Health Assessment Test 1 Study Material

Acrochordons (skin tags)

overgrowths; form stalk; are polyp-like

Strabismus

(squint, crossed eye) disparity of the eye axes

MOBILITY

- Gait - Range of motion

Personal distance

1 1/2 to 4 feet

List the significant information considered in each of the 4 areas of a GENERAL SURVEY.

1. Physical Appearance 2. Body structure 3. Mobility 4. Behavior.

There are ____ pairs of cranial nerves.

12

8. After assessing the patient's pulse, the practitioner determines it to be "normal." This would be recorded as:

2+

subjective

_________________ data consists of info provided by the affected individual.

There are ___ pairs of spinal nerves.

31

Social distance

4 to 12 feet

How would you asses for pain in an individual with dementia?

They communicate pain through their behavior. Such as: Agitation, pacing, repetitive yelling, cry, hit, kick, or moan

Goiter

An enlargement / tumor of the thyroid gland caused by hypothyroidism (can be brought on by a lack of iodine in the body)

Exercise-

BP is elevated

Confrontation

Clarifying inconsistent information

Facilitate

Encourages client to say more

Bells palsy affects which nerve?

Facial

largest population of non hispanic white

Hispanics

_______ is an inherited condition that results in excessive cartilage formation at the growth plates, forming long arms and legs.

Marfan's Syndrome

Describe characteristics of normal cervical lymph nodes during childhood

Nodes do not palpate

Sign

Objective abnormality that can be detected by examination or lab values.

Crying

Relief, sign of important topic

Active listening

Route to understanding. Not only what but the way they say it Look for what is being left out

Symptom

Subjective sensation that the patient feels; cannot be observed. Use quotations to include the patients words.

Face and teeth muscles, chewing?

Trigeminal

values

a desirable or undesirable state of affairs and a universal feature of all cultures

cranial nerve VI?

abducens

bruise

an injury appearing as an area of discolored skin on the body from ruptured blood vessels.

cranial nerve V function?

chewing

Miosis

constricted pupils

Cafe au lait spot

large round or oval patch of light brown pigmentation - usually normal

Oral teaching

simple short sentences. Tell patient what they will gain by following instruction

culture

the nonphysical attributes of a person- the thoughts communications, actions, beliefs. values, and institutions of racial, ethnic, religious or social groups

Causes of Diaphoresis

thyrotoxis, MI, anxiety, pain

cranial nerve X?

vagus

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

"ADOPIE" stands for:

Response to someone who has spoken to you in a sexually aggressive way.

"I am uncomfortable with the way you are speaking to me, please stop."

Which of the following statements describing a headache would warrant an immediate referral?

"I have never had a headache like this before; it is so bad I can't function." A sudden severe headache in an adult or child who has never had it before warrants an immediate referral. A sudden severe headache could indicate a subarachnoid hemorrhage.

The most appropriate introduction to use to start an interview with an older adult patient is:

"Mr. Jones, I want to ask you some questions about your health so that we can plan your care."

An example of an open-ended question of statement is:

"Tell me about your pain."

Which of the following statements made by the interviewer would be appropriate response?

"Tell me what you mean by 'bad blood.'"

Myopia

"nearsighted"; refractive error in which near vision is better than far vision

List the basic characteristics of culture.

(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; and (4) dynamic and ever changing.

Describe 4 sources of error that may occur when using the 24-hour diet recall.

(1) the individual or family member may not be able to recall the type or amount of food eaten; (2) intake within the last 24 hours may be atypical of usual intake; (3) the individual or family member may alter the truth for a variety of reasons; and (4) snack items and use of gravies, sauces, and condiments may be underreported.

5. differentiate caput succedaneum from cephlhematoma in a newborn infant.

Edematous swelling and ecchymosis on the head caused by birth trauma. It feels soft, and it may extend across suture lines. It gradually resolves during the first few days of life and needs no treatment.

List the 3 layers associated with the skin, and describe the contents of each layer.

-Epidermis: thin, tough -horny cell layer: dead keratinized cells -basal cell layer: forms new cells -Dermis: middle layer made of connective tissue/collagen -holds nerves, sensory receptors, blood vessels, lymphatics -Subcutaneous: adipose

Nursing Process

(ADPIE) Assessment Diagnosis Planning Implementation Evaluation

Episodic or problem-centered database

For limited or short-term problems Collect "mini" database, smaller scope and more focused than complete database Concerns mainly one problem, one cue complex, or one body system

Hordeolum

(stye) red, painful pustule that is a localized infection of hair follicle at eyelid margin

Quality

(timbre) characteristics of the sound

PHYSICAL APPEARANCE

- Age -Sex -LOC -Skin Color -Facial Features

What are important aspects of PHYSICAL APPEARANCE?

- Age -Sex -LOC -Skin Color -Facial Features

BEHAVIOR

- Facial Expression: - Mood and Affect - Speech - Dress - Personal hygiene

What are important aspects of BEHAVIOR?

- Facial Expression: - Mood and Affect - Speech - Dress - Personal hygiene

What are important aspects of MOBILITY?

