Data Collection in Client Care _ Chapter 47

Primary care provider's goals when performing a physical examination ?

- Assess for abnormalities to establish a medical diagnosis - Monitor the progression of a disease - Track any changes in a client's condition

What are some examples of lifestyle risk factors ?

- Obesity - Smoking - Lack of exercise - High fat diet

When assessing a patient' breath sounds, what would be considered abnormal sounds if heard ?

- Rales - Rhonchi - Crackles - Wheezes -Stridor

What is the correct order using the 5 techniques to find out information about a client ?

1. Observation 2. Inspection 3. Auscultation 4. Palpation

In measuring temperature in (F) what would be considered a fever by the oral route ?

100-103 degrees F

Vesicle

<0.5cm diameter, well defined border, elevated cavity filled with serous fluid

What are the different stages of complications that may occur in a client ?

A complication is an unexpected event in the disease's course that often delays the client's recovery. Complications may occur at early, continuing, late, or terminal stages of a disease

Inflammation

A condition resulting from irritation in any body part, marked by pain, heat, redness, and swelling.

Chronic Disease

A disease of long duration that generally manifests itself in an individual as recurring problems that tend to worsen in severity over time.

Macule

A flat discolored spot on the skin (also, macule); an area surrounding the fovea near the center of the retina; the region of greatest visual acuity.

Induration

A hardened place, a lump, as in the skin in a positive reaction to a tuberculin test.

Hemoccult

A test for occult (hidden) blood in stool or body secretions.

Homan's sign

A test for thrombophlebitis in which pain occurs behind the knee when the foot is hyperflexed upward (dorsiflexion).

Emaciation

A wasting away of the flesh, causing extreme leanness, starvation (adjective: emaciated).

Cognitive Function

Ability to think and reason.

Herniation

Abnormal protrusion of an organ or tissue through the structure usually containing it, as an inguinal hernia or hiatal hernia; rupture; condition is called herniation.

A canal or passage leading to a/an ________________________ is called a wound sinus.

Abscess

Pallor

Absence of skin pigment; paleness.

A/An ______________________ disease develops suddenly and runs its course in days or weeks.

Acute

Accommodation

Adjustment, as the accommodation of the lens of the eye.

Lordosis

An abnormal increase in the lumbar curvature of the spine; sometimes called swayback.

Kyphosis

An abnormal increase in the thoracic curvature of the spine, giving a hunchback appearance, commonly as a result of osteoporosis.

Fistula

An abnormal, unintended open section between two areas of bowel wall.

Complication

An unexpected event in a disease's course that delays a person's recovery.

A client is to undergo a chest radiograph. What should the nurse do before the radiograph ?

Answer: Ensure that the client's chart is up-to-date RATIONALE: The nurse should ensure that the client's chart is up-to-date. A special checklist may be used to ensure that all requirements are met. The nurse should ensure adequate protection for the client and for herself. The nurse does not need to develop a nursing care plan, collect data for a nursing care plan, or evaluate the outcome of nursing care before the tests are performed. After the tests are performed on the client, the nurse can obtain data for preparing a nursing care plan. The nurse evaluates the outcomes of the nursing care plan when examining the client at various stages of the treatment.

A nurse is preparing a pregnant client for a physical examination. What format of physical examination will be used for this client ?

Answer: Focused physical examination RATIONALE: A focused physical examination is performed on a pregnant client, with the focus on her pregnancy and fetus. A head-to-toe physical examination is done for a general survey; it focuses on structures and functions of body areas. A body system examination focuses on a particular body system, such as the cardiovascular or respiratory system. Physical examinations are generally

A nurse is caring for a client who complains of constipation and gas pains. How should the nurse examine the client ?

Answer: Inspect, auscultate, and palpate RATIONALE: The nurse should inspect, auscultate, and palpate the abdomen to search for physical clues about the cause of the pain. Palpation is done only after inspection and auscultation, to prevent pockets of gas from moving in the intestines and being mistaken for normal bowel sounds.

Which technique involves tapping or striking of fingers on the client's body ?

Answer: Percussion RATIONALE: Percussion involves tapping or striking of fingers on the client's body. The sounds thus produced indicate the location and density of body tissues or organs. Auscultation is the technique of listening for sounds from within the body using a stethoscope or an ultrasound bloodflow detector. Palpation is the technique of feeling body tissues or parts with the hands or fingers. Observation is the technique of watching the client for general characteristics that do not require closer scrutiny or use of measurement aids, such as overall appearance, skin color, grooming, body posture, gait, mood, and interactions with others.

A nurse is interviewing a client with eczema. Which should the nurse record as a sign of the disease ?

Answer: Rash RATIONALE: The nurse should record a rash as a sign of the disease. Signs are objective evidence of disease that can be seen or measured. Pain, nausea, and itching are not signs but symptoms of disease, because they are subjective evidence of disease—sensations that only the client knows and can report.

