Nursing 251 Exam 1 questions with correct answers

Nursing Process Identifying and treating human responses to actual or potential health problems; continual; revise as necessary Nursing Process 5 Steps Assessment, Diagnosis, Planning, Implementation, Evaluation Nursing Diagnosis Clinical judgement about clients, family, community responses to actual or potential health problems Assessment Collecting subjective and objective data; establish data base with client's wellness, health practices, past illnesses, and establish goals Subjective Data Sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information stated by the patient Objective Data Physical characteristics, body functions (heart rate), appearance, behavior, measurements, results of labs; observed by examiner Types of Assessment Initial comprehensive, ongoing or partial, focused or problem-oriented, and emergency Initial Comprehensive Assessment Occurs when clients first presents to health care system; collect both subjective and objective Ongoing or Partial Assessment Occurs after comprehensive database is established; reassessment of initial problem looking for improvement or deterioration Focused or Problem-Oriented Assessment Occurs because of a specific health concern Emergency Assessment Occurs when life saving action needs to be taken; ABC's (airway, breathing, cardiac) Culture The learned, shared, and transmitted values, beliefs, norms, and way of life of a particular group that guides their thinking, decisions, and action in patterned ways Cultural Sensitivity Recognize that some cultural groups have definitions of health and illness, as well as practices that attempt to promote health and cure illness, that may differ from your own Cultural Competence Be willing to modify health care delivery in keeping with the client's cultural background; Do not expect all members of one cultural group to behave in exactly the same way Spiritual Assessment An RN may conduct this to understand the patient's source of strength and guidance and to respect their rituals and beliefs Spirituality Impacts Care Changing the course of treatment; health care providers may need to modify treatment plans Stereotype A simplified generally inflexible conception of the members of a group or subgroup Ethnocentrism A tendency to view people unconsciously by using your own group and your own customs as standards for all judgements Standard Precautions Guidelines used to prevent the passage of pathogens; MUST BE USED AT ALL TIMES HIPAA Health Insurance Portability and Accountability Act; protection for health information health insurance coverage 4 Physical Assessment Techniques Inspection, palpation, percussion, auscultation Inspection DO THIS FIRST; The use of senses to observe the general status of the client and note normal/ abnormal aspects of specific systems Palpation The use of tactile sense (touch and feel) to further delineate visual findings, or to identify findings not seen Palpation Palmer Surface Used to feel vibrations Palpation Dorsal Surface Temperature Light Palpation Less than 1cm little to no depression (pulses, skin texture, moisture, temperature) Moderate Palpation 1-2cm of depression; use dominant hand in curricular motion; assess body organs and masses Deep Palpation 2.5 to 5cm; two hand technique placing non-dominant hand over dominant hand to assess deep organs Bimanual Palpation Capture organ or mass between 2 hands; uses to assess breast tissue, spleen, uterus, and masses AAA (Aortic Abdominal Aneurysm) NEVER PALPATE PULSING ABDOMINAL AREA Percussion Discriminating sounds produced when striking the hand over different organs and cavities; skin, muscle, fat, bone, fluid, and air Key Points for Percussion Percuss directly on skin, need quiet room, obese and muscular people use more force, dense tissue=quiet sounds Direct Percussion 1-2 fingertips; ex. determine skin tenderness Blunt Percussion Non-dominant hand flat on organ; dominant hand (fist) hits non-dominant hand; ex. kidneys Indirect Percussion Assess the density of underlying structure (air, fluid, solid); middle finger of dominant hand on body part, pad of middle finger of dominant hand strikes middle finger of non-dominant hand Auscultation Listening for sounds of movement within the body Key Points of Auscultation Need quiet room, placed directly on skin, warm stethoscope, make sure there's no friction Diaphragm of Stethoscope High pitched sounds (breath sounds, bowel sounds, heart sounds) Bell of Stethoscope Low pitched sound (vascular sounds, extra heart sounds) Vital Signs Temperature, pulse, respirations, blood pressure, pain Normal Temperature 37 degrees C or 98.6 degrees F; ranges from 36.5 to 37.7 C and 96.9 to 99.9 F Older Adults Pulse the same, temperature goes down, decrease in arterial wall Conserve Heat Shiver Lose Heat Sweat Pulse Shock wave produced by blood pumped from heart as it travels through artery Normal Pulse Adult 60-100bmp Normal Pulse Child 80-120bmp Normal Pulse Infant 120-160bmp Tachycardia >100bmp Bradycardia <60bmp Changes in Pulse From sympathetic and parasympathetic nervous system Increase in Pulse Exercise, blood loss, pain, medication, fever Decrease in Pulse Hypothermia, head injury, vagal stimulation, medications Pulse Characteristics Rate, rhythm, amplitude, elasticity Rate of Pulse Beats per minutes Rhythm of Pulse Regular or irregular