UMMC nursing Test 1

What do you document on abuse?

Pictures are the best way

How can you screen for Intimate Partner Violence (IPV)?

"Do you feel safe at home?" TESTS: HITS: Hurt, Insult, Threaten, Scream OAS/OVAT: Ongoing Abuse Screen / Ongoing Violence Assessment Tool STaT: Slapped, Threatened, and Throw Assessment HARK: Humiliation, Afraid, Rope, Kick WAST: Women Abuse Screening Tool

BMI (body mass index)

Weight (lbs) ___________________ X 703 height (in inches) ^2

open ended question examples:

"Tell me how I can help you" "What brings you to the hospital?" "Tell me more about......." "Anything else?"

3. Using Authority

"Your doctor/nurse knows best" is a response that promotes dependency and inferiority. You effectively diminish the client's concerns with one short sentence, and you cut off communication. Using authority should be avoided. Although you may have more professional knowledge than the client, you both have equally important roles since the client must make the final decision about his or her health.

Obtunded

(Transitional state between lethargy and stupor; some sources omit this level.) Sleeps most of time; difficult to arouse—needs loud shout or vigorous shake; acts confused when is aroused; converses in monosyllables; speech may be mumbled and incoherent; requires constant stimulation for even marginal cooperation.

Implementation

- Implement in a safe and timely manner - Use evidence-based interventions - Collaborate with colleagues - Use community resources - Coordinate care delivery - Provide health teaching and health promotion - Document implementation and any modification

What is the most abused psychiatric drug is?

alcohol

Evaluation

- Progress toward outcomes - Conduct systematic, ongoing, criterion-based evaluation - Include patient and significant others - Use ongoing assessment to revise diagnoses, outcomes, plan - Disseminate results to patient and family

Outcomes identification

-identifies expected outcomes -individualize to the person -identify expected culturally appropriate outcomes -establish realistic and measurable outcomes -develop a timeline

Assessment

-Collect Data: review of the clinical record health history physical examination functional assessment risk assessment review of the literature - Use Evidence based assessment questions - document relevant data -subjective and objective info

Diagnosis

-Compare clinical findings with normal and abnormal variation and developmental events -Interpret data (Identify clusters of clues, make & test hypotheses, Derive diagnoses -validate diagnoses -document diagnoses

Planning

-establish priorities -develop outcomes -set timelines for outcomes -identify interventions -integrate evidence-based trends and research -document plan of care

Holistic Assessment Factors Include:

-lifestyle behaviors -culture -values -family roles -social roles -self-care behaviors -job-related stress -developmental skills -failures and frustrations of life

IPV - Intimate Partner Violence

-physical violence -sexual violence -stalking -psychological aggression

5 steps of EBP

1) ask the clinical question 2) acquire sources of evidence 3) appraise and synthesize evidence 4) apply relevant evidence in practice 5) assess the outcome

STaT is a 3-term tool that includes the following questions:

1- Have you ever been in a relationship where your partner has pushed or slapped you? 2- Have you ever been in a relationship where your partner threatened you with violence? 3- Have you ever been in a relationship where your partner has thrown, broken, or punched things? answering yes to any of these means positive IPV.

EASI questions

1. Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals? 2. Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids, or medical care or from being with people you have wanted to be with? 3. Have you been upset because someone talked you in a way that made you feel shamed or threatened? 4. Has anyone tried to force you to sign papers or to use your money against your will? 5. Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?

What are the steps to assessing your patient?

1. Inspection 1. Palpation 3.Percussion 4. Auscultation

What are the ten traps of interviewing?

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

What 3 things can a trained interpreter do for your patients?

1. improve use of primary care 2. increase client satisfaction 3. improve overall health outcome

Culture has 4 basic characteristics

1. learned from birth through the processes of language acquisition and socialization 2. shared by all members of the same cultural group 3. adapted to specific conditions related to environmental and technical factors and to the availability of natural resources 4. dynamic and ever changing

What 4 factors does EBP clinical decision making depend on?

1. the best evidence from a critical review of research literature 2.the patients own preferences 3. the clinicians own experience and expertise 4. physical examination and assessment

How many drinks a week consider MEN at heavy or at risk drinking?

15 or more

What is the normal BMI

18.5-24.9

What is an overweight BMI?

25-29.9

What is classified BMI as obesity class 1?

30 -34.9

___% of women and ____% of men report being abused by a intimate partner

33%, 25%

extreme obesity BMI

40 and up

ADUIT points for women: greater than or qual to ____ means _____

4; hazardous alcohol consumption

How many drinks a week consider WOMEN at heavy or at risk drinking?

