Health Assessment test #1

The new grad asks the preceptor to explain why the order of the examination is different for the abdomen. The best response by the preceptor would include

"Palpation will increase bowel motility and alter the sounds heard on auscultation."

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?

"They make sure that any microorganisms on my hands do not touch your skin."

Which question is appropriate for a nurse to ask a client to assess the client's recent memory?

"What did you eat for breakfast today?"

Pain scale

0-10; 0- no pain 5- moderate 10- worst pain ever

deep palpation

1 1/2 to 2 inches for organ masses

documentation of level of counsciousness and vital signs

1. level of counsciousness and orientation of person, place, and time 2. patient's orientation to situation 3. their appearance 4. their mood 5. vital signs

light palpation

1/2 to 3/4 of an inch

suicide

11th leading cause of death in the US clues to pending suicide are variable and subtle 90% of patients have depression, mental disorders, or substance abuse

patients with depression

2/3 present with somatic complaints (body systems) 1/2 present with multiple unexplained somatic complaints functional syndrome- frequently co-occur and share key symptoms and selective objective abnormalities symptom overlap- vague symptoms (headaches, fatigue, pain)

medically unexplained

30% of symptoms are medically unexplained

Pain Management

4 A's: Analgesia Activities of daily living Adverse effects Aberrant drug-related behaviors

pain

5th vital sign- to ensure frequent pain assessment it is what the patient says it is- mainly subjective usually overlooked and not managed right

For which of the following clients should the nurse choose to perform a focused examination?

A man who has presented with an acute onset of chest pain

The nurse is preparing to assess a client's mental status within the general survey. Which data should the nurse use to assess this status?

Asking the client to describe elements of his health history.

Data collection occurs where in the nursing process?

Assessment

Nursing process

Assessment Diagnosis Planning Implementation Evaluation

screening for alcohol and substance abuse

CAGE Have you ever felt the need to CUT DOWN on drinking? Have you ever felt ANNOYED by criticism of your drinking? Have you ever felt GUILTY about drinking? Have you ever taken a drink first thing in the morning (EYE OPENER) to steady your nerves or get rid of a hangover?

Implementation

Can be done by patient, family, or health care team; relates to the diagnosis, different for everyone, modified as changes occur, positive outcomes

Dementia

Chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning

This type of assessment includes a health history and physical assessment.

Comprehensive

The school nurse provides care for a child who fell on the school playground and sustained multiple abrasions to the lower extremities. Which actions by the school nurse are appropriate when caring for this child? Select all that apply.

Correct Putting on nonsterile gloves prior to assessing the child's injuries. Correct Asking the child permission to assess the injuries. Correct Performing handwashing before touching the child. Correct Putting on nonsterile gloves prior to assessing the child's injuries.

During the introduction phase of the interview, the patient begins to talk nonstop about health problems, family issues, and fears related to illness. What can the nurse do to control the interview process?

Courteously interrupt the patient to clarify some information.

why do we health assess

Determine health status, risk factors, health education, nursing plan of care, set priorities

After completing the interview process, the nurse analyzes the data collected for what priority reason?

Develop nursing interventions

Health History for Mental Status

Do you have any dizziness or headaches? Do you have seizures? What triggers them? Have you ever had a head injury/lost consciousness? Any changes in vision, speech, ability to think, etc? Do you have any weakness, numbness, tingling, tremors?

The nurse is assessing an adult client when suddenly the client refuses to continue the examination. Which action by the nurse is the priority?

Document what was done and what was refused.

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?

Ensure that contact with the skin is maintained

Patient's perspective

FIFE Feelings- fears/concerns about issue Ideas- nature and cause of problem Function- effect on patient's life Expectations- based of prior experiences

The nurse asks the patient about whether other family members have been diagnosed with diabetes. Which component of the comprehensive health history is the nurse addressing?

Family history

A nurse is preparing to interview a client who is a Seventh Day Adventist. The nurse does not agree with this religion's view of modern medicine. Reflection of the nurse on her personal feelings regarding this patient and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation?

Formation of judgments that may interfere with the interview.

review of symptoms

General Skin HEENT Neck Breasts Respiratory Cardiovascular GI Peripheral Vascular Urinary Genital Musculoskeletal Psychiatric Neurologic Hematologic Endocrine

Suzanne, 25 years old, comes to the clinic to establish care. The student nurse is preparing to enter the examination room to interview the client. Which of the following is the most logical sequence for the client-provider interview?

