Nursing Assessment Exam with correct answers 2024.

What are the 6 steps of the nursing process? if asking for 5 remove (outcome identification) - answer-ADOPIE Assessment Diagnosis Outcome Identification Planning Implementation Evaluation What are the types of Health Assessment? - answer-1) Comprehensive assessment 2)Problem-based/Focused assessment 3) Emergency assessment What are the 3 primary components of Health Assessment? - answer-History (subjective data) Physical examination (objective data) Documentation of data Why do we document all of our data? - answer-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. - answer-True What is context of care? - answer-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? - answer-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? - answer-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 emergency assessment? - answer-life-threatening situation What is a screening assessment? - answer-a short examination focused on disease detection. usually conducted in health fairs. What is Health promotion? - answer-Behavior motivated by desire to increase well-being and actualize health potential. What is Health protection? - answer-Behavior motivated by desire to avoid illness, detect illnesses early, and maintain functioning when ill. What are the 3 levels of health promotion? - answer-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? - answer-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. - answer-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)Tertiary prevention of health care-associated infections C)Reasoning patterns - answer-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 - answer-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? - answer-Health history Physical examination Is a health history subjective or objective data? - answer-Subjective Single-most important factor for successful interviewing is the ______ skill of the nurse. - answer-communication What are some factors that affect a nurses therapeutic communication? - answer-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? - answer-open-ended. encourage a free-flowing open response. If want more precise data from your patients what type of question should you ask? - answer-Close-ended What do directive questions do? - answer-lead patient to focus on one set of thoughts. Most often used in reviewing systems and evaluation functional status. Use _____ to help concentrate on pt. responses and subtleties. - answer-listening _______ uses verbal and nonverbal phrases to encrourage patinets to continue to talk further. - answer-Facilitation _____ is used to gather more information. - answer-Clarification. _______ is repeating what patient says ini different words to confirm interpretation. - answer-Restatement _____ reflection is repeating what the patient said and encourages elaboration or more information. - answer-Reflection ______ is used when inconsistencies are noted between patient report and nurse's observations. - answer-Confrontation _______ is used to share conclusions drawn from data. Pt. may then confirm, deny, or revise - answer-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 - answer-Summary What are the components of a comprehensive health history? - answer-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. - answer-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." - answer-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. - answer-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? - answer-Hand hygiene. T/F health care professionals are not at risk of a latex allergy if they don't already have it. - answer-False; latex allergies can develop because of frequent exposure. Physical Exams being with _____. What do we achieve from this data? - answer-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? - answer-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? - answer-A gentile touch, warm hands, and short nails to prevent discomfort or injury. What do we use percussion for? - answer-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? - answer-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? - answer-it requires both hands, methods can vary by ststem being assessed. What does percussion help with? - answer-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? - answer-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? - answer-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. - answer-False; it blocks out extraneous sounds when evaluating the patient and allows you to focus on a specific aream. On a stethoscope what is the diaphragm usually used for? - answer-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? - answer-Used to hear soft, low-pitched sounds like extra heart wounds. press lightly to body. What is a sphygmomanometer? - answer-A blood pressure cuff, What is pulse oximety measured in? Where do we put the sensors? - answer-% of estimate of oxygen saturation in arterial blood and pulse rate. Sensor taped to ear, finger, or toe What is a penlight used for? - answer-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. When does general inspection begin? - answer-The moment nurse meets the patient. Body temperature is regulated by the ______. Expected temperature ranges from 96.4 to 99.1. - answer-Hypothalamus T/F Temperature during menstrual cycle increases .5-1.0 F. At ovulation and remains elevated until menses