Chapter 1-4, 8-10 Flashcards Preview

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Flashcards in Chapter 1-4, 8-10 Deck (72)
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1
Q

After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be

A

Objective Data

2
Q

A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be:

A

Subjective Data

3
Q

The patients record, laboratory studies, objective data, and subjective data combine to form the:

A

Database

4
Q

Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as

A

Intuition

5
Q

piece of information, sign or symptom, piece of laboratory or imaging data

A

Cue

6
Q

tentative explanation for a cue or a set of cues that can be used as a basis for further investigation

A

hypothesis

7
Q

six steps of the nursing process (ADOPIE)

A

assessment, diagnosis, outcome identification, planning, implementation, evaluation

8
Q

What level of priority?

Those that are emergent, life threatening, and immediate, such as establishing, an airway or supporting breathing

A

First level priority problems

9
Q

What level of priority?
mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security

A

Second level priority problems

10
Q

What level of priority?

those that are important to the patient’s health but can be attended to after more urgent health problems are addressed.

A

Third level priority problems

11
Q

systematic approach to practice that emphasizes the use of best evidence in combination with the clinicians experience, as well as patient preferences and values, when making decisions about care and treatment. More than best practice techniques

A

evidence based practice

12
Q

The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?

a. Patient with postoperative pain
b. Newly diagnosed patient with diabetes who needs diabetic teaching
c. Individual with a small laceration on the sole of the foot
d. Individual with shortness of breath and respiratory distress

A

D.

  • ABC- airway, breathing, circulation
13
Q

Second-level priority problems include which of these aspects?

a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs

A

C.

14
Q

A critical thinking skill helps the nurse see relationships among the data

A

Clustering related cues

15
Q

A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?

A

Breathing, pain, sleeping

16
Q

What step of the nursing process includes data collection by health history, physical examination, and interview?

A

Assessment

17
Q

What does the holistic health include?

A

Viewing the mind, body, and spirit as interdependent

18
Q

The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?

a. Establish priorities.
b. Identify expected outcomes.
c. Evaluate the individuals condition, and compare actual outcomes with expected outcomes.
d. Interpret data, and then identify clusters of cues and make inferences.

A

C.

*After implementation, next do evaluation.

19
Q

learned from birth through language acquisition and socialization.

A

culture

20
Q

the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society

A

culture

21
Q

large groups of people with shared characteristics that are not common to all members of a culture.

A

subculture

22
Q

implies that the caregiver understands and attends to the total context of the individuals situation. This competency includes awareness of immigration status, stress factors, other social factors, and cultural similarities and differences

A

culturally competent

23
Q

implies that the caregiver possess some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting where they are practicing

A

culturally appropriate

24
Q

implies that caregiver possess some basic knowledge of and constructive attitudes towards the diverse cultural populations found in the setting in which they are practicing

A

culturally sensitive

25
Q

pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, values, traditions, symbols, or food preferences.

A

ethnicity

26
Q

process of adopting the culture and behavior of the majority culture

A

acculturation

27
Q

unidirectional, proceeding in a linear fashion from unacculturated to accultrated

A

assimilation

28
Q

dual pattern of identification

A

biculturalism

29
Q

mini database, small in scope; concerns mainly one problem, one cue complex, one body system

A

focused database

30
Q

What kind of database?
a patient with heart failure with the primary health care provider at regular intervals to reevaluate medications, identify changes in symptoms, and discuss coping strategies

A

follow up database

31
Q

health history and full physical examination

A

complete database

32
Q

Arises out of each persons unique life experience and his or her personal effort to find purpose in life.

A

spirituality

33
Q

What are the four processes of communication?

A

sending, receiving, internal factors, external factors

34
Q

What does sending include?

A

verbal and nonverbal communication, body language

35
Q

What does receiving include?

A

words and gestures must be interpreted in a specific context to have meaning. it attaches meaning determined by his or her experiences, culture, self-concept, and current physical and emotional states.

36
Q

what does internal factors include?

A

liking others, empathy, ability to listen, self awareness

37
Q

what does external factors include?

A

ensure privacy, refuse interruptions, physical environment, dress, note-taking, electronic health record

38
Q

asks for narrative information. states the topic to be discussed but only in general terms. for example: “tell me how I can help you.”

A

open-ended questions

39
Q

elicit a two word answer like yes or no

A

close or direct questions

40
Q

10 TRAPS of interviewing

A
  1. providing false assurance or reassurance
  2. giving unwanted advice
  3. using authority
  4. using avoidance language
  5. distancing
  6. using professional jargon
  7. using leading or biased questions
  8. talking too much
  9. interrupting
  10. using “WHY” questions
41
Q

what are the nonverbal skills? (7)

A
  • physical appearance, posture, gestures, facial expression, eye contact, voice, touch
42
Q

Verbal Responses: Client’s perspective

A
  • facilitation, silence, reflection, empathy, clarification
43
Q

Verbal Responses: Examiner’s perspective

A
  • confrontation, interpretation, explanation, summary
44
Q

When observing a patients verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should:

a. Ask someone who knows the patient well to help interpret this discrepancy.
b. Focus on the patients verbal message, and try to ignore the nonverbal behaviors.
c. Try to integrate the verbal and nonverbal messages and then interpret them as an average.
d. Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings.