Greet the client, establish rapport, invite the client's story, establish the agenda, expand and clarify the client's story, and negotiate a plan.

Exam of abdomen

Inspection Auscultation Percussion Palpation "I Ate Perfect Pasta."

The nurse is admitting a client with a fractured hip. The client points to the painful hip and describes it as a constant throbbing. Which would the nurse include when continuing the pain assessment on this client?

Intensity, precipitating and relieving factors, impact on ADLs, and coping strategies.

Mini-mental State Exam

MMSE brief test useful in screening for cognitive dysfunction or dementia can use to follow patient's course over time

A patient recovering from a stroke complains of pain. The nurse suspects this patient is most likely experiencing which type of pain?

Neuropathic

The client has a heart murmur that the nurse hears utilizing the stethoscope. This is what type of data?

Objective

The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable?

Objective

7 Attributes of a symptom

Onset Location Duration Characteristic symptom Associated manifestations Relieving/ exacerbating factors Treatment OLD CART

As part of assessing the client's level of consciousness, the nurse asks questions related to person, place, and time. Which of these statements is true?

Orientation to time is usually lost first and orientation to person is usually lost last.

During a comprehensive health history, a client reports smoking cigarettes for 20 years. The nurse will document this information in which of the following sections?

Past history

The nurse is collecting data for a comprehensive health history on a patient new to the clinic. Under what component of the health history would the nurse place data on a chronic childhood illness?

Past history

The nurse is performing an abdominal assessment and has just completed auscultation. Which technique would the nurse correctly choose to use next in this assessment?

Percussion

As a nursing student you learn that mastering all the components of the comprehensive history provides what?

Proficiency

When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following?

Quote the client's words.

The nurse educator is observing a student nurse who is performing cervical palpation on an adult client. Which technique is appropriate for this assessment?

Side to side pressure of 1/2-1 cm using the finger pads.

The nurse is going to conduct a physical assessment on a patient who is on bed rest. The best position for the nurse to begin the head to toe assessment would be to:

Stand on the right side of the bed.

What tool does the nurse use to auscultate the client's abdomen?

Stethoscope

The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session?

The binaurals should fit snugly in the ears. The stethoscope works by blocking out environmental sounds. Short tubing provides the listener with the most accurate sounds.

A young adult client notes height as "5 feet 11 inches" and weight as "200 lbs." Upon assessment, the client is found to be 5 feet 9 inches tall with a weight of 225 lbs. Which is the most likely cause of this discrepancy?

The client may have an image of self that is inconsistent with actual findings.

Which of the following would the nurse use as the primary assessment for a client's pain?

The client's report of the pain

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen

Which is an example of subjective data from a primary source?

The patient states, "My chest hurts and my left arm feels numb."

oriented x 3

Time, place, person has to get all of those correct do not ask them orientation if there is nothing in the environment or if they weren't told anything

The nurse is applying standard precautions by performing which of the following?

Wears gown, gloves, and mask during the physical exam

mood

a more sustained emotion that may color a person's view of the world

serial assessments

a repeated assessment to look for changes in patients condition

Tolerance

a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time. the more pain meds you take, the more you will need

lethargic

able to open eyes; drowsy and falls asleep readily

validation

acknowledge the legitimacy of the emotional experience

Delirium

acute disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech you can come out of this severe infections when elderly gets infections

Tertiary prevention

after an event to improve outcomes ; rehab programs, provision of hospital and community facilities, prevention of skin breakdown, improve patients ability to function after an illness

ongoing assessment

after the comprehensive; mini interview; for returning patient

exam with an older adult

allow more time in between positional changes take into account sensory devices take breaks assist with taking them to restroom before

affect

an observable, episodic feeling or tone expressed through voice, facial expression, and demeanor what you look like on the outside; pleasant or flat, grouchy, angry

During a physical assessment the client asks the nurse repeatedly, "Is everything ok?" The nurse concludes which for this client?

anxiety

higher cognitive functions

asses by vocabulary, amount of info, abstract thinking, calculations, and construction of objects that have 2 or 3 dimensions

Assessing Pain

assess it with the OLD CART method

Using both verbal and nonverbal clues given by the patient, what is the nurse constantly doing?

assessing

The nurse is conducting a physical examination on a client with a history of heart problems. Which technique would most likely provide the most information about the client's current cardiac status?