cease because of progesterone secretion. - answer-True If taking a oral temperature delay ____ if patient ingested hot or cold, liquids or smoked - answer-10 minutes. Why do we put oral electronic thermometer under the tongue in the sublingual pocket? - answer-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. - answer-False. It has questionable accuracy. _____ artery is most frequently used to measure heart rate because accessible and easily palpated. - answer-Radial What arteries are common alternative sites to assess pulse rate? - answer-Brachial, and carotid Where do you auscultate the heart? - answer-Located over the fifth intercostal space at the mid clavicular line. What does respiratory rate involve? - answer-counting number of ventilator cycles and inhalation and exhalation, each minute. What are some factors that increase respiratory rate? - answer-fever, anxiety, exercise, depth, and high altitude What are some ways to describe the respiratory rate? - answer-regular or irregular. Depth by observing excursion or movement of chest wall. Depth described as deep, normal, or shallow. What is cardiac output? - answer-the volume of blood ejected from heart each minute. What is Peripheral resistance? - answer-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? - answer-in millimeters of mercury (mm Hg) What is the systolic blood pressure? - answer-maximum exerted on arteries when ventricles eject blood from heart What is diastolic blood pressure? - answer-represents minimum amount of pressure exerted on vessels when ventricles of heart relax. What physiologic factors affect blood pressure. - answer-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. - answer-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. - answer-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. - answer-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. - answer-is What is culture? - answer-All the socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, lifeways, and characteristics that influence a worldview What is Ethnicity? - answer-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? - answer-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 - answer-False. Individuals from the same racial group are not necessarily from the same culture. What is religion? - answer-an organized system of beliefs, rituals, and practices in which an individual participates. What is spirituality? - answer-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? - answer-There are 14 national standards to ensure euitable and effective treatment. Which part of the CLAS are we suppose to know? - answer-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 stereotype what must a nurse do? - answer-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... - answer-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. - answer-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? - answer-Pain relief Pain assessment is also known as the ____ vital sign - answer-fifth T/F The nurse can judge a persons perception of the pain and can make their own score. - answer-False only the patient can perceive their own pain. What effect can pain have on your patient? - answer-Reduce mobility Impair sleep Contribute to loss of appetite The perception ofo pain is influenced by ______ and ______ factors. - answer-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? - answer-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? - answer-False Cultural influences may affect how pain is communicated. What is the difference between acute pain, and chronic pain? - answer-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 Referred pain? - answer-Pain felt in a location away from the injury. Often visceral pain, as many abdominal organs have no pain receptors. What is Phantom pain? - answer-Pain felt in an amputated extremity. When collecting data from patients you follow the mnemonic OLD CARTS. What does it stand for? - answer-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? - answer-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? - answer-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? - answer-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? - answer-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. - answer-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. - answer-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? - answer-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? - answer-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? - answer-Alcohol abuse, drug abuse, and personal abuse. Interpersonal violence is not an illness, but it is a ____ and ______ _______ _____ - answer-crime, and human rights violation. When taking a personal and psychosocial history of a person what questions do you want to ask them? - answer-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? - answer-It is used to help determine if it is a health problem. What is major depression? - answer-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? - answer-patient's ability to work, study, sleep, eat, and enjoy pleasurable activities What clinical findings must the nurse find to help diagnosis major depression? - answer-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? - answer-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 are the 4 broad goals of nursing? - answer--To promote health (state of optimal functioning