8 or more

ADUIT points for men: greater than or qual to __ means ______

8; hazardous alcohol consumption

1. Providing false assurance or reassurance

A pregnant woman says, "I've been spotting on and off all day, and I haven't felt the baby kick. I just know I'm going to miscarry." Your automatic response may be to provide reassurance, "Don't worry. I'm sure you and the baby will be fine." Although this helps relieve your anxiety and gives you the sense that you have provided comfort, it actually trivializes the woman's anxiety and closes off communication. You have also just promised something that may not be true, which can diminish rapport. Consider these responses: "You're really worried about your baby, aren't you?" "It must be hard to wait for the doctor. Is there anything I can get you or anything that you'd like to talk about?" These responses acknowledge the feeling and open the door for more communication. A genuine, valid form of reassurance does exist. You can reassure clients that you are listening to them, that you understand them, that you have hope for them, and that you will take good care of them. Client: "I feel so lost here since they transferred me to the medical center. My family lives too far away to visit, and no one here knows me or cares." Response: "I care what happens to you. I will be here all day today and for the next 3 days. Please call if you need anything." This type of reassurance makes a commitment to the client, and it can have a powerful impact.

Denver II screening test

allows direct interaction with the young child to assess the mental status

When nonverbal and verbal messages are congruent, the verbal message is _________

reinforced

Stalking

repeated, unwanted attention that leads to fear

What is AUDIT?

Alcohol Use Disorders Identification Test

What are the 5 levels of consciousness?

Alert Lethargic (or Somnolent) Obtunded Stupor or Semi-Coma Coma Delirium (Acute Confusional State)

orientation

Alert x 4 oriented to person, place, time and event

If you have a child or infant that is sleeping, what do you do first?

Ascultate

10. Using "Why" Questions

Children ask why questions constantly. Why is the sky blue? Why can't I have a cookie for dinner? Their motive is an innocent search for information. The adult's use of "why" questions usually implies blame and condemnation; it puts the person on the defensive. Consider your use of "why" questions in the health care setting. "Why did you take so much medication?" Or "Why did you wait so long before coming to the hospital if you were having chest pain?" The use of a "why" question makes the interviewer sound accusatory and judgmental. By using a "why" question, the client must produce an excuse to rationalize his or her behavior. To avoid this trap, say, "I see you started to have chest pain early in the day. What was happening between the time the pain started and the time you came to the emergency department?"

7. Using Leading or Biased Questions

Asking a client, "You don't smoke, do you?" or "You don't ever have unprotected sex, correct?" implies that one answer is "better" than another. If the client wants to please you, he or she will either answer in a way corresponding to your values or feel guilty when he or she must admit the other answer. The client feels that he or she risks your disapproval by not answering the question "correctly." If the client feels dependent on you for care, he or she won't want to alienate you and may not answer truthfully. Make sure that your questions are unbiased, and do not lead clients to a certain "correct" answer. For example, you might instead ask, "Do you smoke?" or "When you have sexual intercourse, do you use protection?"

What does Alert mean?

Awake or readily aroused, oriented, fully aware of external and internal stimuli and responds appropriately; conducts meaningful interpersonal interactions.

What part of the hand is best for vibration?

Base of fingers (metacarpophalangeal joints) OR ulnar surface of the hand

EBP (evidence based practice)

Based from research NOT based from opinion/something published

This requires the use of both of your hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa for more precise delimitation.

Bimanual palpation

How do you assess orientation?

By asking questions about the persons address, phone number, and health history

"What are the typical methods of discipline used in the home?" "Do you routinely use any specific cultural practices to promote healing (cupping, coining, etc)" "Does the child take any medication to easily cause bruising?"

Child abuse / neglect questions

What type of questions do you ask when your patient is critical or severe illness?

Closed-ended because this decreases response burden.

Delirium (Acute Confusional State)

Clouding of consciousness (dulled cognition, impaired alertness); inattentive; incoherent conversation; impaired recent memory and confabulatory for recent events; often agitated and having visual hallucinations; disoriented, with confusion worse at night when environmental stimuli are decreased.

coma

Completely unconscious; no response to pain or any external or internal stimuli (e.g., when suctioned, does not try to push the catheter away); light coma has some reflex activity but no purposeful movement; deep coma has no motor response.

In some cultures, full disclosure of a diagnosis such as cancer is a _____?

Culture taboo

What shape is the bell?