- Gait - Range of motion

BODY STRUCTURE

- Stature - Nutrition - Symmetry - Posture - Position - Body build, Contour

What are important aspects of BODY STRUCTURE?

- Stature - Nutrition - Symmetry - Posture - Position - Body build, Contour

Describe normal posture and body build?

-*Posture:* a person stands comfortably erect as appropriate for age -*Body Build-Proportions are:* 1) Arm span equals height 2) Body length from crown to pubis roughly equal to length from pubis to sole of foot

State the body mass index for: --->a male weighing 190 lb who is 5' 10" tall ---> female weighing 136 lb who is 5' 4" tall

--> 27.3 --> 23.3 weight in kg/(height in cm)^2 Normal BMI= 18.5-24.9

List factors that affect blood pressure.

--> Age: normally a gradual rise occurs through childhood to adult years --> Gender: After puberty, females usually have a lower BP reading than males. After menopause females have higher BP --> Diurnal rhythm: high in late afternoon and declines to an early morning low --> Weight: BP is higher in obese persons --> Exercise: BP is elevated --> Emotions: Momentarily rises with fear, anger and pain as a result of stimulation of the sympathetic nervous system --> Stress: BP is elevated

Describe Stage 1 Hypertension

--> SBP: 140-159 --> DBP: 90-99

Describe Stage 2 Hypertension

--> SBP: Equal or greater than 160 --> DBP: Equal or greater than 100

Read this in-depth description of Phase V Korotkoff Sounds Decreased velocity of blood flow. Streamlined blood flow is silent. The last audible sound is diastolic pressure

--> Silence --> Decreased velocity of blood flow. Streamlined blood flow is silent. --> The last audible sound is diastolic pressure

Describe Prehypertension

--> Systolic BP: 120-139 -->Diastolic BP: 80-89 --> No anti hypertensive drug

What changes in height and weight distribution would you expect from an adult in his or her 70s or 80s.

--> Weight-Body weight decreases. --> Muscles shrinkage. --> Sucutaneous fat is lost from face and periphery -->Additional fat deposited on abdomen and hips --> Height-Shorter --> Shorter trunk with longer extremities

Related the use of the wrong size blood pressure cuff to the possible findings that might be obtained?

--> Wider cuffs deliver false low reading --> Narrow cuffs give a false high reading (because it takes extra pressure to compress the artery).

Read this in-depth description of Phase IV Korotkoff Sounds

--> abrupt muffling --> Sound mutes to a low pitched, cushioned murmur, blowing quality. --> Artery no longer closes in any part of cardiac cycle. --> Chang in quality, not intensity

Read this in-depth description of Phase 1 Korotkoff Sounds

-->Soft, clear tapping, increasing in intensity. -->Systolic pressure-as the cuff pressure lowers to reach intrluminal systolic pressure, the artery opens, and blood first sputs into the brachial artery. --> Blood is at a very high velocity because of small opening of artery and large pressure difference across opening. -->This creates turbulent flow, which is audible

Relate the qualities of normal respirations to the appropriate approach for counting them.

-Relaxed, Regular, Automatic, Silent -Count without the patient being aware for 30 seconds after taking radial pulse -Normal adult takes 10-20 respirations per minute

Describe the tympanic membrane and temporal artery thermometers, and compare their use with other forms of temperature measurements.

-Tympanic membrane and temporal artery thermometer are fast and comfortable. -*Tympanic membrane thermometer:* Senses infrared emissions of tympanic membrane, noninvasive, nontraumatic device, fast and efficient, minimal chance of cross contamination -Oral is the best measurement (take in sublingual pocket) -Rectal is actually the best but is invasive and should only be used when necessary

3 factors related to socialization

-acculturation-process of adapting to and acquiring another culture -assimilation-process by which a person develops a new cultural identity and becomes like members of the dominant culture -biculturalism-dual pattern of identification and often divided loyalty

5 methods of complementary interventions

-accupuncture: pricking skin w/ needles; used to diminish pain -therapeutic touch: laying of hands on the body to induce a relaxed feeling -massage: rubbing of joints and muscles to relieve stress and tension -relaxation: different techniques to reduce stress and anxiety -imagery: imagining relaxing scenes

3 major theories on the ways in which people view causes of illness

-biomedical: all events have cause and effect; the human body is like a machine; all life can be reduced or dived; reality can be observed -naturalistic: the forces of nature must be kept in balance -magicoreligious: the world is seen as arena in which supernatural forces dominate

religious preferences may influence what

-explanation of the cause of illness -perception o it's severity -and choice of healers

Stage I Pressure Ulcer

-intact skin, red, does not blanch

4 basic characteristics of culture

-learned from birth through process of acquisition and socialization -shared by all members of the same cultural group -adapted to specific conditions related to environmental and technical factors and to the availability of natural resources -dynamic and ever changing

Intimate zone

0 to 1 1/2

List the 9 types of responses examiners use during the interview and examples of each.