or well being with physical, social, and mental components) -to prevent illness -to treat human responses to health and illness -to advocate for individuals, families, communities, and populations what are ethical principles that guide nursing practice? - answer-nonmaleficence, beneficence, autonomy, justice, and privacy/confidentiality what are the core nursing values? - answer-respect unity diversity integrity-being honest, strong moral principles excellence primary prevention - answer-strategies of preventing problems immunizations, health teaching, safety precautions, nutrition counseling secondary prevention - answer-early diagnosis to health problems and prompts treatment to prevent complications Vision screening, Pap smears, BP screening, hearing testing, scoliosis screening, and tuberculin skin testing tertiary prevention - answer-preventing complications of an existing disease and promoting health to the highest level Diet teaching for patients with diabetes, inhaler teaching for patients with lung disease, and exercise programs for those who have had myocardial infarction health assessment - answer-gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings, and evaluating patient care outcomes -includes both history and physical assessment -first step in care -includes physiological data, psychological, sociocultural, spiritual, economic, and life-style factors health history - answer-includes interviewing to collect the patient's past medical and surgical histories, risk factors, and current symptoms comprehensive health history - answer-includes nutrition; development; mental health; social, cultural, and spiritual dimensions; and safety issues the nursing process - answer-The nursing process is a systematic problem-solving approach to identifying and treating human responses to actual or potential health difficulties -patient centered focused on solving problems and enhancing strengths -can involve overlapping steps -assessing -diagnose -identify outcome -plan -implementation -evaluating assessment interview - answer-accurate health assessment to promote health at the highest level -all future care depends on, needs to be accurate -determines the patients health care status -determine patients strengths and problem areas assessment physical - answer-includes inspection, palpation (feeling and touching), auscultation, and percussion head to toe diagnose - answer-is the clustering of data to make a judgment or statement about the patient's difficulty or condition -provides basis for selection of nursing interventions -use diagnostic reasoning and critical thinking -use data clustering, cluster interpretation, and diagnostic validation to ensure accuracy in selecting the correct diagnosis -Diagnoses may identify actual problems, risks for developing the problems, and possible difficulties, or they may be wellness oriented outcomes - answer-includes the formulation of measurable, realistic, patient-centered goals -more specific than goals -realisitc and measurable plan care - answer-activities include determining resources, targeting nursing interventions, and writing the plan of care -you analyze the individual patient and his or her needs in order to provide individualized and holistic care -verbal and document on paper -can be documented in many ways (map, case note, pathway, etc-incorporates nursing process and critical thinking -set priorities, establish outcomes, set target dates implement / interventions - answer-any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient outcome -to monitor health status; prevent, resolve, or control a problem; assist with activities of daily living; or promote optimal health and independence -two parts: action and documentation evaluation - answer-the judgment of the effectiveness of nursing care in meeting the patient's goals and outcomes based on the patient's responses to the interventions -make judgments about the progress of the patient, analyze the effectiveness of nursing care, review potential areas for collaboration and referral to other health care professionals, and monitor the quality of nursing care and its effect on the patient -be aware of most current research and use the evidence critical thinking - answer--Entails purposeful, outcome-directed (results-oriented) thinking -Is driven by patient, family, and community needs -Is based on the nursing process, evidence-based thinking, and the scientific method -Requires specific knowledge, skills, and experience -Is guided by professional standards and codes of ethics -Is constantly reevaluating, self-correcting, and striving to improve - identifies patterns and trends, consider missing or conflicting assessment information, and decide the type and frequency of future assessments diagnostic reasoning - answer--based on critical thinking includes gathering and clustering data to draw inferences and propose diagnoses -based on defining characteristics (observable cues and inferences) seven step process of diagnostic reasoning - answer-Identify abnormal data and strengths Cluster data Draw inferences Propose nursing diagnoses Check for presence of defining characteristics Confirm or rule out the nursing diagnosis Document conclusions whats the difference between critical and diagnostic reasoning? - answer-diagnostic reasoning refers to the result (outcome) of critical thinking or clinical reasoning—the