NYU HAP Midterm Exam 2023

Nursing Process Steps - Answer- Assessment Diagnosis Planning Implementation Evaluation Assessment Primary Components - Answer- Health History, Physical Assessment, Psychosocial Subjective Data - Answer- Information from patient or patient family, symptoms Objective Data - Answer- Findings from direct observation using your senses, SIGNS How do you collect objective data? - Answer- Inspection, Palpation, percussion, Auscultation What are the types of assessments? - Answer- Comprehensive, Episodic, Shift Assessment, Focused Assessment, Emergency ______ of assessments depends on patient needs, setting can be ICU, long term, post treatment, etc. - Answer- Frequency ______ of info gathered depends on content of care, patient need, expertise of nurse - Answer- Amount _____ based on assessments, life threatening is #1 - patient's #1 complaint should be one of your highest priorities - Answer- Prioritize PES - Answer- Problem, Etiology, Signs and Symptoms Evaluation - Answer- Judgment of effectiveness of nursing care in meeting patient goals and outcomes Primary Prevention - Answer- Optimize health and disease prevention through promotion of healthy lifestyle Secondary Prevention - Answer- identifying at early stage before too much damage Tertiary Prevention - Answer- Minimize effects of disease Phases of The Interview - Answer- pre-interaction, beginning, working, closing Health History - Answer- Patient's statement of current and past health, problems, biographic data Review of Systems - Answer- Evaluation of past and present health state of each body system, subjective information General Inspection - Answer- Always comes first, visual examination of patient including physical appearance, body structure, mobility, mental health Palpation - Answer- Use to assess temperature, texture, moisture, organ location/size, vibration, abnormal lumps or masses Percussion - Answer- Produces sound or elicits tenderness Resonant (sound) - Answer- Low pitched, hollow, heard over normal lung tissue Hyper Resonant (sound) - Answer- Abnormal adult lung (emphysema, COPD) or normal child lung Tympany (sound) - Answer- drum-like, loud, empty quality heard over air-filled organ like stomach or intestine, shaky up and down Dull (sound) - Answer- dense organ like liver or spleen, short waves but dwindles Flat (sound) - Answer- large muscle, bone, tumor, when no air is present Auscultation: Use _____ for high pitched sounds - Answer- diaphragm Auscultation: Use ____ for low pitched - Answer- bell Hormone that determines Dwarfism or Gigantism - Answer- GH Growth Hormone Cushing Syndrome - Answer- buffalo hump or moon face from too much steroids, pituitary gland has tumor and causes increase release of ACTH Polydactyly - Answer- extra fingers or toes Normal Body Temp Range - Answer- 98.6 - 99.1 F Fever temperature - Answer- 101.4 Normal Beats Per Minute (BPM) - Answer- 60 - 100 Normal Respiratory Rate - Answer- 12-20 breaths per minute Systolic Blood Pressure - Answer- Max Pressure during left ventricle contraction Diastolic - Answer- Resting pressure or pressure that blood exerts constantly between each contraction at end of diastole (pressure when heart isn't beating Normal Blood Pressure - Answer- 120/80 Factors that cause false high blood pressures? - Answer- Anxious, exercised, arm below heart, legs crossed, cuff too loose or narrow, deflate too slowly Factors that cause false low blood pressures? - Answer- Arm above the heart, cuff too wide, not finding occlusion first, deflate too quickly, rushing Normal O2 Saturation - Answer- 95-100% Abnormal Respiratory Rate - Answer- bradypnea: 12 tachypnea: 20 Children's signs of pain - Answer- Increased heart right, hypertension, pallor, sweating, decrease O2 saturation Urgent Assessment needed when: - Answer- extreme anxiety, acute distress, pallor, cyanosis, mental status change Pallor - Answer- anemia, shock, arterial insufficiency (albinism and vitiligo) Cyanosis - Answer- central (whole body), peripheral (local to foot or arm), blue Erythema - Answer- redness, seen w/ venous stasis, CO poisoning, hyperemia, polycythemia Jaundice - Answer- increase serum BR, could be carotenemia (inc vit A), uremia Edema Rating Scale - Answer- 1 - mild pitting w/ slight indent, seen with sock taken off 2 - moderate, indentation subsides quickly 3 - deep pitting, indent remains for short time and leg looks swollen 4 - very deep pitting, indent lasts long, leg very swollen Annular Lesion - Answer- circular, begins in center and spreads to periphery Confluent Lesion - Answer- lesions run together, hives Discrete Lesion - Answer- distinct, individual lesions that remain separate Gyrate Lesion - Answer- twisted, coiled spiral, snakelike Grouped Lesion - Answer- clusters of le