NURS 130 Final Exam | Actual study |
Questions and Answers
nursing process - ANSW-ADPIE = Assessment, Diagnosis, Planning, Implementation, Evaluation
subjective data - ANSW-symptoms - what the client says about himself or herself
objective data - ANSW-signs - what the health professional observes during the exam
cultural competency - ANSW-caregivers understand and attend to the total context of the individuals
situation
- immigration status
- stress and social factor
- cultural similarities and differences
exam technique on older adults - ANSW-- do everything slower
- don't overwhelm with questions
- assist them as needed
- don't talk in elder voice
interviewing interventions for diverse cultures - ANSW-- use interpreters if necessary
- don't make assumptions
- make sure you understand their beliefs and restrictions regarding healthcare
purpose of health history - ANSW-- collect subjective data
- provides picture of person's past and present health
- describes person as a whole and how the person interacts with their environment
- records health strengths and coping skills
- recognize and affirm what patient is doing right and point out improvements needed
collecting data on allergies - ANSW-note the allergen and the reaction
mental status - ANSW-level of consciousness - alert and oriented to person, time, and place
A&O X3, lethargic, stuporous, comatose
older adult expected findings (related to mental status) - ANSW-*delirium* - acute confusional change or
loss of consciousness and perceptual disturbance, may accompany acute illness (pneumonia, alcohol or
drug intoxication), usually resolved when underlying cause is treated
*dementia* - gradual progressive process causing decreased cognitive function even though person is
fully conscious and awake, not reversible, 2/3 is alzheimer's, not part of normal aging, non-caucasions,
older adults, women, singles living alone, lower education and income are more at risk
*depression* - sad gloomy and dejected, symptoms may occur with rainy weather, after a holiday, or
with illness; if situation is temporary, symptoms fade quickly
abstract reasoning - ANSW-math problems, picking what word doesn't fit, anything that involves deeper
thinking
assessing techniques and sequence - ANSW-inspect, percuss, palpate, auscultate
normal changes with the older adult (general overview) - ANSW-*physical appearance* - sharper body
contour, angular features, redistributed body proportions
, *posture* - general flexion
*gait* - wider base to compensate for diminished balance, arms out, steps shorter or uneven
*weight* - body weight decreases, subcutaneous fat lost from face and periphery, more fat accumulates
at hips and abdomen
*height* - vertebral discs thinning, vertebrae shortening, kyphosis posture, flexion in knees and hips
vital signs and normal ranges - ANSW-*temperature* - normal is 98.6 F or 37 C (oral, rectal, tympanic,
temporal, axillary)
*pulse* - normal is 60-100 bpm, graded 0-3+
*respirations* - normal is 12-20 bpm
*blood pressure* - normal is <120/80 mmHg
*oxygen saturation* - normal is 95-100%
age related changes to vital signs - ANSW-*temperature* - sweat gland activity diminished, increased
risk of hypothermia, decreased risk for fever
*pulse* - radial artery may feel stiff, rigid, or tortuos, more rigid vessels (easier to palpate)
*respirations* - decreased vital capacity and inspiratory reserve volume, shallower and faster breathing
*blood pressure* - systolic pressure increases due to rigid aorta and arteries, increased overall bp
pain - ANSW-- can be acute or chronic
- use PQRSTU method to asses pain
*P*: provocation/palliation - what triggers and relieves it
*Q*: quality/quantity - what does it feel like
*R*: region/radiation - where is it, where does it radiate
*S*: severity scale - rate on scale of 1-10
*T*: timing - when did it start, how long does it last, how often, sudden or gradual
*U*: how does the pain affect YOU, what is your understanding of it
subjective and objective data for nutrition - ANSW-*subjective*
- eating patterns
- usual weight
- changes in appetite, taste, smell, chewing, or swallowing
- recent surgery, trauma, burns, or infection
- chronic illnesses
- nausea, vomiting, diarrhea, or constipation
- food allergies or intolerances
- medications or nutritional supplements
- patient-centered care
- alcohol or illegal drug use
- exercise and activity patterns
- family history
