tremens What are some clinical findings of AWS? Symptoms begin 6 to 24 hours after last drink, peak in 24 to 36 hours, and end after 48 hours of abstinence. Severe withdrawal symptoms can last 2 weeks What are some characteristics of mild to moderate AWS? Fine tremors Increased heart rate and blood pressure Nausea and vomiting Anxiety Irritability What are some characteristics of severe AWS? Uncontrolled shaking Worsening hypertension and tachycardia Hyperthermia may occur Extreme agitation Confusion and hallucinations What is delirium? Delirium is characterized by disturbance of consciousness and rapidly developing change in cognition. Manifestations are 1 or more weeks. Reversible with treatment. What are clinical findings od delirium? Altered level of consciousness. Impaired memory. Fluctuating attention span. May have hallucinations or delusions. "Sundowning" may increase. Speech may be rapid, inappropriate, or rambling. What are some characteristics of dementia? Dementia is characterized by memory impairment: Aphasia Apraxia Agnosia Disturbance of executive function Dementia is not reversible. Clinical findings: Onset slow Consciousness intact but memory, judgment, and calculation impaired Flat affect May have delusions Speech is slow and incoherent During the initial intake, the nurse asks the patient a series of questions. When asked how long he has been working in real estate, the patient responds by saying, "I think 5 years. My dad was in real estate, but my mom worked in an office. I like offices because they are usually organized and neat. My son is very messy, but he is good at guitar. Do you play any musical instruments?" The nurse should document that the patient: A) Appears concerned about son. B) Suffers from manic disorder. C) Demonstrates flight of ideas. D) Is able to multitask but struggles with echolalia. Correct Answer: C Rationale: The nurse would not chart a medical or psychiatric diagnosis based on this interaction. "Flight of ideas" includes continuous talking with rapid switching of ideas. Echolalia is automatic and meaningless repetition of other's words. After completing a dressing change and tidying up the room, the nurse asks the patient if she needs anything. The patient responds, "I am just tired of being tired. Ever since my husband died, I can't seem to sleep more than 3 to 4 hours a night. I can't find anything fun to do, and all my friends seem to have disappeared." The nurse discloses this information to the social worker and recommends that the patient: A) Start taking diphenhydramine at bedtime. B) Be assessed on the Beck short form. C) Undergo AUDIT assessment. D) Undergo CAGE assessment. Correct Answer: B Rationale: The Beck short form is used to screen for depression. The nurse could talk with a nurse practitioner or physician about a sleep aid, but further assessment is needed. The AUDIT and CAGE tests are used to assess for alcohol use. What are the 3 classifications of nutrients? macronutrients, micronutrients, and water What are the macronutrients? Carbohydrates, proteins, and fats. What is the bodies main source of energy and fiber? Carbohydrates. What are some characteristics of carbohydrates? One gram of carbohydrate produces 4 kilocalories (kcal) of energy. Fiber provides bulk that stimulates peristalsis. Main sources are plant foods and lactose. Some stored in liver and muscle as glycogen, reserve energy between meals. Moderate amounts must be ingested at regular intervals to meet energy demands. Surplus carbohydrates stored as adipose tissue. What are some characteristics of protein? Protein is essential for growth and repair of body tissues; also source of energy: Twenty different amino acids combine in a number of different ways to form proteins. Ten amino acids considered essential but not synthesized in body. Foods containing complete proteins include meat, fish, poultry, milk, and eggs. Foods containing incomplete proteins include cereals, legumes, and some vegetables. Combinations of _____ proteins can provide all essential amino acids. incomplete Each gram of protein provides ___ kcal of energy; RDA for protein is adult diet is? 4kcal: 56 g/day for adult men. 46 g/day for adult women. 71 g/day for pregnant or lactating women. Ideally, protein should account for 12% to 20% of total kilocalories. ____ is main source of fatty acids and is essential for normal growth and development. Fat. What are some functions of fat? : Synthesis and regulation of certain hormones, tissue structure, nerve impulse transmission, energy, insulation, and protection of vital organs. What are two essential fatty acids for metabolic processes are... linoleic(Omega 3) and linolenic (Omega 6) One gram of fat produces ___ kcal of energy. 