1) Facilitation - Nodding "yes" 2) Silence - waiting for response with interruption or moving on 3) Reflection - summarizing something client just said. 4) Empathy - "this situation must be very hard for you right now" 5) Clarification - "Breathing becomes difficult when you run, but not when walking, is that correct?" 6) Confrontation - "You say you would like to lose weight but refuse to go to change your current lifestyle, is that correct?" 7) Interpretation - "It seems every time you come in due to migraines, you are also under extreme pressure at home." 8) Explanation - "You must not consume any alcohol while on this medication or else you will experience extreme side effects." 9) Summary - Review important parts of the interview. Client should have time and space to make corrections/clarifications.

collagen. elastic tissue

dermis

Ten traps of interviewing. Provide examples.

1) False assurance/reassurance - "Don't worry, everything will be fine." 2) Giving unwanted advice - "If I were you, I would follow the doctor's recommendation no matter what." 3) Using authority - "Your health provider knows best" 4) Using avoidance language - "Your loved one has now gone to a better place." 5) Distancing - "There is an unusual growth on the left lung." 6) Using professional jargon - "It seems you've been experiencing angina pectoris" 7) Leading or biased questions - "You haven't been drinking, have you?" 8) Talking too much - talking and explaining more than listening to the client 9) Interrupting - cutting the client off and continuing his or her sentence 10) Why Questions - "Why did you wait so long before seeking medical attention?"

List 7 nonverbal behaviors made by an examiner.

1) Physical appearance 2) Posture 3) Gestures 4) Facial expression 5) Eye contact 6) Tone of voice 7) Touch

Explain the significance of phase I, phase IV, and phase V Korotkoff sounds during blood pressure movement.

1) *Phase I:* Systolic pressure, blood spurts into artery, first appearance of sound 2) *Phase IV:* Muffling of sound 3) *Phase V:* Final disappearance of sound, diastolic

Describe five methods of complementary interventions.

1) Acupuncture 2) Therapeutic touch 3) Meditation 4) Hypnosis 5) Biofeedback

Special considerations when interviewing an older adult.

1) Always address by proper sirname (Mr. or Mrs. ___) 2) Avoid "elderspeak" 3) Adjust pace of the interview 4) Consider any physical limitations

Name the aspects of normal gait

1) Base is as wide as the shoulder width. 2) Foot placement is accurate 3) Walk is both, coordinated, even and well balanced 4) Symmetrical arm swing present

List at least 5 names for various folk healers and the culture they represent.

1) Curandero(ra) - Hispanic 2) Hougan (voodoo priest) - Blacks 3) Shaman - American Indian 4) Acupuncturists - Asian 5) Braucher - Amish

Describe the points to consider in preparing the physical setting for the interview.

1) Ensuring privacy is very important - this means finding a private room in a hospital, clinic, or home, and if it is not possible, behind curtains or some kind of partition for "psychological privacy". This also extends to limiting people in the room, or making sure the client is comfortable with answering openly and honestly if there is someone present. 2) Refuse interruptions or let the client know beforehand if one is expected. 3) One also needs to take into consideration the physical environment, meaning: • Quiet setting • Removing distractions • Enough lighting • Comfortable room temperature • Personal space; keeping a comfortable distance between yourself and client • "Equal status seating," meaning remaining at eye level or in a position where the client is not looking up to you, even if he or she is bedridden.

List the pros and cons of note-taking during the interview.

1) Pros • Being able to record important details • Not having to rely solely on memory • Organizing information for formal documentation 2) Cons • Breaks eye contact with client • Impedes ability to take notice clients nonverbal behavior • Shifts your attention away from the person, making him or her feel less important • Client may feel uncomfortable or threatened when he or she is disclosing sensitive info while you are recording • Impedes client's ability to talk at a natural pace to ensure you get everything down

Describe the items included in a functional assessment.

1) Self-Esteem, Self-Concept. 2) Activity/Exercise. 3) Sleep/Rest. 4) Nutrition/Elimination. 5) Interpersonal Relationships/Resources. 6) Spiritual Resources. 7) Coping and Stress Management. 8) Personal Habits. 9) Alcohol 10) Illicit or Street Drugs. 11) Environment/Hazards. 12) Intimate Partner Violence. 13) Occupational Health.

What are the expected ranges for: 1) temperature 2) pulse 3) respirations 4) blood pressure

1) Temperature: 35.8-37.3C (96.4-99.1F) 2) Respirations: 10-20 3) Pulse: 50-90 4) B/P: 120/80

List 5 points to consider when using an interpreter.

1) Use a trained interpreter who knows medical terminology. 2) Avoid interpreters from a rival tribe, state, region, or nation 3) Be aware of gender differences between interpreter and client; same gender usually preferred. 4) Be aware of age differences between interpreter and client; older interpreter usually preferred. 5) Be aware of socioeconomic differences between interpreter and client.

Parts of a health history

1. Biographical data - name, DOB etc, 2. source of history - patient, family, interpreter, 3. Reason for seeking care - 1 or 2 symptoms and duration, 4. Present health/history of present illness with symptom analysis, 5. Past health events - injuries, hospitalizations etc. 6. Family history, 7. Review of body systems, 8. Functional assessment - ADL's etc.

List at least 5 points to consider when using an interpreter during an interview.

