NUR 300 Health Assessment Exam 1Questions And Answers Verified Correct Answers

6 phases of nursing progress - correct answers Assessment Diagnose Outcome identification Planning Implementation Evaluation OLDCAARTSS - correct answers Onset Location Duration Characteristics/quality Associated symptoms Aggravating/alleviating Radiating Timing Severity/quantity Setting cultural competence - correct answers"Cultural competency includes attitudes, knowledge, and skills necessary for providing quality care to diverse populations." p 22 It is important to know what a patient needs that may have a cultural or religious aspect to it - interpreters subjective data - correct answersthings a person tells you about that you cannot observe through your senses; symptoms, review of symptoms, chief complaint, family history, HPI(history of presenting symptoms), medications, surgeries Type of medications to ask about - correct answersprescription, OTC, homeopathic, herbal, supplements PQRSTU - correct answersProvocative/palliative Quality/quantity Region/radiation Severity scale Timing Understanding patient's perception SOAP - correct answerssubjective objective assessment plan What are the 4 components of mental status exam what two factors can affect this? - correct answersAppearance, Behavior, Cognition, Thought Process -medications and illness can affect these components is appearance, behavior, cognition, thought process and judgement subjective or objective data? - correct answersobjective data blocking - correct answerssudden interruption of train of though Confabulation - correct answersfabricates events to fill in memory gaps neologism - correct answersthe creation or use of new words or senses circumlocution - correct answersan indirect way of expressing something (substituting a phrase for a word) loosening of associations - correct answerscontinual shifting from topic to topic without any apparent logical or meaningful connection between thoughts word salad - correct answersincoherent picture of words perseveration - correct answerspersistent repeating echolalia - correct answersrepeat others words or phrases clanging - correct answersword choice based on sound, not meaning, includes nonsense rhymes and puns Scoring MMSE - correct answershigher score (24-30)= no cognitive impairment low score = cognitive impairment Mini cog test - correct answersTest for dementia that asks clients to remember 2 words and draw a clock face levels of consciousness - correct answersAlert, Lethargic, Obtunded, Stupor/Semi-Coma, Coma lethargic vs obtunded vs stupor - correct answerslethargic: can be aroused obtunded: difficult to arouse stupor: very hard to arouse (spontaneously unconscious) Glasgow coma scale - correct answerseyes, verbal, motor Max- 15 pts, below 8= coma delirium vs dementia vs depression - correct answersdelirium; sudden onset, last hours/days (fluctuates) dementia: slow onset, last years (progressive) orientation in patients with delirium? dementia? - correct answersdelirium: impaired dementia: may be normal memory in patients with delrirum? dementia? - correct answersdelirium: impaired dementia: impaired, may remember recent events two speech areas of the brain - correct answersbrorcas and wernickes dysphonia - correct answersspeech disorder attributable to difficulty or discomfort in talking dysarthia - correct answersspeech disorder damaging the control of speech production/ articulation aphasia - correct answersa speech disorder resulting from brain damage CAGE - correct answerscut down Annoyed Guilty Eye opener palpation vs percussion - correct answerspercussion identifies density and may elicit a reflex Auscultation - correct answersListening with a stethoscope (heart, lungs, blood vessels, abdomen) diaphragm vs bell - correct answersDiaphragm is used for high pitched sounds Bell is used for low pitched sounds, requires light touch Korotokoff - correct answersdiscovered systolic and diastolic sounds systolic and diastolic sounds through stethoscope - correct answerssystolic sounds: turbulent blood flow as it first beings to move through constricted artery diastolic sounds: silence after artery is not compressed BP classifications - correct answersNormal: 120/80 Prehypertension: 120-139/80-89 Stage 1 Hypertension: 140-159/90-99 Stage 2 Hypertension: or equal to 160/100 risk factors for high blood pressure - correct answersSmoking, high cholesterol (dyslipidemia), & obesity, diabetes, men and postmenopausal women, family Hx of cardiovascular;ar disease dyslipidemia - correct answersabnormal blood lipid levels ideal HDL levels - correct answers60 or above is best women w diabetes: above 50mg/dl men w diabetes: above 40mg/dl ideal triglyceride levels - correct answersless than 150 mg/dl levels over 500 mg/dl are considered dangerously high ideal cholesterol level - correct answersless than 200 mg/dL What is the fifth vital sign - correct answerspain is pain assessment subjective or objective? - correct answerssubjective nociceptive pain - correct answerspain caused by tissue damage (chronic pain) neuropathic pain - correct answerspain caused by nerve damage psychogenic pain - correct answersPaine that is affected by psychological factors visceral pain - correct answersoriginates from internal organs such as the stomach, intestines, gallbladder, pancreas; caused by either trauma, tumors, ischemia - cholecystitis, appendicitis, etc somatic pain - correct answerscomes from the musculoskeletal and body surface - deep somatic pain comes from blood vessels, joints, tendons, muscles, and bone(aching or throbbing) referred pain - correct answerspain that is felt in a location other than where the pain originates (appendicitis can be felt in the periumbilical area) breakthrough pain - correct answersPain that occurs between doses of pain medication chronic pain - correct answersepisode of pain that lasts for 6 months or longer; may be intermittent or continuous layers of skin - correct answersepidermis, dermis, subcutaneous what layer of skin contains blood vessels, nerves, sensory receptors, lymphatics, sweat glands, hair follicles and sebaceous glands are embedded in this layer - correct answersdermis skin color is determined by - correct answersmelanin, carotene Where is melanin and carotene found - correct answersepidermis heat is dissipated through and heat is stored in - correct answerssweat glands subcutaneous layer UV converts cholesterol to____ - correct answersvitamin D sebum - correct answersoily substance secreted by sebaceous glands sweat glands - correct answerseccrine and apocrine eccrine glands - correct answersglands that produce sweat; found over most of the body apocrine glands - correct answersSweat glands in the pubic and underarm areas that secrete thicker sweat two types of hair - correct answersvellus - cover most of the body and terminal- - scalp, eyebrows and chest; after puberty the axilla, chest, pubic and face Nails are made of - correct answershard keratin lunula - correct answersThe half-moon-shaped, whitish area at the base of a nail lesions - correct answers Decubitus Ulcers stages - correct answersStage I: skin intact but reddened, does not blanch (stays red when touched) Stage II: partial skin thickness erosion (loss of epidermis and dermis), shallow Stage III: full thickness erosion and goes into the subcutaneous tissue Stage IV: involves all skin layers and goes into underlying tissue (exposes muscle, tendon or bone) linear pigmentation on nails - correct answers indicates melanoma face bones - correct answers mandible, maxilla, and zygomatic (lateral to eyes) skull bones - correct answers frontal, parietal, occipital, temporal lots of lymphoid in this area - correct answers sternocleidomastoid- m