9 kcal What is gluconeogenesis? process converts fat to glucose if energy needs exceed carbohydrate intake. What happens is more fat is ingested than needed? it is stored in adipose tissue. What are micronutrients? vitamins and minerals, are essential for growth and metabolic processes that occur continuously. What are the two qualifications of vitamins? What is the difference? water soluble and fat soluble. Water-soluble vitamins cannot be stored in body; must be ingested in diet daily. Fat-soluble vitamins can be stored in body, and vitamin toxicity can result if taken in large quantity. What are some characteristics of water in relation to our body. Water composes 60% to 70% of total body weight. Critical component for cellular function. Constant loss requires replacement for survival. 2.5 to 3 L metabolized daily in foods and fluids. Increased needs in certain conditions: Fever Infections Gastrointestinal losses Respiratory illness T/F Nutritional deficiencies are hard to uncover with routine exams. False many nutritional deficiencies become apparent though routine exams. What do you want to assess for nutrient deficiencies? Measure height and weight for body mass index (BMI). Assess general appearance and level of orientation: Well-nourished individual is alert; body is well proportioned and within acceptable weight range. Inspect skin for surface characteristics, hydration, and lesions: Skin should be smooth, elastic, and without lesions, cracks, or bruising. What do you want to inspect for people who could have a nutrient deficiency? Inspect hair and nails for appearance and texture. Inspect eyes for surface characteristics. Inspect oral cavity for dentition and intact mucous membranes. Patient should have muscle strength, coordinated muscle movement, and full sensation to extremities When does obesity occur? When there is greater energy intake than energy expenditure. What are some causes of obesity? Genetics, overeating, inactivity. What are some clinical findings of obesity? Obesity characterized by excessive adipose tissue on face, neck, trunk, and extremities. Overweight, obesity, and extreme obesity are clinically defined as BMI greater than 25, 30, and 40, respectively. What is Hyperlipidemia? Hyperlipidemia is associated with elevated serum lipids, including cholesterol, triglycerides, and phospholipids. Causes of hyperlipidemia? dietary fat and genetics. Clinical findings of hyperlipidemia? Hyperlipidemia is not associated with clinical symptoms until cardiovascular event occurs. Biochemical indications = Elevations in serum lipids. In adults, cholesterol levels from 200 to 239 mg/dL considered borderline high. Cholesterol levels of 240 mg/dL or higher are considered high. What is protein calorie malnutrition? Protein calorie malnutrition (PCM) refers to inadequate protein and calorie intake and is the most common form of undernutrition. Poor or limited food intake Wasting disease Malabsorption syndromes What are some clinical findings of protein calorie malnutrition? Appear thin with muscle wasting and loss of subcutaneous fat. Patient is considered underweight with a BMI of less than 18.5 or if more than 10% below desired body weight . What are the Three prevalent eating disorders? Anorexia nervosa Bulimia nervosa Binge eating disorder What are common characteristics of Anorexia? Refusing to eat Extreme thinness Other symptoms of protein calorie malnutrition What are common characteristics of Bulimia? Recurrent binge-and-purge eating cycles Electrolyte imbalances Chronic irritation or erosion of the pharynx, esophagus, and teeth (from exposure to hydrochloric acid) What are common characteristics of Binge Eating disorder? Consumption of large quantities of food until uncomfortably full Frequently, the patient experiences feelings of being out of control during the binge episodes. Patients needing dialysis treatments require careful monitoring of their dietary intake. The nurse works with the dietitian in an effort to help patients manage intake to optimize dialysis treatment and overall outcomes. The best technique to accurately assess dietary intake is: A) 24-hour recall. B) Typical food intake. C) Food frequency questionnaire. D) Comprehensive diet history. Correct Answer: D Rationale: The first three may not totally reflect intake. Although they may be more convenient, there may be gaps in important information. The comprehensive diet history can provide a more accurate assessment if conducted by a skilled dietitian. The doctor exits the room and then discusses with the nurse the signs of protein deficiency in the patient's diet. These signs and symptoms include: A) Skin that is dry, scaling, and bruised. B) Hypopigmented hair and abdominal edema. C) Bone pain and arthralgia. D) Diarrhea, oily skin, and stomatitis. Correct Answer: B Rationale: Skin that is dry and scaling would indicate deficiency in vitamin A, essential fatty acids, and zinc, and bruising could be caused by a vitamin K deficiency. Bone pain may be associated with vitamin D deficiency, and arthralgia could be connected to vitamin C deficiency. See Table 9-4 for further deficiency-related disorders.