A

D.

**When nonverbal and verbal messages are congruent, the verbal message is reinforced.

45
Q

Define symptom:

A

subjective sensation that the person feels from the disorder

46
Q

define sign:

A

objective abnormality that you as the examiner could detect in a physical examination or through diagnostic testing

47
Q

Pain Scale:

Remember PQRSTU!

A
P- provocative or pallative
Q- quality or quantity
R- region or radiation
S- severity scale
T- timing
U- understand patient's perception of the problem
48
Q

Know the CAGE for alcoholics:

A

CUT
ANNOYED
GUILTY
EYE OPENER

49
Q

Which of these statements represents subjective data the nurse obtained from the patient regarding the patients skin?

a. Skin appears dry.
b. No lesions are obvious.
c. Patient denies any color change.
d. Lesion is noted on the lateral aspect of the right arm.

A

C.

50
Q

Assessment that includes ADL’s like: occupation, activity/exercise, sleep/rest, nutrition/elimination, interpersonal relationships/resources, coping/stress management, environment, home safety hazards

A

Functional assessment

51
Q

What are the four techniques in the physical examination process? (in order)

A

inspection, palpation, percussion, auscultation

*IPPA (PP remember a before e)

52
Q

Palpation applies to what factors?

A

temperature, moisture, organ location and size, swelling, vibration/pulsation, rigidity/spasticity, presence of lumps/masses, tenderness/pain

** identify any tender areas and palpate them last

53
Q

Which technique is tapping the person’s skin with short, sharp strokes to assess underlying structures?

A

percussion

54
Q

Percussion includes:

A
  • stationary hand, striking hand, and production of sound
55
Q

Palpation techniques include:

A

fingertips, fingers and thumb, dorsa of hands and fingers, base of fingers and ulnar surface of hand

56
Q

the use of this will block out extraneous room sounds

A

stethoscope

57
Q

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?

a. Palpation
b. Inspection
c. Percussion
d. Auscultation

A

A

58
Q

Which part of the stethoscope is best use for high pitch sounds like breath, bowel, and normal heart sounds?

A

diaphragm (flat edge)

59
Q

When do you wash your hands?

A
  • before and after every patient encounter
  • after contact with blood/body fluids/secretions
  • after contact with any alcohol based hand sanitizer (takes less time than hand washing with soap & water)
  • after removing gloves
60
Q

What technique would the nurse listening to a sounds produced by the body, such as heart, blood vessels, lungs and abdomen?

A

auscultation

61
Q

funnels light into the ear and onto the tympanic membrane:

A

otoscope

62
Q

illuminates the internal eye structures

A

ophthalmoscope

63
Q

height appears within the normal range for age and genetic heritage

A

stature

64
Q

person stands comfortably erect as appropriate for age

A

posture

65
Q

body parts look equal bilaterally and are in relative proportion

A

symmetry

66
Q

person sits comfortably in chair or on bed or examining table, arms relaxed at sides, head turned to examiner

A

position

67
Q

How do you assess the pulse?

A
  1. rate
  2. rhythm
  3. force
  4. elasticity
68
Q

The nurse is performing a general survey. Which action is a component of the general survey?

a. Observing the patients body stature and nutritional status
b. Interpreting the subjective information the patient has reported
c. Measuring the patients temperature, pulse, respirations, and blood pressure
d. Observing specific body systems while performing the physical assessment

A

A.

69
Q

The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that:

a. Rapid measurement is useful for uncooperative younger children.
b. Using the TMT is the most accurate method for measuring body temperature in newborn infants.
c. Measuring temperature using the TMT is inexpensive.
d. Studies strongly support the use of the TMT in children under the age 6 years.

A

A.

**TMT is useful for young children who may not cooperate for oral temperatures and fear rectal temperatures. However, the use a TMT with newborn infants and young children is conflicting.

70
Q

When assessing an older adult, which vital sign changes occur with aging?

a. Increase in pulse rate
b. Widened pulse pressure
c. Increase in body temperature
d. Decrease in diastolic blood pressure

A

B.

**With aging, the nurse keeps in mind that the systolic blood pressure increases, leading to widened pulse pressure.

71
Q

Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?

a. Wait 30 minutes if the patient has ingested hot or iced liquids.
b. Leave the thermometer in place 3 to 4 minutes if the patient is afebrile.
c. Place the thermometer in front of the tongue, and ask the patient to close his or her lips.
d. Shake the mercury-in-glass thermometer down to below 36.6 C before taking the temperature.

A

B.

**and up to 8 minutes if the person is febrile. The nurse should wait 15 minutes if the person has just ingested hot or iced liquids and 2 minutes if he or she has just smoked.

72
Q

Which technique is correct when the nurse is assessing the radial pulse of a patient?

The pulse is counted for:

a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiplied by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities.

A

A.

**Recent research suggests that the 30-second interval multiplied by 2 is the most accurate and efficient technique when heart rates are normal or rapid and when rhythms are regular. If the rhythm is irregular, then the pulse is counted for 1 full minute.