1. Use a trained interpreter if necessary. 2. Using family- confidentiality is violated. 3. Using family- the family may not know medical terminology, procedures, or ethics. 4. document who interpreted. 5. Line by line- ensures accuracy, used most for interviews. 6. Summary- progresses faster, useful for simple health techniques.

The capillary beds should refill after being depressed in:

1-2 seconds

The steps of the diagnostic reasoning process are listed below. Consider the clinical example given for "cue recognition," and fill in the remaining diagnostic reasoning steps. 1. Cue recognition 2. Hypothesis formulation 3. Data gathering for hypothesis testing 4. Hypothesis evaluation

1. AJ is a 62-year-old man, appears pale, diaphoretic, and anxious 2. AJ may be experiencing chest pains 3. run auscultating tests, take vital signs, check pulses, ask questions related to chest pain 4. evaluate data collected during tests to determine where AJ is experiencing chest pains

Describe the process of nociception using the four phase of : 1. Transduction 2. Transmission 3. Perception 4. Modulation

1.Transduction: Initially the first phase, occurs when a noxious stimulus in the form of traumatic or chemical injury, burn, incision, or tumor takes place in the periphery 2. Transmission: the 2nd phase, the pain impulse moves from the level of the spinal cord to the brain. 3. Perception: the 3rd phase, signifies the conscious awareness of a painful sensation. 4. Modulation:Last phase, pain message is inhibited through this phase

List the 10 traps of interviewing, and give a short example of each

1. False assurance-- don't assure something. reassure clients you are listening or that you understand, hope for them, take good care of them. 2. Unwanted advice- don't give advice based on hunch or feeling or personal opinion. involve patient in solving problem. 3. Using authority- equal roles, even if you know better, patient has to make decision. 4. Using avoidance language- don't used passed on instead of dead. promotes avoidance of reality. allows patient to hide feelings. use direct language. 5. Distancing- may show you are afraid of procedure or disease, client may use it to avoid admitting a problem. direct terms will help cope with reality of situation 6. Professional jargon- make sure patient knows what they are saying with their jargon, as well as understand yours. 7. Leading or biased questions- one answer is better than the other- may cause lying response. don't lead questions to have a correct answer. avoid biased questions, keep them neutral 8. Talking to much- allow the patient to express himself, listen more than you talk 9. Interrupting- shows impatience or boredom. Give a second of space between the end of the client speaking and your next statement. 10. Why questions- implies blame, puts person to defend. Sounds judgemental.

A successful interview is:

1. Gather complete and accurate date about the person's health state including the description and chronology of any symptoms of illness. 2. Establish trust so the person feels accepted and thus free to share all relevant data. 3. Teach the person about his or her health state 4. Build rapport for a continuing therapeutic relationship: this rapport facilitates future diagnosis, planning, and treatment. 5. Discuss health promotion and disease prevention

List and define the critical characteristics used to explore each symptom the patient identifies.

1. Location - ask the patient to point to the specific location of the symptom 2. Character or quality - describing the symptom 3. Quantity or severity - quantify the severity of the sign or symptom 4. Timing - when did it begin, how long does it last, how often does it occur 5. Setting - where was the patient when they experienced the symptom 6. Aggravating or relieving factors - what worsens, induces, and relieves the pain 7. Associated factors - are there associating factors to the primary symptom 8. Patient's perception - what does the symptom mean for the patient, how has it affected their daily functioning.

Define the elements of the health history: reason for seeking care; present health state or present illness; past history, family history; review of systems; functional patterns of living.

1. Reason for seeking care - brief, spontaneous statement in the person's own words that describes the reason for the visit. 2. Present health state - For the well person, this is a short statement about the general state of health. For the ill person, this section is a chronologic record of the reason for seeking care, from the time the symptom first started until now. 3. Past history - Past health events are important because they may have residual effects on the current health state. 4. Family History - an accurate family history highlights diseases and conditions for which a particular patient may be at increased risk. 5. Review of systems - The purposes of this section are (1) to evaluate the past and present health state of each body system, (2) to double-check in case any significant data were omitted in the Present Illness section, and (3) to evaluate health promotion practices. 6. Functional patterns of living - Functional assessment measures a person's self-care ability in the areas of general physical health or absence of illness

3. Define the elements of the health history: reason for seeking care; present health state or present illness; past history, family history; review of systems; functional patterns of living.

1. Reason for seeking care- brief, spontaneous statement in patients own words. 2. Present health state- statement about the general state of health. 3. Past history- important since they may have residual effects on the current health state. 4. Review of systems- evaluate past & present health state of each body system. 5. Functional patterns of living- measures a persons self care ability.

List various sources of pain.

1. Visceral pain: originates from larger interior organs. *That is why visceral pain often presents with autonomic responses such as vomiting, nausea, pallor, and diaphore 2.Deep somatic pain: comes from sources such as the blood vessels, joints, joints, tendons, muscles, and bone. Injury may result from pressure, trauma, or ischemia 3. Cutaneous pain: Linking pain to a mental disorder (psychogenic pain) negates person's pain report 4. Somatic Pain: originates from musculoskeletal tissues or the body surface. 5. Referred Pain: Pain that is felt at a particular site but originates from another location.