Deep, hollow, cuplike shape

5. Distancing

Distancing is the use of impersonal speech to put space between a threat and the self: "There is a lump in the left breast." By using "the" instead of "your," you are allowing the woman to deny any association with her diseased breast and protect herself from it. Health professionals use distancing to soften reality, but in actuality it may communicate that you are afraid of the procedure or disease. Clients use distancing to avoid admitting that they have a problem: "My doctor told me that the prostate was enlarged." Using specific language and blunt terms indicates that you are not fearful of the disease or procedure and may decrease anxiety and help the client cope with the reality of the situation.

When should you screen for abuse?

EVERY. SINGLE. TIME!

HITS scoring:

Each question is scored from 0 (never) to 5 (frequently) and the answers are totaled. A score greater than 10 on the HITS tool is indicative of IPV.

Verbal and Nonverbal behavior meant to inflict FEAR and DISTRESS... (Humiliation, Embarrassment, Controlling behavior, social isolation, and damaging/destroying property..

Emotional or psychological abuse

Mini-Cog Test

Reliable, quick, and easily available instrument to screen for cognitive impairment otherwise healthy older adults

What part of the hand is best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps?

Fingertips

What part of the hand is best for detecting position, shape, and consistency of an organ or mass?

Grasping action with your fingers and thumb

Stethoscope - DIAPHRAGM

HIGH pitched sounds (heart/lung/bowel sounds)

Where do you place your BELL?

LIGHTLY on the skin.

yin/yang theory

Health exists when all aspects of the person are in perfect balance.

What are the 4 HITS questions?

How often does your partner: 1. Physically hurt you 2. Insult or talk down to you 3. Threaten you with harm 4. Scream or curse at you

What is concentrated watching?

Inspection

Why should you not ask a friend or relative to interpret for you?

It invades client confidentiality. The interpreter is probably not familiar with medical terminology. It adds stress to the situation and may disrupt family situations.

2. Giving Unwanted Advice

It is important as a health care provider to recognize when giving advice is warranted and when it should be avoided. People often seek health care because they want professional advice. A parent may ask how to care for a child with chickenpox, or an older man may ask if it is appropriate to receive a pneumonia vaccine. These are straightforward requests for information, and you respond by providing the appropriate information. But if advice is based on a hunch or feeling or is your personal opinion, then it is most likely inappropriate. Consider a young woman who has just met with her physician about her infertility issues: "Dr. Compton just told me I have to have surgery and that, if I don't, I won't be able to get pregnant. What would you do?" If you provide an answer, especially if the answer begins with "If I were you ..." you would be falling into a trap. You are not your client and therefore cannot make decisions for her. Providing an answer shifts accountability to you instead of the client. The woman must work out her own decision. So what do you do? Response: What are your concerns about the recommendation? Woman: I'm terrified of being put to sleep. What if I don't wake up? Now you know her real concern and can help her deal with it. She will have grown in the process and may be better equipped to make her decision. When asked for advice, other preferred responses are: "What are the pros and cons of ________ [this choice] for you?" "What is holding you back?" Although it is quicker just to give advice, take the time to involve the patient in a problem-solving process.

What is the definition of EBP?

It is multifaceted and reflects holistic practice

What is the most common illicit drug?

Marijuana

What are the 7 categories of illicit drugs?

Marijuana cocaine heroin hallucinogens inhalants methamphetamine non-medical use of psychotherapeutics (pain relievers, tranquilizers, stimulants, sedatives)

what do you need to wear when procedures are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions?

Mouth, Nose, and Eye protection

get an interpreter means what?

NO family member, no guessing.. get the REAL DEAL!

What is included in a general survey?

NOT heart sounds or skin inspection 1. physical appearance 2. body structure 3. Mobility 4. Behavior

Failure to meet the basic needs such as hygiene, nutrition, hydration, clothing, shelter, and medical care.

Neglect - elder abuse

Lethargic

Not fully alert; drifts off to sleep when not stimulated; can be aroused to name when called in normal voice but looks drowsy; responds appropriately to questions or commands but thinking seems slow and fuzzy; inattentive; loses train of thought; spontaneous movements are decreased.

Where do you place your diaphragm?

On bare firm skin! never on clothes.

What follows and often confirms what you noted during inspection?

Palpation

4. Using Avoidance Language

People use euphemisms instead of discussing unpleasant topics. For example, people use "passed on" or "has gone to a better place" to avoid the reality of dying. Using euphemisms promotes the avoidance of reality and allows people to hide their feelings. Not talking about uncomfortable topics doesn't make them go away but instead makes them even more frightening. The best way to deal with frightening or uncomfortable topics is by using direct language.