*objective*
Questions and Answers
nursing process - ANSW-ADPIE = Assessment, Diagnosis, Planning, Implementation, Evaluation
subjective data - ANSW-symptoms - what the client says about himself or herself
objective data - ANSW-signs - what the health professional observes during the exam
cultural competency - ANSW-caregivers understand and attend to the total context of the individuals
situation
- immigration status
- stress and social factor
- cultural similarities and differences
exam technique on older adults - ANSW-- do everything slower
- don't overwhelm with questions
- assist them as needed
- don't talk in elder voice
interviewing interventions for diverse cultures - ANSW-- use interpreters if necessary
- don't make assumptions
- make sure you understand their beliefs and restrictions regarding healthcare
purpose of health history - ANSW-- collect subjective data
- provides picture of person's past and present health
- describes person as a whole and how the person interacts with their environment
- records health strengths and coping skills
- recognize and affirm what patient is doing right and point out improvements needed
collecting data on allergies - ANSW-note the allergen and the reaction
mental status - ANSW-level of consciousness - alert and oriented to person, time, and place
A&O X3, lethargic, stuporous, comatose
older adult expected findings (related to mental status) - ANSW-*delirium* - acute confusional change or
loss of consciousness and perceptual disturbance, may accompany acute illness (pneumonia, alcohol or
drug intoxication), usually resolved when underlying cause is treated
*dementia* - gradual progressive process causing decreased cognitive function even though person is
fully conscious and awake, not reversible, 2/3 is alzheimer's, not part of normal aging, non-caucasions,
older adults, women, singles living alone, lower education and income are more at risk
*depression* - sad gloomy and dejected, symptoms may occur with rainy weather, after a holiday, or
with illness; if situation is temporary, symptoms fade quickly
abstract reasoning - ANSW-math problems, picking what word doesn't fit, anything that involves deeper
thinking
assessing techniques and sequence - ANSW-inspect, percuss, palpate, auscultate
normal changes with the older adult (general overview) - ANSW-*physical appearance* - sharper body
contour, angular features, redistributed body proportions
, *posture* - general flexion
*gait* - wider base to compensate for diminished balance, arms out, steps shorter or uneven
*weight* - body weight decreases, subcutaneous fat lost from face and periphery, more fat accumulates
at hips and abdomen
*height* - vertebral discs thinning, vertebrae shortening, kyphosis posture, flexion in knees and hips
vital signs and normal ranges - ANSW-*temperature* - normal is 98.6 F or 37 C (oral, rectal, tympanic,
temporal, axillary)
*pulse* - normal is 60-100 bpm, graded 0-3+
*respirations* - normal is 12-20 bpm
*blood pressure* - normal is <120/80 mmHg
*oxygen saturation* - normal is 95-100%
age related changes to vital signs - ANSW-*temperature* - sweat gland activity diminished, increased
risk of hypothermia, decreased risk for fever
*pulse* - radial artery may feel stiff, rigid, or tortuos, more rigid vessels (easier to palpate)
*respirations* - decreased vital capacity and inspiratory reserve volume, shallower and faster breathing
*blood pressure* - systolic pressure increases due to rigid aorta and arteries, increased overall bp
pain - ANSW-- can be acute or chronic
- use PQRSTU method to asses pain
*P*: provocation/palliation - what triggers and relieves it
*Q*: quality/quantity - what does it feel like
*R*: region/radiation - where is it, where does it radiate
*S*: severity scale - rate on scale of 1-10
*T*: timing - when did it start, how long does it last, how often, sudden or gradual
*U*: how does the pain affect YOU, what is your understanding of it
subjective and objective data for nutrition - ANSW-*subjective*
- eating patterns
- usual weight
- changes in appetite, taste, smell, chewing, or swallowing
- recent surgery, trauma, burns, or infection
- chronic illnesses
- nausea, vomiting, diarrhea, or constipation
- food allergies or intolerances
- medications or nutritional supplements
- patient-centered care
- alcohol or illegal drug use
- exercise and activity patterns
- family history
*objective*