Describe how you would validate the following data. 1. Mr. Quinn tells you his weight this morning on the clinic scale was 165 lb. 2. The primary counselor tells you Ellen is depressed and angry about being admitted to residential treatment in the clinic. 3. When auscultating the heart, you hear a blowing, swooshing sound between the first and second heart sounds.

1. Weighing Mr. Quin again on another scale 2. Ask specific questions related to the youth's behaviors to validate depression and anger. Or ask the youth how she feels directly 3. Listen again, run an EKG, and ask for a second opinion

List 4 situations in which you clean your hands promptly and thoroughly

1. before and after every physical pt encounter 2. after contact with blood, body fluids, secretions, and excretions 3. after contact with any equipment contaminated with body fluids 4. after removing gloves

Public distance

12+ feet

You examine nail beds for clubbing. The normal angle between the nail base and the nails is:

160 degree

Four inner factors of liking others

1. empathy, liking others, ability to listen, self-awareness​

goal of review of systems

1. evaluate past and present health state 2. double-check in case significant data was omitted 3. evaluate health promotion practices

6. Discuss the rationale for obtaining a systems review.

1. evaluate the past and present health state of each body system. 2. double check incase any significant data were omitted in the present illness section. 3. evaluate health promotion practices.

List the pros of note-taking during the interview

1. helps to remember 2. easier charting. 3. history.

An adult patient's pulse is 46 beats per minute. The term used to describe this rate is: tachycardia. bradycardia. weak and thready. sinus arrhythmia.

bradycardia. A heart rate of less than 50 beats per minute in an adult is bradycardia.

Culture has four characteristics

1. learned from birth through 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 4. Dynamic and every changing

List the cons of note-taking during the interview

1. less eye contact 2. can't see nonverbal 3. patient may feel unimportant

List 8 items of information that should be communicated to the client concerning the terms or expectations of the interview

1. name and explanation of role 2. purpose 3. how long it is going to take. 4. expectation of me and of the patient 5. identify other people in the room 6. confidentiality 7. time/place of interview 8. cost

Explain how acute and chronic pain differ in terms of nonverbal behaviors

Acute Pain: is short-term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals. Ex. incident pain is an acute pain Chronic Pain: Is a diagnosed when the pain continues for 6 months or longer. It is divided into malignant and nonmalignant.

State at least 7 nonverbal behaviors that interviewer could make

1. physical appearance 2. posture 3. gestures 4. facial expressions 5. eye contact. 6. voice 7. touch

Maslow's Hierarchy of Needs

1. physiological 2. safety 3. love/belonging 4. esteem 5. self-actualization

Describe the points to consider in preparing the physical setting for the interview

1. private area 2.quiet 3. lighting 4. social distance 4-12 ft. personal space 1 1/2 to 4 ft 5. eye level 6. setting

steps to cultural competency

1. understand your own heritage based on cultural values beliefs attitudes and practices that are relevant to health and illness 2. identify the meaning of health to the other person remembering that concepts are derived in part from the way in which members of a cultural group define health 3. understand health care delivery system, how it works, what it does, meanings of various procedures and costs, and consequences to the patients and to you as a nurse 4. must be knowledgeable about social backgrounds of your patients, meanings of immigrations, racism, socioeconomic status, welfare reform, and aging 5. must be familiar with language people speak, resources available to help with interpretation, and resources within the community.

ABCDEE

A - asymmetry B - borde C - color D - diameter E - elevation and enlargement

To assess for early jaundice, you will assess: A) Sclera and hard palate B) Nail beds C) Lips D) All visible surfaces

A. Except for physiological jaundice in newborns, jaundice does NOT occur normally. It is FIRST noted in the junction of the hard and soft palate in the mouth and in the sclera. DO NOT confuse scleral jaundice with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons. The scleral yellow of jaundice extends up to the edge of the iris.

AUSCULTATORY GAP -

A brief period when Korotkoff sounds disappear during auscultation of blood pressure; Common with hypertension

Erythema

due to excess blood in superficial capillaries (fever, inflammation) light skin looks red dark skin not visible - feel for warmth, hardening

1. State the purpose of the complete health history.

To collect subjective data and combine it with objective data from the physical examination and diagnostic tests. Ill person's history includes a detailed, chronological record of the health person. All history's include abnormal symptoms, health problems and concerns.

Cyanosis

due to non-oxygenated blood (chronic heart/lung disease, anxiety, cold)

Pallor

due to non-oxygenated hemoglobin light skin looks pale, white-pink dark skin looks ashen, gray

You are assessing capillary refill. The room is warm. Which finding would be considered normal? A) <1 second B) >2 seconds C) 2 to 3 seconds D) Time is not significant as long as color returns

A. Normally color return is instant or at least within a few seconds in a cold environment. This indicates the status of the peripheral circulation. A sluggish color return takes longer than 1 or 2 seconds.

5. State the body mass index for a male weighing 190 lb who is 5' 10" tall___, female weighing 136 lb who is 5' 4" tall ___.

28, 23

Which of the following is an expected response on the cover test?