What is tapping the person's skin with short, sharp strokes to assess underlying structures?

Percussion

When an elder is intentionally injured, assaulted, threatened with a weapon, or inappropriately restrained.

Physical abuse

The use of force that could cause death, disability, or injury

Physical violence

How do we warm our stethoscope?

Rubbing the end-piece in your palm.

In general the _________ gender is preferred for an interpreter.

SAME

What is not a standard precaution?

SWEAT

MMSE continued

Scores that occur with dementia and delirium are classified as follows: 18-23 = mild cognitive impairment; 0-17 = severe cognitive impairment.

What are the Instrumental ADLs (IADLs)?

Skills such as shopping, preparing meals, house cleaning, writing checks, taking medications, doing laundry, using the telephone, managing finances, nutrition, social relationships and resources, self concept, coping, and home environment

What should your palpation technique be?

Slow, systematic, calm, and gentle.

If hands are contaminated with visibly soiled blood or body fluids should you wash them with soap/water or alcohol based rub?

Soap and water.

8. Talking Too Much

Some examiners positively associate helpfulness with verbal productivity. If the air has been thick with their oratory and advice, these examiners leave thinking that they have met the client's needs. Just the opposite is true. Eager to please the examiner, the client lets the professional talk at the expense of his or her need to express himself or herself. A good rule for every interviewer is to listen more than you talk.

stupor or semi-coma

Spontaneously unconscious; responds only to persistent and vigorous shake or pain; has appropriate motor response (i.e., withdraws hand to avoid pain); otherwise can only groan, mumble, or move restlessly; reflex activity persists.

"My left foot hurts so bad" subjective or objective?

Subjective data

After you assessment you should review your documentation with the client.

TRUE

You are not required to have proof before reporting suspected elder abuse.

TRUE

When a trained interpreter is unavailable, what can you use?

Telephone translation services can be used 24 hours a day

What does palpation assess?

Texture Temperature Moisture Organ location and size Swelling, vibration, or pulsation Rigidity or spasticity Crepitation Presence of lumps or masses Presence of tenderness or pain

MMSE continued

The MMSE is quick and easy, includes a standard set of only 11 questions, and requires only 5 to 10 minutes to administer. It is useful for both initial and serial measurement; therefore you can demonstrate worsening or improvement of cognition over time and with treatment. It concentrates only on cognitive functioning, not on mood, thought processes, or executive function. It is a valid detector of organic disease but lacks sensitivity for mild cognitive impairment.

What part of the hand is best for determining temperature because the skin is thinner than on the palms?

The dorsa (back) of hands and fingers

MMSE continued

The maximum score on the test is 30; people with normal mental status average 27. Scores between 24 and 30 indicate no cognitive impairment.

6. Using Professional Jargon

The medical profession is fraught with jargon that sounds exclusionary and paternalistic. It is important to adjust your vocabulary to ensure understanding without sounding condescending. Just because your client uses medical jargon, don't assume that he or she understands the correct meaning. Some people think "hypertensive" means tense. This misunderstanding may cause them to take their medication only when they are feeling tense and stressed instead of taking it all the time. Misinformation must be corrected immediately to ensure compliance.

What do you do if you need to listen to a man who has chest hair?

Wet the hair before auscultating

objective data

What YOU observe by inspecting, percussing, palpating, and auscultating during physical examination

What is the goal of EBP (Evidence-Based Practice)?

To make EBP the greatest influence of health status

What is a nonverbal skill that is very important to older people?

Touch

financial abuse - elder abuse

Unauthorized or improper use of the elder's resources for monetary or personal benefit, profit, or gain, such as forgery, theft, or improper use of guardianship or power of attorney.

9. Interrupting

When you think you know what the client is going to say next, it is easy to cut him or her off and finish the statement. Unfortunately you are not proving that you are clever, but you are signaling impatience or boredom. Related to interruption is preoccupation with yourself. As the client speaks, you may be thinking about what to say next. If you are focused on your next statement instead of his or her statements, you are unable to fully understand what the person is saying. The goal of the interview is to include two people listening and two people speaking. Leave at least a second of space between the end of the client speaking and your next statement. This ensures that the client has finished.

What is more accurate than percussion?

X ray images

Is EBP proved and peer reviewed?