conclusion, decision, or opinion you make. emergency assessment - answer-involves a life-threatening or unstable situation, such as a patient in an ED who has experienced a traumatic injury -do assessments and interventions simultaneously -assessments: A—Airway (with cervical spine protection if an injury is suspected) B—Breathing—rate and depth, use of accessory muscles C—Circulation—pulse rate and rhythm, skin color D—Disability—level of consciousness, pupils, movement E—Exposure -interventions: Provide assistance with circulation (cardiopulmonary resuscitation [CPR] if needed). Open the patient's airway. Assist the patient's breathing. Protect the cervical spine if the patient is injured. Ensure that the disoriented or suicidal patient is safe. Provide pain management and sedation. comprehensive assessment - answer-complete health history and physical assessment -annually outpatient basis -following admission to a hospital, long term care facility, or every 8 hours in ICU -history obtained by detailed patient fill out (family and personal illness, medical treatment, surgeries -note dates of diagnostics and treatments as well as medications -also includes a patient's perception of health, strengths to build upon, risk factors for illness, functional abilities, methods of coping, and support systems -if urgent may need to look at secondary sources -asses health beliefs and discuss health promotions -physicla includes all body systems in head to toe format focused assessment - answer-based on health issues -can occur in all settings, including the clinic, hospital, and home health setting - involves one or two body systems and is smaller in scope than the comprehensive assessment but more in depth on the specific issue or issues ex coming in with a cough how do you prioritize in nursing - answer-depend on the gravity of the patient's health care situation -use clinical experience, knowledge, expertise, and judgment to determine priorities -first address any life-threatening situation or any issue that needs immediate attention -If the patient is stable, then your priority is any issue that is very important to the patient, or something on which you are spending a lot of time subjective data - answer-based on patient experiences and perceptions -individual describes the feelings, sensations, or expectations; you then document them as subjective data or put them in quotes - gather information to improve the patient's health status and to help determine the cause of the patient's current symptoms objective data - answer-data the nurse observes measurable appearance; assess vital signs; listen to the heart, lungs, and abdomen; and assess peripheral circulation documentation - answer-subjective and objective findings is essential for legal purposes and also to communicate findings to others -changes are noted between assessments - form of flow sheets, case notes, or care planning problem oriented recording: database-what data you gathered from the patient problem-numbered prioritized problems plan of care-outcomes and interventions progress note-how the patient responded to the interventions communication - answer-verbal Care of the patient is collaborative, and nurses use an organized method when communicating with other health care providers describe the situation, background, and assessment data to make recommendations about the treatment that is indicated—a system known as SBAR communication functional assessment - answer--focuses on the functional patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs -use the functional patterns to collect subjective data following a health history but a head-to-toe system for the physical assessment head to toe assessment - answer--most organized system for gathering comprehensive physical data -check things from head to toe in order (arm problems, still check heart and lungs first then go to arm) -more efficient, provides modesty -start vital signs first body systems approach - answer-is a logical tool for organizing data when documenting and communicating findings -promotes critical thinking and allows you to analyze findings as you cluster similar data. -data from head to toe and functional are reorganized -consider body, vital signs, general survey -Rather than identifying one piece of data in isolation, a systems approach allows you to cluster similar data to identify issues types of data in assessment - answer-subjective objective historical-health events that happened prior to admins. current-data from the visit ex current vital signs what are the precautions used to prevent infection - answer-hand hygiene use of gloves standard precautions when should a nurse wear gloves? - answer-when touching blood, body fluids, secretions, excretions, and contaminated items -Put on clean gloves just before touching the mucous membranes and nonintact skin of patients -Wear gloves when general contact with any "wet" body secretion is anticipated when should a nurse change gloves? - answer--Between tasks and procedures on the same patient after contact with a material that contains a high concentration of microorganisms (such as a dressing changes or tracheostomy care) -When going from a contaminated to a cleaner area standard precautions - answer-intention of standard precautions is to prevent disease transmission during contact with nonintact skin, mucous membranes, body substances, and blood-borne contacts -serve to help ensure that health care providers treat all patients equally. transmission based precautions - answer-precautions in health care, and the latest routine infection prevention and control practices applied for patients who are known or suspected to be infected or colonized with infectious agents inspection - answer--general survey -preformed for every body part and every system -physical characteristics, behaviors, odors -gain overall impression and assess severity of situation -adequate exposure for each body part is necessary -adequate lighting -remove devices that limit visibility such as a splint -use good descriptions palpation - answer--use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema -ask for permission -use finger pads for fine discrimination (pulses, lymph nodes, small lumps) -palmar surface of fingers and finger joints are best for assessing firmness, contour, position, size, pain, and tenderness -back of the hand is most sensitive to temperature -warm hands avoid any tender or painful areas during palpation until - answer-the end light palpation - answer-assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin -Place the finger pads of the dominant hand on the patient's skin and slowly move the fingers in circular areas of approximately 1 cm in depth (about ½ in. -Intermittent palpation using this technique is more effective than a single continuous palpation, because your fingers sense the movement of skin and tissue beneath the finger pads -1 hand moderate to deep palpation - answer-assess the size, shape, and consistency of abdominal organs -note any unexpected findings of pain, tenderness, or pulsations -use the palmar surface of the fingers. Pressure is firm enough to depress approximately 1 to 2 cm. (moderate) Observe the patient for any guarding, grimacing, or tension -During deep palpation, place the extended fingers of the nondominant hand over the dominant hand to use the pressure of both hands. Use the same circular motion to palpate 2 to 4 cm. what do we palpate for - answer-temp texture moisture organ size and location rigidity or spasticity edema crepitation (crackling), vibration position size, fullness presence of lumps or masses tenderness or pain percussion - answer--produce sound or elicit tenderness -If the vibrations travel through dense tissue, the percussion tones are quiet -if they travel through air or fluid, the tones are louder -The loudest tones are over the lungs and hollow stomach; the quietest are over bones direct percussion - answer-tap with your fingers directly on the patient's skin -assess for location, size, density indirect percussion - answer-use your nondominant hand as a barrier between the dominant hand and the patient -Place your nondominant palm on the patient and initiate a quick, moderately strong tap with the dominant hand. - Indirect percussion requires coordination of both hands. Place the hyperextended middle finger of your nondominant hand firmly over the area to be percussed. Lift the other fingers on that hand from the patient and spread them slightly to avoid contact with the patient, which can dampen the sound of the striking finger. Then position the slightly flexed middle finger of your dominant hand approximately 2 to 3 cm (about 1 in.) above the distal interphalangeal joint in contact with the patient. Using only the wrist of the dominant hand, raise the dominant finger 4 to 5 cm (about 2 in.) and quickly strike and raise the nondominant joint twice while listening for the elicited sound flatness - answer-bone or muscle dullness - answer-heart, liver, spleen resonance - answer-air filled lungs, hollow tympani - answer-air filled stomach drumlike auscultation - answer-listen for sounds produced by the body -requires quiet environment with no distractions - blood pressure, lungs, heart, and abdomen -describe sounds in terms of intensity, pitch, duration, and quality procedure for using a stethoscope - answer-make sure to disinfect the stethoscope between patients to avoid spreading pathogens (Schneider et al., 2011). Place the stethoscope directly on the patient's skin so that complete contact with the skin surface is made. -When holding the chestpiece, place the endpiece between the index and the middle fingers, not on top of the stethoscope, which distorts the sound. Position the stethoscope so that tubing is away from objects that might brush against it (moisten hair on chest) diaphragm - answer-high pitched sounds firm pressure bell - answer-low pitched sounds light pressure considerations for older adults - answer--may chill more easily -fatigue quickly (preform assessments in the beginning) -elevation of head for better breathing order in which you should do assessment techniques - answer-inspection palpation percussion auscultation normal temperature - answer-97-98.6 36-37 C hypothermia - answer-< 95 <35 sources of heat loss - answer-Skin (primary source) Evaporation of sweat Warming and humidifying inspired air axillary temp - answer-often inaccurate : needs to be held in position must be still long measurement time needed recommended for: infants, young children, and patients that have an impaired immune system rectal temp - answer-as accurate as oral temp needs lube needs to be held in position cannot be used with: Newborns Diarrhea Rectal surgery or bleeding *don't insert farther than 1 inch oral temp - answer-no