A normal response to the cover test is a steady fixed gaze

c

A nurse precepting a student nurse asks, "What's the most important step in the critical-thinking process?" a. clustering subjective and objective data b. analyzing health data c. using evidence based assessment techniques d. prioritizing health concerns

3. List the facial structures that should appear symmetric when inspecting the head.

eyebrows, palpebral fissures, nasolabial folds, and sides of the mouth.

facial expressions, taste?

facial

b

A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority? a. Ineffective self-health management b. Impaired gas exchange c. Readiness for enhanced spiritual well-being d. Risk for infection

Amplitude is: A) the intensity (soft or loud) of sound. B) the length of time the note lingers. C) the number of vibrations per second. D) the subjective difference in a sound's distinctive overtones.

A. Amplitude is the intensity of sound. Duration is the length of time the note lingers. Pitch is the number of vibrations per second (high or low). Quality is the subjective difference owing to a sound's distinctive overtones.

Parents or caregivers accompany children to the health care setting. Starting at __ years of age, the interviewer asks the child directly about his or her presenting symptoms.

7

A patient has blurred peripheral vision. You suspect glaucoma, and test the visual fields. A person with normal vision would see your moving finger temporally at:

90 degrees

d

A complete database is a. used to collect data rapidly and is often compiled concurrently with lifesaving measures. b. used to evaluate the cause or etiology of disease. c. used for a limited or short-term problem usually consisting of one problem, one cue complex, or one body system. d. used to perform a thorough or comprehensive health history and physical examination.

c

A patient has recently received health insurance and would like to know how often he should visit the provider. How do you respond? a. "It would be most efficient if you visit on an annual basis" b. "There is no recommendation for the frequency of health care visits." c. "Your visits may vary, depending on your level of wellness" d. "Your visits will be based on your preference"

b

A patient in the emergency department with nausea and vomiting. Which would you include in the database? a. a complete health history and full physical examination b. a diet and GI history c. previously identified problems d. start collection of data in conjunction with livesaving measures.

c

A patient says she is very nervous and nauseated, and she feels as if she will vomit. This data would be what type of data? a. objective b. reflective c. subjective d. introspective

Define a pedigree or genogram.

A pedigree or genogram is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations such as parents, grandparents, and siblings.

Vertigo

A sense that either one's own body (subjective) or the environment (objective) is revolving; may indicate inner ear disease

Deep palpation is used to: A) identify abdominal contents. B) evaluate surface characteristics. C) elicit deep tendon reflexes. D) determine the density of a structure.

A. Deep palpation is used to identify abdominal contents. Light palpation is used to evaluate surface characteristics. Percussion with a reflex hammer is used to elicit deep tendon reflexes. Percussion is used to determine the density (air, fluid, or solid) of a structure by a characteristic note.

Which of the following factors control a person's blood pressure? (Select all that apply.) Select all that apply. A. Cardiac output B. Age C. Emotions D. Viscosity E Vascular resistance

A, D, E

To examine a toddler, the nurse should: A) allow the child to sit on the parent's lap. B) remove the child's clothing at the beginning of the examination. C) ask the child to decide whether parents or siblings should be present. D) perform the assessment from head to toes.

A. A toddler should be sitting up on the parent's lap for the examination. An infant will not object to having clothing removed; a toddler does not like to take off his or her clothing. A school-age child has a sense of modesty; to maintain privacy, ask a child who is 11 or 12 years old to decide whether parents or siblings should be present. The sequence of the examination for a toddler should start with nonthreatening areas first; save distressing procedures such as assessment of the head, ears, nose, or throat for last.

A flat macular hemorrhage is called a(n): A) purpura. B) ecchymosis. C) petechiae. D) hemangioma.

A. Purpura is a flat, macular, red-to-purple hemorrhage that is a confluent and extensive patch of petechiae and ecchymoses greater than 3 mm. An ecchymosis is a hemorrhage that is greater than 3 mm. Petechiae are tiny punctate hemorrhages that are 1 to 3 mm; round and discrete; and dark red, purple, or brown caused by bleeding from superficial capillaries. Hemangiomas are vascular lesions caused by a benign proliferation of blood vessels in the dermis.

The components of a nail examination include: A) contour, consistency, and color. B) shape, surface, and circulation. C) clubbing, pitting, and grooving. D) texture, toughness, and translucency.

A. The nails should be assessed for shape and contour, consistency, and color.

Which of the following is considered when preparing to examine an older adult? A) Base the pace of the examination on the patient's needs and abilities. B) Avoid physical touch to avoid making the older adult uncomfortable. C) Be aware that loss will result in poor coping mechanisms. D) Confusion is a normal, expected finding in an older adult.

A. The pace of the examination should be adjusted to match the possible slowed pace of the aging person. Use physical touch (if it is not a cultural contraindication) to offset the disadvantages of diminishing vision and hearing. Be aware that loss is inevitable, and adaptation to loss affects health status. Confusion with a sudden onset may signify a disease state and is not a normal process of aging.

To determine if a dark-skinned patient is pale, the nurse should assess the color of the: A) conjunctivae. B) earlobes. C) palms of the hands. D) skin in the antecubital space.

A. To detect pallor in a dark-skinned patient, the nurse should assess an area with the least pigmentation, such as the conjunctivae or mucous membranes.

