HA Exam 1
Naturalistic
illness is part of nature/creation. Eastern medicine
Biomedical
western medicine approach to care- body are parts)
Subjective data
what the patient tells you hx portion of assessment (OLD CARTs)
Curing
absence of disease
Nursing assessment focuses on:
diagnoses and treatment of the actual or potential human responses
Vitamin E
Almonds sunflower seeds spinach turnip greens bell peppers
The Nursing Process
Assessment: recognize cues Analysis: Analyze cues/prioritize hypotheses Plan: Generate solutions Intervention: Take action Evaluation: Evaluate outcomes
When learning about a patient's culture, it is important to avoid using ____. A. Humility B. Stereotyping C. Collaboration
B. stereotyping
A nurse is caring for a client who follows a vegan diet. Which of the following foods should the nurse offer the client? A. Bagel with cream cheese B. Fried egg C. Fruit with vanilla yogurt D. Wheat toast with peanut butter
D. Wheat toast with peanut butter A client following a vegan diet does not eat animal products. Wheat toast and peanut butter are plant based.
FICA spiritual tool
F: faith and belief I: importance C: community A: address in care
Iron
beans/lentils tofu cashews baked potato dark green leafy vegetables fortified foods
Vitamin C
Chili and Yellow peppers kale mustard greens broccoli brussels sprouts citrus fruit
Secondary level of prevention
Focus early disease detection, and its target is healthy-appearing individuals with subclinical forms of the disease
Primary level of prevention
Focuses on improving overall wellness and protecting from disease or disability
Vitamin K
Green leafy vegetables like: kale, mustard greens; beef liver chicken pork chops hard cheese prunes kiwi
HOPE spiritual tool
H: sources of hope, comfort, meaning, strength, love, peace O: organized religion P: personal spirituality E: effects on medical care and end-of-life issues
RESPECT Model
Rapport Empathy Support Partnership Explanations Cultural competence Trust
Race
artificial categorization of people based on genetic inheritance and physical characteristics (skin color, hair, eyes etc.)
Nationality
one's place of birth
Which questions would the nurse initially ask to conduct a culturally competent assessment interview? SATA A. Can you tell me about the reasons for coming here today? B. What do you believe is the cause of your depression? C. Does religion have a role in your perception of health and wellness? D. Do you believe that we can help with your mental health issues? E. Have you ever sought treatment for a mental health problem before?
A. Can you tell me about the reasons for coming here today? B. What do you believe is the cause of your depression? C. Does religion have a role in your perception of health and wellness? E. Have you ever sought treatment for a mental health problem before? Respectfully ask about the charm, dress, or item to learn more of their beliefs. Helps start the conservation and trust.
The nurse is providing education about excellent food sources of Vitamin A for a client who is deficient in this vitamin. Which foods would the nurse include in the teaching? SATA A. Carrots B. Oranges C. Tomatoes D. Leafy green vegetables E. Cantaloupe
A. Carrots D. Leafy green vegetables E. Cantaloupe Orange vegetables (like sweet potato) provide Vitamin A Green leafy vegetables- a go to When assessing nutrition, a 24-hour recall is done.
The client reports difficulty in breathing. The nurse auscultates lung sounds and assess the respiratory system. What is the purpose of the nurses' action? A. Data collection B. Data validation C. Data clustering D. Data interpretation
A. Data collection The nurse is collecting objective data to support the subjective data the client's report of difficulty breathing. The nurse uses critical thinking (clinical judgement) to interpret the data and analyze to provide care.
Which questions would the nurse ask the client when obtaining the health history? (SATA) A. Tell me about your food habits. B. Do you use alcohol or tobacco? C. Have you sustained any personal loss recently? D. Have you experienced any allergic reactions.? E. Does any family member have a long-term illness?
A. Tell me about your food habits. B. Do you use alcohol or tobacco? D. Have you experienced any allergic reactions.? A health history includes the client's food habits to assess nutritional status. The nurse also assesses the client's habit and lifestyles patterns. By asking about smoking and drinking ETOH can assess lungs and liver based on answer. Nursing health assessment= comprehensive health history and complete PE.
The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of objective data? (SATA) A. The client weighs 68.5 Kg B. The client's pain is 7 on the numeric pain scale (1-10) C. The client's blood sugar is 95mg/dL D. The client's blood pressure is 140/90 mm Hg
A. The client weighs 68.5 Kg C. The client's blood sugar is 95mg/dL D. The client's blood pressure is 140/90 mm Hg The client's pain score is subjective. BUT treat as objective data when giving pain meds. Objective data- assessment, diagnostic testing, observations and measurements Weight is measured on a scale not what the patient states.