A nurse is caring for a client with a wound. There is a clear discharge from the wound. How should the nurse document this finding ?

Answer: Serum RATIONALE: The nurse should document this finding as serum. Serum is a clear discharge from a wound. A discharge from the wound or exudate is described as purulent if it contains pus, because of the presence of bacteria. Discharge from a nasal cold is mucoid. Necrosis is the death of tissue, which may be sloughed, leaving behind an area that fills with new tissue.

A nurse is assessing the function of a client's cranial nerves. Which action should the nurse ask the client to perform ?

Answer: Stand with eyes closed RATIONALE: The nurse should ask the client to stand with eyes closed. The nurse may also ask the client to smile; swallow; follow a moving finger with the eyes; move or clench the jaw; shrug the shoulders; turn the head; or stick out the tongue and move it from side to side. The nurse does not need to ask the client to move the hands up and down, to open and close the fist, or to hold an object firmly, because these movements are part of musculoskeletal assessments.

A nurse is preparing a client who is to undergo a biopsy at the healthcare facility. When is a biopsy performed ?

Answer: When determining the presence of cancer RATIONALE: A biopsy is performed to determine the presence of cancer or other disorders. A piece of tissue or a small amount of fluid is obtained and examined microscopically. An endoscopy may be done to determine the structure and function of an organ. Arterial blood gas analysis is used to determine a client's respiratory status.

What is a major nursing precaution when using dye involved in radiology testing ?

Asking the patient if they are allergic to shellfish or iodine. Rationale : Many dyes contain iodine or similar chemicals.

Observation

Assessment tool that relies on the use of the five senses to discover objective information about the client.

The presence of ________________________ cause purulent exudate.

Bacteria

Ecchymosis

Bleeding into the tissues under the skin, leaving small bruises.

What is complementary and alternative medicine (CAM) ?

CAM uses treatments such as vitamins, herbs, or homeopathic remedies. Some forms of CAM have been proven to be helpful and safe; others pose serious health risks to the individual when used after self-diagnosis.

Inspection

Careful, close, and detailed visual examination of a body part.

__________________________ is the inflammation of the gallbladder.

Cholecystitis

A _____________________ disease may continue for months, years, or life.

Chronic

Acuity

Clearness; or a disorder's level of severity; minimum level or need for healthcare services that must be met for a client to be admitted to an acute-care facility.

Abscess

Collection of pus in a localized area

Conjunctivitis

Commonly called pink eye; inflammation of the conjunctiva.

A secondary infection is a _________________________ infection.

Dependent

Dysphasia

Difficulty in understanding or expressing language.

What is a secondary disease ?

Directly results from, or depends on, another disorder. Example recent Hx. of influenza and the current diagnosis is pneumonia.

Acute disease

Disease or illness that develops suddenly and runs its course in days or weeks; disorders that interfere with the health-illness continuum for a relatively short period of time.

Diplopia

Double vision

What is the purpose of a metabolic panel ?

Evaluates clients with total body situations ( e.g., alcoholism or drug toxicity)

UT ox (Urine Toxicology) blood test

Evaluates situations, such as driving under the influence of alcohol, amount of ID of drug use in a suicide or presence of drugs of abuse

Risk Factor : Heredity

Examples of possible disease or disorder : - Coronary artery disease - Diabetes mellitus - Hypertension - Hemophilia - Sickle Cell Disease - Huntington's Disease

Risk Factor : Age

Examples of possible disease or disorder : - Sickle Cell Disease - Tay Sachs

Hemorrhage

Excessive bleeding (internal or external); escape of blood from non-intact blood vessels.

Auscultation

Externally listening to sounds from within the body to determine abnormal conditions, as auscultation of blood pressure with a stethoscope.

T/F: The term for massive generalized edema is termed pitting edema.

FALSE : Massive generalized edema is known as anasarca

T/F: A serous exudates contains yellow colored fluid.

False

T/F: Deep palpation is appropriate for any nurse to perform in any situation.

False

Malaise

Feeling of illness; general bodily discomfort.

Pain

Feeling of suffering, distress or agony, caused by stimulation of specialized nerve endings, a protective device of the body; a subjective sensation (reported by the client).

The ER department commonly uses which type of physical examination ?

Focused physical examination - One body system is thoroughly examined because the client has a particular complaint or probable in that area.

Anasarca

Generalized, totally body edema.

A common format for the physical examination is the ________________ to ________________________ method.

Head to toe

Auscultation

Helps determine a client's digestive or respiratory structure and function

Percussion

Helps determine fractures and other pathology

Observation

Helps determine the presence of cancer and other disorders

Inspection

Helps determine the status of the client's nervous system

Palpation

Helps evaluate a client's cardiovascular status

What should be the primary nursing goal for performing a physical examination ?