YES!

psychological aggression

a form of emotional abuse wherein the aggressor uses verbal or nonverbal communication to exert control or harm the person emotionally

What is a health disparity?

a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage

MMSE (Mini Mental State Examination)

a test of the cognitive functions of the mental status examination (memory, orientation to time and place, naming, reading, copying or visuospatial orientation, writing, and the ability to follow a three-stage command). It requires paper and pencil; the person must be able to write and have no vision impairment.

What do you do for a clinical setting everytime?

an environmental survey

sexual violence

any attempted or completed sex acts without the consent of the other person.

Steps of the nursing process (6 steps)

assessment diagnosis outcome identification planning implementation evaluation

What are the Basic ADLs (BADLs)?

bathing, dressing, toileting, eating, walking

Make sure the information provided matches the injury / event that you observe clinically.

child abuse and neglect

nonverbal communication is even more important to ____ than it is to adults.

children

substance abuse is a ______ issue.

chronic

substance abuse

chronic illness or disease of the brain. it is not something we brush off

history of present illness

chronic record of reason for seeking care from the symptom started until now

yin food are ____

cold

CAGE

cut down, annoyed, guilty, eye opener

yang food are ___

hot

Cold foods are eaten with a ____ illness and Hot foods are eaten with a _____ illness.

hot, cold

What four functions does the Denver II screening detect in infants and preschoolers?

delays in gross moto, language, fine moto-adaptive, personal social skills

listening with your eyes is just as important as listening with your _____

ears

what is an EHR

electronic health record

Who do you use standard precautions for?

everybody

In nearly 60% of elder abuse and neglect incidents, the perpetrator is usually a ________

family member - an adult child or spouse

Yin energy represents ______

female and negative forces such as emptiness, darkness and cold

What shape is the diaphragm?

flat edged

IPV includes both current and _____ partners, so the person need not currently be in a relationship to experience IPV.

former/past

otoscope

funnels light into the ear canal and onto the tympanic membrane

Substance abuse can be influenced by ___________

genetic, environmental, and developmental factors

Alcohol increases the risks for chronic diseases such as:

hypertension, heart disease, store, early cancers(liver , colorectal) , mental illness (depression and anxiety),

ophthalmoscope

illuminates the internal eye structures

Elder abuse includes both ________ acts and _____ to act by a caregiver or trusted person.

intentional; failure

affect

is a temporary expression of feelings or state of mind (how i represent what i say) ex: I could say i am happy but my "affect" may not show that

open-ended questions

it leaves the person free to answer in any way. it lets them express themselves.

Auscultation is normally the ____ thing you do in your assessment.

last

auscultation

listening to sounds produced by the body

Alcohol is a major cause of ___________, which is the 8th leading cause of death in the United States

liver cirrhosis

Yang forces represents

male and positive forces such as emitting warmth and fullness

Functional Assessment

measures a person's self-care ability in the areas of general physical health

mood

mood is more durable, a prolonged display of feelings that color the whole emotional life. (what i say i feel)

37.0 C or 98.6 F

normal temperature

"My pulse rate was 94" subjective or objective?

objective data

pictures are ______

objective data

cue

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

What is the number one health disparity?

poverty

Denver II screening, mmse, and mini cog are not used to diagnose but specifically see how they are ___________.

progressing.

what is the most accurate (but invasive) site to take a temperature?

rectal temp

Avoid interpreters from a __________

rival tribe, state, or nation

Any sexual contact against the elder's will.

sexual abuse or abusive sexual contact

Stethoscope - BELL

soft, low-pitched sounds -extra heart sounds, murmurs

EBP now encompasses ___(4 things)?

the integration of research evidence, clinical experience, clinical knowledge, and patient values and preferences.

Holistic health depends on what factors working together?

the mind, body, and spirt

Holistic Health

the view that the mind, body, and spirit are interdependent and function as a whole within the environment

verbal communication

the words you speak, vocalizations, the tone of voice

nonverbal communication

this is your body language -- posture, gestures, facial expressions, eye contact, foot tapping, touch, even where you place your chair.

Palpation applies your sense of ______

touch

When they are incongruent, the nonverbal messages tends to be the ______ one because _______________.

true; it is under less conscious control

Elder abuse is _______

underreported

An interpreter can ____?

verbally translate the conversation but also can describe to you the cultural aspects and meanings of the persons situations.

You should make sure your hands are _____ when palpating.

warm

subjective data

what the PERSON says about himself or herself during history taking

closed-ended questions

yes or no questions

Do you separate the child from the caregiver during a child abuse screening?

yes!!, this child will not feel safe answering questions under the influence of their caregiver!!

Asians believe in what theory

yin/yang