Which activities would the nurse participate in while providing a primary level of preventive care? SATA A. Individual and mass screening activities. B. Education about adequate housing and recreation. C. Education about attention to personality development. D. Instruction about the standard of nutrition adjusted to development of phases of life. E. Providing a hospital and community facilities for retraining to maximin use of remaining capacities.
B. Education about adequate housing and recreation. C. Education about attention to personality development. D. Instruction about the standard of nutrition adjusted to development of phases of life. Primary- key words are educate and instructions in this question. Primary= promote health and prevent disease with specific protections Immunizations Nutrition-Fitness activities Health education in schools or communities Health fairs are secondary- could find a disease
An adolescent with a body mass index (BMI) of 30 reports fatigue, frequent urination and a tingling sensation on the feet. The adolescent is then diagnosed with type 2 diabetes. Which nursing interventions would be appropriate? (SATA) A. Bariatric surgery B. Physical activities/exercise C. Dietary restrictions D. Dietary counseling E. Behavior modification
B. Physical activities/exercise D. Dietary counseling E. Behavior modification BMI—20 is weight appropriate Less than 20 is underweight BMI of 25 overweight BMI 30 and over is obese
Which activities would the nurse consider to be part of the secondary level of preventive care? SATA A. Using specific immunizations. B. Preventing the spread of communicable disease. C. Providing facilities to limit disability and prevent death D. Providing adequate treatment to arrest the disease process. E. Educating the public and industry to use rehabilitated individuals to the fullest possible extent.
B. Preventing the spread of communicable disease. C. Providing facilities to limit disability and prevent death D. Providing adequate treatment to arrest the disease process. Secondary prevention focuses on identifying illness, providing treatment and preventing a worsening health status. Preventing complications and sequel Smoker= educate to quit Obesity= weight loss program Tertiary- individuals already have the disease—goal to improve quality of life and restoring function.
Which actions would the nurse take to obtain subjective data about a client's respiratory status? (SATA) A. Palpate the chest and back for masses. B. Question the client about shortness of breath (SOB). C. Check the hematocrit and hemoglobin values D. Inspect the skin and nails for integrity and color E. Ask the client about the color and quantity of sputum.
B. Question the client about shortness of breath (SOB). E. Ask the client about the color and quantity of sputum. Subjective data is collected directly from the client. Objective data= the assessment findings. Slides are main area for test questions. If slide has red then know that slide.
Spirituality is a vital human experience shared by all humans. A. True B. False
B. true Spirituality is a vital human experience shared by all humans, even atheists and non-practitioners have a spiritual dimension. An estimated 77% of the world is religious, and religion is the basis of spirituality.
Which scenario would contribute to health disparities? A. An English-speaking critical care nurse assess a Hispanic client in a coma. B. An English-speaking nurse plans the nursing procedures for a black Latino client. C. An English-speaking nurse provides discharge instructions to an English-speaking client who is hard of hearing. D. An English-speaking nurse conducts the admission interview or a Puerto Rican immigrant with limited knowledge of English.
D. An English-speaking nurse conducts the admission interview or a Puerto Rican immigrant with limited knowledge of English. Be conscious of their beliefs, culture and customs.
Nursing health assessment= comprehensive health history and complete PE.
Demographic information CC HPI- history of present illness PMH- past medical history Family history Psychosocial history Health promotion ROS PE
Vitamin D
Fatty fish like salmon canned tuna egg yolks fortified foods:milk, orange juice, breakfast cereals
Tertiary level of prevention
Focuses on decreasing effects of disease or disability when disability is permanent or irreversible. Goal is to achieve highest level of functioning possible.
Cultural Humility
Process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners. 3 Dimensions: Self-awareness Respectful communication Collaborative partnerships
Holistic health
as a state of complete physical, mental, and social well-being rather than merely the absence of disease or infirmity.
Ethnicity
belonging to a common group with shared heritage (often shared language, race and nationality). Relatively homogenous
Social determinants of health
economic stability neighborhood and physical environment education food community and social context healthcare system
Neurologic
s/sx: altered LOC implications: vitamin B12 deficiency
A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. Which food items would the nurse recommend the client to select for the upcoming meals? A. Meatloaf and fried potatoes. B. Meatloaf and strawberries. C. Chicken soup and baked apple pie. D. Chicken soup and buttered bread.