auscultation

orientation

awareness of personal identity, place, and time

insight

awareness that symptoms or disturbed behaviors are normal or abnormal

The nurse educator is teaching a group of nursing students the correct assessment of heart murmurs. Which part of the stethoscope will the educator press against the client's chest during this assessment?

bell

remote memory

birthdays, anniversaries, SSN, names of schools attended, jobs held, past historical events

hyper-resonance

booming sound over air; lung with emphysema

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds? Select all that apply.

bruits abnormal heart sounds/murmurs

The nurse is conducting a physical examination of a patient who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular

c, d, e, b, a

assessing orientation

can be determined by interview ask naturally for specific dates, address, phone #, etc

dementia

can remember birthday, but not how old they are

functional syndromes

condition that impairs the normal function of a bodily process, but where every part of the body looks normal under exam. ex: IBS, fibromyalgia, chronic fatigue

side effect of pain medicine

constipation; need to treat that too

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is

continuous

inspection

continuous throughout the exam observe details about patient use nose to denote smells

empowering the patient

convey interest in the person, follow patient's lead, validate emotional content, share info with patient, explain what you are doing and why, reveal the limits of your knowledge- it is okay not to know everything

comprehensive assessment

detailed health history and physical exam; for new patients

Aphagia

difficulty swallowing

reassurance

don't provide false reassurance, identify the patient's feelings, convey info in competent manner

tympany

drum like; over enclosed air in the bowel

A patient arrives at the Emergency Department reporting shortness of breath. She is cyanotic with bilateral wheezing. The patient begins to gasp for air and cannot speak. The nurse begins to gather information so that interventions can resolve the immediate breathing problem. Her assessment and interventions are concurrent. The nurse is performing what type of health history?

emergency

recent memory

events of the day, weather, today's appointment time, lab tests taken during the day

A genogram is developed to visually show what?

family health patterns

flatness

flat; over dense tissue; muscle or bone

thought processes

flight of ideas- jump from topic to topic without any connectivity incoherence- jumbled; doesnt make sense

working phase

get patient info, "meat of the interview," N-naming U-understanding ReS- respecting

fingers and thumb

grasping an organ or mass

focus assessment

has a problem-oriented focus

complete physical exam

head-to-toe exam identify changes in body document everything in clear manner put info in medical records

diaphragm

high; firm placement heart sounds, bowel sounds,, lung sounds

draping

holding it loosely around the patient

resonance

hollow; part air part solid lung

empathetic responses

identify the patient's feelings, do not assume you know how the patient feels- ask them, respond with understanding and acceptance

higher cognitive function

info and vocab during interview ask about hobbies, work, etc calculating ability abstract thinking similarities constructional ability

cardinal techniques of exam

inspection- eyes palpation- hands percussion- hands auscultation- listen "I'll Properly Perform an Assessment."

abnormal posturing

involuntary sign of severe brain injury may be uni-lateral depending on the side of the brain effected decorticate and decerebrate rigidity

"assessments are temporal"

it reflects the patients status at a specific point in time

paraphasias

jumbled words (dementia)

somatoform symptom

lacks an adequate medical or physical explanation

decorticate rigidy

less severe flexion and internal rotation of upper extremity joint and legs damage between brain and spinal cord sides of body can be different

bell of stethoscope

light, low; light placement

advance directives

living wills, and healthcare power of attorney; comprehensive health assessment

thought processes

logic, coherence, and relevance of person's thought

parts of stethoscope

look at pic

ophthalmoscope

looking in eyes

Aphasia

loss of language skills

The nurse is assessing a client's abdomen. Which sound is expected when percussion is used during the assessment?

loud, low pitched

psychogenic/idiopathic pain

many factors that influence the patient's report of pain without identifiable etiology (no idea why)

red flags for selective mental health screening

medically unexplained somatic symptoms multiple somatic symptoms or "high symptom count" high severity of presenting somatic symptom chronic pain symptoms for more than 6 weeks "difficult encounter" with patient recent stress, low self-rating of health high use of health care services suspicion of substance abuse

decerebrate rigidy

neck and elbow extension with the wrists and fingers flexed more serious flaced; no posture; nothing

comatose

no response to repeated painful stimuli; abnormal posturing

judgment

note patient's responses to family situations

insight

note whether patient is aware that a particular mood, thought, or perception is abnormal or part of an illness (what their responses are)

attention

number list serial 7s spelling backward need to consider possibility of limited education