positioning needed Must place thermometer tip in left or right mouth pocket under tongue Is influenced by hot & cold fluids Is influenced by mouth breathing Must be awake, alert, and oriented tympanic temp - answer-not proven to be accurate little positioning needed not influenced by foods can be used with almost all ages -influenced by outside temps and packs, swimming, ear wax tympanic for children - answer-ear down and back tympanic for adult - answer-up and back pulse - answer-wave of blood pumped into arterial circulation by the heart pulse sites - answer-temporal radial brachial dorsalis pedis popliteal femoral carotid apical assessing pulse - answer-rate rhythm amplitude (+2) counting pulse - answer-count pulse for 30 seconds and x 2 for irregular/kids -count for 60 seconds -never use your thumb when do you use apical pulse - answer-pulse is difficult to feel or count pulse is very fast or very slow machine BP is inaccurate with - answer-very fast or slow pulses weak or skipping arm movement normal pulse rates - answer-babies to age 1: 100-160 children ages 1-10: 60-140 children Aage 10+ to adults: 60-100 well conditioned athletes: 40-60 what is a doppler for - answer-when you can't hear pulse inspecting respirations - answer-rate rhythm depth symmetry *once cycle is breath in and out -place patients arm across chest -make sure they not know you're taking it -watch while taking pulse count for 30 x 2 normal respiratory rates - answer-newborn-6 weeks: 30-60 infant (6 weeks- 6 mos): 25-40 toddler (1-3 yrs): 20-30 young children (3-6 yrs): 20-25 older children (10-14 yrs): 15-20 adults: 12-20 tachypnea - answer-> 20/min bradypnea - answer-<12min systolic - answer-max pressure diastolic - answer-pressure when heart at rest measured in mmHg normal BP - answer-<120/80 prehypertension - answer-120/80-139/89 stage 1 hypertension - answer-140/90-159/99 stage 2 hypertension - answer-> 160/100 postural hypotension - answer-when BP drops with change in position from lying sitting standing taking BP - answer--make sure patient is calm -supine or sitting -arm at heart level -cuff size 80% of arms circumference or 40% width -palpate brachial artery -center 2.5 cm above the artery -estimate SBP -wait -inflate BP cuff 20-30 above SBP -delate -first sound=systolic second=diastolic -record in even numbers oxygen saturation - answer-indicator of % of hemoglobin saturated with O2 -nail polish interferes pain history - answer-pain characteristics past and current management medical/family history psychosocial history impact of pain on daily life patient expected goals for treatment eupnea - answer-normal respirations febrile - answer-body temp elevated fever - answer-elevation above the normal temp pyrexia korotkoff sounds - answer-series of sounds that correspond to changes in blood flow through an artery as pressure is released orthopnea - answer-breathing easier when the patient sits or stands pulse deficit - answer-difference between the apical and radial pulse rates pulse pressure - answer-difference between the systolic and diastolic pressure physical effects of a fever - answer-loss of appetite; headache; hot, dry skin; flushed face; thirst; muscle aches; and fatigue -Respirations and pulse rate increase -herpes simplex outbreak young children with fevers may experience - answer-seizures older adults with fevers may experience - answer-confusion and delirium what order should you do vital signs in - answer-temperature, pulse, respiration, BP, pain how does axillary temp differ from oral - answer-lower 98.4 oral 97.4 axillary where should the thermometer be in the mouth according to ATI - answer-Deep in the posterior sublingual pocket what temperature practice should be used if a nurse wants the most accurate core temp - answer-rectal smoking causes what to the BP - answer-hypertension vasoconstriction when does the general survey begin - answer-once you see the patient and it is ongoing -intro -shake hands -make mental notes what is an acute/urgent situation - answer-serious or dangerous situation what are indicators of an acute/urgent situation - answer-extreme anxiety, acute distress, pallor, cyanosis, and a change in mental status Stridor Respirations less than 10 breaths/min or greater than 32 breaths/min Increased effort to breathe Oxygen saturation less than 92% Pulse less than 55 beats/min (bpm) or greater than 120 bpm Systolic BP less than 90 or greater than 170 mm Hg Temperature less than 35°C (95°F) or greater than 39.5°C (103.1°F) New onset of chest pain Agitation or restlessness what things do you note during a general survey - answer--overall appearance (age, deformities, symmetry) -hygiene and dress -skin tone -body structure and development -behavior -facial expressions -level of consciousness -speech -posture -range of motion -gait vital signs - answer-Temperature, pulse, respirations, and blood pressure, pain -Vital signs reflect health status, cardiopulmonary function, and overall body function -regulated thru homeostatic mechanisms -change in vs can indicate a change in the patient abnormal findings with vital signs - answer-hyperthermia->37.8 C hypothermia-<35 C nutrition imbalances-more than , less than impaired gas exchange ineffective breathing pattern when/ why to assess vitals - answer-upon admission based on policy change in patients condition pre/post surgical or invasive diagnostic procedures before administering