B. Meatloaf and strawberries. Protein build up-> liver/kidney->ascites (fluid in the stomach) Decrease in iron-> anemia-> pale-pallor
Worldview
a culture's way of looking at their universe and their relationship to that universe
Dehydration common signs
decreased BP increased HR dry mucous membranes weakness weakened pulse short-term weight loss
Medical assessment focuses on:
diagnoses and treatment of the disease
Dysphagia
difficulty chewing or swallowing
Over-hydration common signs
edema increased BP or bounding pulse short-term weight gain dyspnea
Amenorrhea
missed periods
Skin, hair, nails
s/sx: petechiae, ecchymoses implications: vitamin K deficiency
Skin, hair, nails
s/sx: petechiae, ecchymosis implications: vitamin K deficiency
Vitamin K
salmon spinach kale broccoli certain cheeses carrots sweet potato winter squash cantaloupe
Calcium
Seeds cheese plain yogurt beans/lentils tofu fortified foods
Body Mass Index (BMI)
weight (lb)/ height (in)^2 x 703 underweight: < 18.5 healthy weight: 18.5-24.9 overweight: 25-29.9 obese: 30 or above
Objective data
what you see physical examination laboratory reports radiologic findings
Interpretor
deal with spoken language and translate orally
Translator
deal with written text
Magico-religious
health is related to "supernatural" forces or good/evil
Cultural Sensibility
A deliberative pro-active behavior by healthcare providers who examine cultural situations through thoughtful reasoning, responsiveness and discreet (attentive, considerate and observant) interactions
Which belief of the nurse may have a negative effect on health services for minority clients? A. The mind, body and spirit are distinct entities. B. The focus of an assessment should be on the culture rather than the race for children from multi racial and multi cultural marriages. C. Chinese clients may believe that disease is caused by fluctuations in opposing forces- the yin-yang energies. D. When taking a client history the nurse should record the client's race according to how she/he self identifies.
A. The mind, body and spirit are distinct entities. Body, mind and spirit are a single entity. Nursing is holistic- care for the mind, body and spirit. Looking at the human response. Multiracial- more than one culture to consider.
A primary health care provider tells a client that Vitamin E is important for healthier skin. Which foods would the nurse recommend? A. Legumes and whole grains B. Seeds and peanut butter C. Oranges and grapefruit D. Carrots and sweet potatoes
B. Seeds and peanut butter Antioxidants (Vit E) inhibit tissue breakdown. Low sodium diet-> Heart health diet-> low fat diet Culture determines diet too. Muslim and Jewish culture do not eat pork. To be culturally competent you ask what beliefs, customs are important to them that can help with the care you give.
The nurse manager oversees an organization that provides secondary care for clients with cancer. Which service would be provided by this type of organization? A. Providing long term care for fatigue. B. Providing treatment for pain management C. Teaching the client about prevention of infection. D. Teaching the client about adverse effects of the therapy.
C. Teaching the client about prevention of infection. Secondary level of prevention involves preventing disease complication. Teaching the client about the prevention of infection would help prevent complications. (fever and neutropenia) Primary care involves health maintenance measures. Tertiary care aims to prevent long term consequences of a chronic illness or disability to support optimal functioning.
Healing
restores the balance and harmony to the body, mind and spirit
GI
s/sx: ascites implications: protein deficiency
The nurse assesses a client with dry and brittle hair, flaky skin, a beefy red tongue and bleeding gums. The nurse recognizes that these clinical manifestations are a result of which? A. A food allergy B. Noncompliance with medications C. Side effects from medications D. A nutritional deficiency
D. A nutritional deficiency All are signs listed in the question indicates poor nutrition lacking in vitamins and protein. Cardiac diet- high in monosaturated fats (omega 3 fats) Dehydration - hypovolemic vs fluid overload Hypovolemic- tachycardia and hypotensive Fluid Overload- respiratory crackles
Vitamin B (B-6, B-9 (folic acid), B-12)
Meats poultry fish eggs milk green leafy vegetables
Cultural Assessment
Refers to systematic, comprehensive examination of individuals, families, groups, and communities regarding their health-related cultural beliefs, values, and practices
Throat/mouth
s/sx: beefy red tongue soft, spongy, bleeding gums swollen neck (goiter) implications: vitamin B12 deficiency vitamin C deficiency iodine deficiency
Musculoskeletal
s/sx: bone p!, bow leg implications: vitamin D or calcium deficiency
Eyes
s/sx: night-blindness implications: vitamin A deficiency
Oligomenorrhea
irregular periods
Anorexia
lack or loss of appetite
7 Facets of health
physical spiritual cultural developmental environmental emotional social
