Health Assessment Quiz 1 Questions With Correct Answers

Medical diagnosis - ANSWER focuses on a disease process (ex: hypertension) Nursing diagnosis - ANSWER -individuals response to disease or risk (subjective and objective data and their response) -foundation for care for patient Steps of nursing process - ANSWER -Assessment -Diagnosis -Outcome identification -Planning -Implementation -Evaluation (ADOPIE) What is health assessment? - ANSWER -data collection, data base, diagnostic or clinical reasoning, *starting point for nursing process What is subjective data? - ANSWER -data given from the subject (what the patient says) What is objective data? - ANSWER -what you can measure or observe (ex: hearing abnormal lung sounds) Example of how something can be subjective and objective - ANSWER -patient says they think they have a fever, you check their temp and they do indeed have a fever Type of data - ANSWER Physical: what am i seeing or smelling Cognitive: patients mental status, behavior, mood Psychosocial: who takes care of them at home, family situation Behavioral: Environmental: "where do you work" "are you by a farm" Developmental: 4 types of dataabse - ANSWER -Complete -Focused, Problem-centered, episodic -Follow up -Emergency Complete total health database - ANSWER -complete health history and full physical examination -current and past health state -first diagnosis Episodic or problem-centered database - ANSWER -short term problem and would collect a "mini database" more focused than complete -*single problem -history and examination follow reason for visit Follow-up database - ANSWER -note changes that have occurred, evaluate whether problem is getting better or worse -broke arm, went back for cast Emergency database - ANSWER -rapid collection of data that must be comprehensive concurrently with lifesaving measures -ex: obstruction in airway First-level priority - ANSWER -life threatening and immediate -ex: BP is 40, someone is not responding or breathing Second-level priority - ANSWER -requires attention to avoid further deterioration -ex: if someone is confused as to where they are at (hospital) needs to be addressed to avoid further confusion Third-level priority - ANSWER -can be addressed after more urgent problems are addressed -ex: BP is slowly creeping up but needs to be watched while 1st and 2st priorities are taken care of Collaborative problems - ANSWER -treatment involving multiple disciplines -ex: taking care of stroke patient who needs PT and SP A 52-year-old male patient is admitted with a new diagnosis of colon cancer. The nurse conducts which type of assessment on his admission? A. A complete assessment B. A problem-based health assessment C. A follow-up data base D. A screening assessment - ANSWER A 4 assessment techniques - ANSWER -Inspection -Palpation -Percussion -Auscultation (HIPPA without H) -Palpation deep and light -When would you palpate tender areas? - ANSWER -deep: 4 in, light 1 in -last -Percussion: direct and indirect -What data can we get from percussion that we cant get from inspection or palpation? - ANSWER -direct: directly pressing, indirect: using the hammer or tip of finger -can check if there's air or fluid in the lungs, locate organ boarders based off of sounds Percussion "notes" -Resonant -Hyperresonant -Tympany -Dull -Flat - ANSWER -Resonant: clear, hollow (normal lung) -Hyperresonant: booming (normal in child's lung, abnormal in adult like emphysema) -Tympany: musical, drumlike (air-filled cavity - stomach, intestine) -Dull: muffled, thud (dense organ - liver, spleen) -Flat: dull, dead stop - no air present (muscle, bone, tumor) Auscultate: listen on what? -What can you auscultate? -Diaphragm is used for? -Bell is used for? - ANSWER -directly on skin, NEVER over clothes -The lungs, abdomen, and heart (most common) -high pitched sounds like breathing, bowel, normal heart (s1 and s2 heart sounds) -soft low-pitched sounds (extra heart sounds or murmurs (s3 and s4 heart sounds) Temperature normal range -What about rectal? -What about axillary? -104 F is ___ C -98.6 F is ___ C -95 F is ___ C -fever is ____ no fever is ____ -drug to lower temp - ANSWER -96.4-99.1 F or 35.8-37.3 C -rectal is .5 degrees higher C or 1 degree higher for F -same with axillary -40 -37 -35 -febrile, afebrile -antipyretic Pulse normal range: -dependent on ____ ____ -bradycardia is? -tachycardia is? -force definition and values -access the pulse for ___, ____, ____ - ANSWER -50-95 -stroke volume -slower <50 -fast >95 -strength of hearts stroke volume; 0+= absent, 1+= weak, thready, 2+=normal, 3+= full bounding -rate, rhythm, force -Normal rate of respirations for an adult, neonatal, 16 year old - ANSWER -adult: 10-20, neonatal: 30-40, 16 year old: 12-20 Blood pressure -systolic pressure -diastolic pressure -Pulse pressure - ANSWER -Systolic= pressure is maximum pressure felt on artery during left ventricular contraction or systole -Diastolic= pressure of elastic recoil or resting pressure that blood exerts constantly between each contraction -Pulse Pressure- difference between systolic and diastolic pressure reflecting stroke volume -Mean arterial pressure: pressure forcing blood into the tissues averages over the Physiologic factors controlling blood pressure 1. Cardiac output 2. Peripheral vascular resistance 3. Volume of circulating blood 4. Viscosity 5. Elasticity of vessel walls - ANSWER 1. Cardiac output: if the heart pumps more blood into the container (i.e., the blood vessels), the pressure on the container walls increases. 2. Peripheral vascular resistance: when the container becomes smaller (e.g., with constricted vessels), the pressure needed to push the contents becomes greater. Conversely, if the container becomes larger (e.g., vasodilation), less pressure is needed. 3. Volume of circulating blood: how tightly the blood is packed into the arteries. Increasing the contents in the container increases the pressure. 4. Viscosity: when the contents are thicker, the pressure increases. 5. Elasticity of vessel walls. When the container walls are stiff and rigid, the pressure needed to push the contents increases Errors in BP measurement: -Korotkoff's sounds- I- systolic pressure, IV -muffling of sounds V- diastolic pressure - ANSWER -Incorrect