meds that may effect cardio functioning what does temp represent? - answer-balance between amount of heat produced by the body and the amount of heat lost to the environment normal temp - answer-97⁰—98.6⁰ (36⁰—37⁰) fever (pyrexia) - answer->100.4⁰ (>38) what influences temperature? - answer-age, exercise, hormones, stress, environment, circadian rhythm ways to take temp - answer-oral, rectal, axillary, tympanic, forehead types of thermometers - answer-disposable electronic-may save time/labor, convenient tympanic temporal artery ear temp - answer-easy not proven to be accurate rapid disposable no interference w breathing no position not ejected by food, drink, or smoking can be used with all age groups useful for confused and uncooperative patients can be effected by hot packs and ice packs extreme outside and inside temp bathing or swimming ear wax don't use if had ear surgery ear temp for adults - answer-pull back up and out point tip to nose opposite for children factors affecting pulse - answer-age blood loss medications exercise stress temp postion nutrition pain caffeine med conditions assessing respirations - answer-rate depth rhythm symmetry counting for 30 instead of 60 - answer-as long as normal rate and rhythm and respirations if not count for 60 normal respirations - answer-12-20/min blood pressure - answer-force of flow of blood against the arterial wall bp measured in - answer-mm of Hg normal blood pressure - answer-<120/80 stage one hypertension - answer-140/90-159/99 bp procedure - answer-be sure patient is calm make sure arm is at heart level cuff must be 80% of arms circumference or 40% of its width palpate the brachial artery center cuff 2.5 cm above the brachial artery estimate SBP-feel for pulse, inflate cuff until pulse is not palpable, deflate cuff slowly, when pulse becomes palpable this indicated estimated SBP wait 15-30 seconds place diaphragm of stethoscope over the artery inflate bp cuff 20-30mmHg above the estimate SBP deflate cuff slowly while listening to pulse sounds first sound- systolic BP last sound-diastolic BP record BP in even numbers temp for older adults - answer-is at the lower end of the normal range less likely to develop fevers but more likely are prone to hypothermia. less fat ABCT - answer-A method of organizing data from the objective assessment: A (appearance) B (behavior) C (cognitive function) T (thought process). Bullying - answer-Verbal and physical violence common among school-age and adolescent populations. Behaviors can range from teasing to physical assault. CAGE - answer-Question-based assessment tool for alcohol and substance abuse: Have you ever felt the need to CUT down on drinking? Have you ever felt ANNOYED by criticism of drinking? Have you ever had GUILTY feelings about drinking? Have you ever had a drink EARLY or first thing in the morning? Child maltreatment - answer-A wide range of abusive and neglectful behaviors toward children. Delirium - answer-Confusion that generally has an underlying medical cause and, once treated, resolves. Dementia - answer-Confusion caused by brain disease that is more common in older adults. It is usually a gradual process over months to years. Elder abuse - answer-Maltreatment of older adults in the form of abuse, neglect, financial exploitation, or abandonment. Abuse includes intentional actions by a caregiver or other person who stands in a trust relationship to a vulnerable elder that cause harm or create a serious risk to him or her. Family violence - answer-All types of violent crime committed by an offender who is related to the victim either biologically or legally through marriage or adoption. Geriatric Depression Scale - answer-A tool to assess for risk of depression in older adults. Hate crime - answer-Crime in which a victim is selected based on a characteristic such as race, ethnicity, sexual orientation, age, and the like and for which the perpetrator provides evidence that hate prompted him or her to commit the crime. HOPE - answer-A tool to assess for spirituality. Human trafficking - answer-The recruitment, transportation, transfer, harboring, or receipt of people by threats, force, coercion, or deception. Intimate partner violence - answer-Behaviors between spouses or nonmarital partners involving threatened or actual physical or sexual violence, psychological/emotional abuse, and/or coercive tactics when there has been prior physical or sexual violence. Mental status examination - answer-As assessment to tell the mental state of the patient. Mini-mental status examination - answer-A tool to quickly assess level of cognitive function. Punking - answer-Verbal and physical violence, humiliation, and shaming, usually done in public or with an audience. SAD PERSONAS - answer-A mnemonic used to assess for risk of suicide. Sexual violence - answer-Forced sex in dating and marital relationships, gang rape, sexual harassment, inappropriate touching or molestation, sex with a patient, or forced prostitution and/or exposure to sexually explicit behavior. Sibling violence - answer-Violence between and among siblings. War/combat violence - answer-Witnessing the killing of human beings, including friends and fellow service people; intentionally killing and injuring other humans; and being intentionally injured or potentially killed by another human. Youth violence - answer-Violence in and around schools and neighborhoods.