Identifying potential or actual problems that can be prevented or treated

A primary infection is a _______________________ infection.

Independent

__________________ is the invasion of cells, tissues, or organs by pathogens, which may result in inflammation, tissue destruction, tissues or organ dysfunction, or even cellular death.

Infection

What is the importance of laboratory tests ?

Laboratory tests help primary healthcare providers establish medical diagnoses and plan client care. Laboratory tests may be done for screening, or they may be specific for certain disorders.

Endoscope

Long, thin, flexible tubes with a light and camera at the distal end of the scope, used to view the small and large intestines.

Exudate

Material that escapes from blood vessels and is deposited in tissues or on tissue surfaces; usually contains protein substances.

Who determines the medical diagnosis in a healthcare facility ?

Medical diagnosis is determined by primary healthcare providers, such as a physician, an osteopath, or an advanced practice nurse.

Granulation Tissue

New tissue that forms when old destroyed tissue is sloughed off.

The diagnosis focuses on the person and his or her needs in response to the disease, rather than on the disease itself.

Nursing

A nurse is caring for a client who is to undergo a diagnostic test. What are the nursing responsibilities before a diagnostic test ?

Nursing responsibilities before diagnostic examinations include the following: •Assisting the client to follow diet requirements as ordered •Administering special medications before the examination as per order •Ensuring that the client's chart is up to date before the test •Referring to a special checklist of requirements if necessary •Assisting the client to dress in a hospital gown •Ensuring that the client either voids or does not void before the test, as ordered • Reassuring the client and answering questions

Crackle

On auscultation, an abnormal discontinuous non-musical respiratory sound heard on inspiration; formerly called rale.

An estimation of the course and outcome of a disease is known as the ________________.

Prognosis

Biopsy

Removal of a sample of body tissue or fluid for diagnostic examination, usually microscopic; most often used to detect the presence of cancer.

Predisposing physical and emotional conditions, genetic predisposition, or lifestyle practices that increase the likelihood of developing a certain disease or disorder are known as ________________________________.

Risk factors

Keloid

Scar or scar tissue.

When assessing the patient's pain level on a scale of 1-10....what is this testing ?

Severity of pain

____________________ are objective evidence of disease that can be seen or measured.

Signs

Erythema

Skin redness produced by capillary congestion, as may follow a tuberculin test; bright red color associated with capillary dilation, can indicate fever or infection.

Guaiac

Stool examination for blood; also known as Hemoccult.

The formation of pus is called __________________________.

Suppuration

T/F: Movement away from the midline of the body is called abduction.

TRUE !

Infection

The invasion and multiplication of infective agents in body tissues with a resultant reaction (illness or injury) to their presence and/or their toxins.

A nurse is caring for a client who is to undergo radiology treatment. What precaution should the nurse take when assisting the client for radiology ?

The nurse should follow standard precautions to protect herself, the client, and other healthcare staff when assisting the client for radiology tests. The nurse, client, and other healthcare staff should wear lead shields to protect vital organs from overexposure to radiation.

A nurse is to measure the knee-jerk reflexes of an adult client. What should the nurse do to obtain knee-jerk reflexes ?

The nurse should use a reflex hammer to obtain knee-jerk reflexes in an adult client. •Hold the hammer between thumb and index finger. •Position the extremity so the tendon is slightly stretched. •Have the client relax, or use distraction techniques to assist the client to relax. •Strike tendon briskly using a full swinging motion. • Repeat on other side of the body, and compare results from both sides. Normally, reflexes should be the same on both sides. Reflexes are graded on a 0 to 14 scale. Reflexes graded as 12 are considered normal. Reflexes greater than 12 are considered hyperactive. Reflexes less than 12 are considered hypoactive. If reflexes are absent, it is written as 0. Findings are documented. The healthcare provider or charge nurse should be notified of abnormal readings or changes from previous readings.

What does the nursing diagnosis focus on ?

The nursing diagnosis focuses on the client and his or her needs in response to the disease and not the disease itself. The nursing diagnosis is a concise, problem-centered description of actual or potential health problems, based on the nursing process and stated in terms of North American Nursing Diagnosis Association (NANDA) groupings.

When educating a patient, what would the nurse describe as the purpose of spirometry testing ?

The testing helps to determine a client's respiratory status

Necrosis

Tissue death.

What is the purpose of a lumbar puncture ?

To determine the status of the client's Central Nervous System and determine intracranial pressure - ICP .

T/F: A collection of pus in a localized area is known as an abscess.

True

T/F: Congenital hypothyroidism is a primary disease.

True

T/F: Use of some complementary and alternative medicines can be harmful and their use should be included in data collection.

True

Nodule

Type of skin lesion appearing as a small knot or protuberance.

Ulcer

Unhealed area of an epithelial tissue wound