Planning

nurse and patient set goals for the diagnosis, be realistic

acute pain

occurs suddenly with recent illness or injury

referred vs. radiating pain

pain felt in a part of a body other than its actual source pain that travels the length of a nerve gallbladder issues: shoulder pain

phantom pain

pain that feels like it is coming from a body part that is no longer there

chronic pain

pain that presists for more than 3-6 months reoccurs at intervals of months or years

What must your clinical documentation (for school) omit?

patient's name, room #, DOB, medical record #, any demographic info

general survey

physical appearance body structure mobility behavior vital signs

6 Facets of health

physical, emotional, social, spirtitual influences, environmental factors

heel-to-toe walk

place heel of one foot in front of the toes of the other foot as they walk in a line walks in a straight line without losing balance

stereognosis

placing a familiar object in their hand and ask them to identify it

indirect percussion

placing a hand flat on body and striking it to produce sound

Primary prevention

prevention of disease- immunizations, accident preventions, reducing risk factors, health education, diet/exercise

During the interview process, the nurse obtains what type of data from the client?

primary

environmental concerns

privacy, modesty, confidentiality- HIPAA

judgment

process of comparing and evaluating alternatives

memory

process of registering or recording info short and long term

fingertips

pulsation, position, texture, turgor, size, consistency

Introduction

put patient at ease, establish trust

comprehensive health history

questions to gather data past medical history past physical issues past psychological issues social history cultural history spiritual beliefs

new learning ability

recent memory give patient 3 or 4 words ask them to repeat wait 3-5 mins, then ask them to repeat back again note accuracy of response

neuropathic pain

related to direct injury to PNS or CNS- burning/stinging; follows a nerve path

psychological

related to mood or anxiety

Nociceptive/somatic pain

related to tissue damage- throbbing

physical (somatic)

relating to a body sensation

stuporus

requires painful stimuli to get a brief response; may have no verbal response

obtunded

responds to light shaking; confused and slow to answer

alert

responsive and able to open eyes; answer questions appropriately

applying painful stimuli

rubbing the sternum- most commin trapezius squeeze patients should reply to this

secondary prevention

screening to treat disease in its early stages; screenings, early treatment of diseases, self-exam

perception

sensory awareness of environment

Pre-interview

setting the stage, plan for the interview, make goals

objective data

signs, what you see, measurable

romberg test

stand with feet together, arms at side and eyes closed stands with minimal swaying for at least 5 secs

physical dependence

state of adaptation that is manifested by a drug class; withdrawal syndrome

addiction

still would need to treat them with their pain

direct percussion

strike of the body to illicit pain or sound

percussion

striking produced a sound wave and a tactile feel; air in gut, hollow direct, indirect, fist

A patient comes to the ED complaining of chest pain. This would be considered

subjective primary data

Termination

summarize important points and discuss a plan

transitions

tell patient when changing directions during interview, orient patient with brief transitional phrases

dorsal surface

temp

vital signs

temp heart rate respiratory rate BP

fist percussion

tenderness of the kidney area, liver, and gallbladder

suicide questions

this is a medical emergency if they have a plan to do it, then they are more likely to carry it out

dullness

thunk; solid organ; liver, heart, spleen

When teaching students how to perform an assessment, the nurse informs the students that the reason this information needs to be accurate and complete is:

to develop a plan with interventions that promote health

graphesthesia

trace a number on their palm with the end of a pencil and ask them to identify it

documentation of pain

use graphic adjectives avoid cliches and use their own words record vital signs always re-assess their pain and use a time-frame

glasgow coma scale

used for brain injuries eye opening response verbal response motor response dead person: 3

Otoscope

used to look at ears

Faces pain scale

used with children, nonverbal patients (dementia)

two-point discrimination

using an open paper clip to determine the smallest distance between the 2 points that they can feel

palpation

using fingers/finger pads/hand assessing skin, lymph nodes, pulses, size of organs, and masses determines tenderness for underlying issues save the tender areas for last

circumlocutions

using many words when few would do

palmar surface and base of fingers

vibration

characteristic symptom

what do the symptoms feel like; describe it; pain scale 0-10

associated manifestations

what else is happening when you experience these signs or symptoms?

relieving factors

what helps relieve these symptoms?

Subjective data

what the patient tells you; symptoms

thought content

what the patient thinks about

onset

when did the sign or symptom begin?

testing for aphasia

word comprehension repetition naming reading comprehension writing