What term refers to a linear skin lesion that runs along a nerve route? A) Zosteriform B) Annular C) Dermatome D) Shingles

A. Zosteriform describes a lesion that has a linear arrangement along a nerve root. Annular describes a lesion that is circular and begins in the center and spreads to the periphery. A dermatome is an area of skin that is mainly supplied by a single spinal nerve. Shingles (herpes zoster) are small grouped vesicles that emerge along the route of a cutaneous sensory nerve, followed by pustules, and then crusts; shingles is caused by the herpes zoster virus.

During a routine visit, M.B., age 78, asks about small, round, flat, brown macules on the hands. What is your best response after assessing the data? A) "These are the result of sun exposure and do not require treatment." B) "There are related to exposure to the sun. They may become cancerous." C) "These are the skin tags that occur with aging. No treatment is required." D) "I'm glad you brought this to my attention. I will arrange for a biopsy."

A. Senile lentigines ("liver spots") are common variations of hyperpigmentation. These are small, flat, brown macules. These circumscribed areas are clusters of melanocytes that appear after extensive sun exposure. They appear on the forearms and dorsal of the hands. They are NOT malignant and require NO treatment.

During a routine visit, M.B. age 78, asks about small, round, flat, brown macules on the hands. The best response is:

A. "age spots" - the result of sun exposure and do no require treatment

The nurse records that the patient's pulse is 3+ or full and bounding. Which of the following could be the cause? A. Anxiety B. Shock C. Bleeding D. Dehydration

A. Anxiety A full, bounding pulse (3+) reflects an increased stroke volume, as with anxiety and exercise. A weak, thready pulse may reflect a decreased stroke volume, as with dehydration. A weak, thready pulse may reflect a decreased stroke volume, as with shock. A weak, thready pulse reflects a decreased stroke volume, as with bleeding.

The nurse documents the following findings for the behavioral portion of the general survey assessment, "patient demonstrates flat affect, lack of eye contact, hair not brushed, and strong body odor". The nurse should be concerned that the patient is which of the following? A. Depression B. Bulimia C. Dysarthria D. Seizures

A. Depression Flat affect, lack of eye contact, unkempt appearance (hair not brushed), and smelling of body odor are common warning signs that the patient may be depressed. Dysarthria is unclear articulation of speech commonly associated with a stroke or a speech disorder. A person with a seizure disorder may have altered affect or eye contact, but may not demonstrate an unkempt appearance. A person with bulimia may have altered mood, affect, or facial expression, but typically not have altered dress or personal hygiene.

6. During an initial home visit, the patient's temperature is noted to be 97.4 F. How would you interpret this?

A. It cannot be evaluated without knowledge of the person's age.

10. Pulse pressure is described as:

A. The difference between the systolic and diastolic pressure.

An adult with a body mass index (BMI) less than 18.5 kg/m2 is considered which of the following? A. Underweight B. Obesity C. Normal weight D. Overweight

A. Underweight A person with a body mass index (BMI) less than 18.5 kg/m2 is classified as underweight. Classification of obesity is a body mass index (BMI) of 30 to 39.9 kg/m2. Classification of normal weight is a body mass index (BMI) of 18.5 to 24.9 kg/m2. Classification of overweight is a body mass index (BMI) of 25 to 29.9 kg/m2.

13. Why is it important to match the appropriate size of blood pressure cuff to the person's arm and shape and not the person's age?

A. Using a cuff that is too narrow will give a false reading that is high.

To perform an accurate assessment of respirations, the examiner should A. count for 30 seconds after completing a pulse assessment and multiply by two. B. inform the person of the procedure and count for 1 minute. C. assess respirations for a full 2 minutes if an abnormality is suspected. D. count for 15 seconds while keeping fingers on the pulse and then multiply by four.

A. count for 30 seconds after completing a pulse assessment and multiply by two. Respirations should be counted for 30 seconds (if regular) and multiplied by two. The respirations should be counted after the pulse assessment. Patients have conscious control over respirations; the examiner should not mention that respirations will be counted. Avoid counting respirations for 15 seconds because the results can vary +4 or −4 with such a small number. Respirations should be counted for 1 minute if abnormalities are suspected.

When considering cultural competence, there are discrete areas that the nurse must develop knowledge of to understand the health care needs of others. These discrete areas include understanding of (Select all that apply): A. his or her own heritage B. cultural and ethnic values C. the heritage of the nursing profession D. the heritage of the patient E the heritage of the health care system

A. his or her own heritage C. the heritage of the nursing profession D. the heritage of the patient E. the heritage of the health care system

Select the statement that is true regarding headaches A. may be precipitated by alcohol and daytime napping B. usual occurrence is two per month each lasting 1 to 3 days C. characterized by throbbing D. tend to be supraorbital, retro-orbital or frontotemporal

A. may be precipitated by alcohol and daytime napping

A common error in blood pressure measurement is A. waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm. B. taking the blood pressure in an arm that is at the level of the heart. C. deflating the cuff about 2 mm Hg per heartbeat. D. using a blood pressure cuff whose bladder length is 80% of the arm circumference.

A. waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm. Waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm will result in a falsely high diastolic pressure r/t venous congestion in the forearm. The patient's arm should be positioned at the level of the heart when obtaining a blood pressure measurement. The cuff should be deflated at a rate of 2 mm Hg per heartbeat. The blood pressure cuff bladder length should be about 80% of the arm circumference.

List the conditions associated with parotid gland enlargment

AIDS Mumps

HEEADSSS

Adolescent interview focus: Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression. Safety from injury/violence.

Describe type 1 diabetes.

the result of pancreatic B cell destruction of which the causes is unknown. Are at risk of ketoacidosis, result of autoimmune process for which the beta cell destruction is unknown

The examiner records "positive consensual light reflex." This is

the simultaneous constriction of the other pupil when one eye is exposed to bright light.

Turgor

the skin's ability to return to place promptly when released (decreased with dehydration, extreme weight loss)

c

An example of objective data is a. a report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion. b. a complaint of left knee pain. c. crepitation in the left knee joint. d. left knee has been swollen and hot for the past 3 days.

d

An example of subjective data is a. decreased range of motion b. crepitation in left knee joint c. arthritis d. left knee has been swollen and hot for past 3 days

3. An 18-month-old child is brought into the clinic for a health screening visit. To assess the height of the child:

B. Use a horizontal measuring board.

Data collection for the general survey begins A. at the beginning of the physical examination. B. at the first encounter. C. while taking vital signs. D. during the mental status examination.

B. at the first encounter. The general survey is initiated at the first encounter with the patient.

The best description of the secretion of the eccrine glands:

B. dilute saline solution

Literacy

Ability to read and write

Health literacy

Ability to understand instructions, navigate the health care system and communicate concerns with health care provider.

Cutis marmorata

transient mottling in the trunk and extremities in response to cooler room temperatures - forms reticulated red or blue pattern over skin

What proportion of Americans ages 12 and older report being current alcohol drinkers? And report being binge drinkers (≥5 drinks/occasion)?

About 52.1% of Americans ages 12 and up report being alcohol drinkers, and almost 40% report being binge drinkers.

Cutis marmorata

transient mottling on trunk and extremities

Contrast the use and settings for the following alcohol screening tools: AUDIT; AUDIT-C; CAGE questionnaire.

AUDIT - covers alcohol consumption, drinking behaviors, or dependency. AUDIT-C - is a shorter form that is helpful for acute and critical care units. The AUDIT-C is a valid screening test for heavy drinking and/or active alcohol abuse CAGE - works well in primary care settings; it takes less than 1 minute to complete and the 4 straightforward yes/no questions are easy for clinicians to remember. The CAGE tests for lifetime alcohol abuse and/or dependence but does not distinguish past problem drinking from active present drinking; less effective with women and minority groups

________ is a brief period when Korotkoff sounds disappear during auscultation of blood pressure --->Common with hypertension

AUSCULTATORY GAP

I turn your head about; going to and fro. There are times I do not know which way to go. ( nerve, name &#)

Accessory, #XI

_________ is due to genetic disorder in converting cartilage to bone. --> Congenital skeletal malformation. --> Relatively large head with frontal bossing midplace hypoplasia short stature short limbs --> Often thoracic kyphosis, prominent lumbar lordosis, abdominal protrusion

Achondroplastic Dwarfism

_______ is a disease characterized by enlarged features, especially the face and hands, caused by hypersecretion of the pituitary hormone after puberty, when normal bone growth has stopped; most often caused by a pituitary tumor

Acromegaly

Ability to listen

Active and demanding. Interpret their meanings, asking follow-up questions and ensuring thorough understanding of what the person is telling you.

What type of pain is short and self-limiting and dissipates after the injury heals? A) Chronic B) Persistent C) Acute D) Breakthrough

Acute

Describe the charecteristics of lymph nodes often associated with: Acute infection, Chronic Inflammation, Cancer

Acute Infection- firm bilateral- enlarged, tender Chronic Inflammation- enlarged able to slightly move Cancer- hard, matted, fixed

Narrow palpebral fissures, epicanthal folds, and midfacial hypoplasia are characteristic of:

fetal alcohol syndrome. Facial characteristics of fetal alcohol syndrome include narrow palpebral fissures, epicanthal folds, and midfacial hypoplasia.

__________ is a psychological disorder characterized by somatic delusions that you are too fat

Anorexia Nervosa

A slight protrusion of the eyeballs may be noticed when examining individuals who come from which ethnic/cultural group?

African Americans normally may have a slight protrusion of the eyeball beyond the supraorbital ridge.

Gender-

After puberty, females usually have a lower BP reading than males. After menopause females have higher BP

13. List factors that affect blood pressure.

Age-normally a gradual rise occurs through childhood to adult years

Which statement is accurate related to aggravating symptoms or triggers of headaches?

Alcohol consumption may precipitate the onset of cluster or migraine headaches. Aggravating symptoms or triggers for cluster headaches include alcohol consumption, stress, or wind or heat exposure. Aggravating symptoms or triggers for migraines include hormonal fluctuations, certain foods, letdown after stress, changes in sleep pattern, sensory stimuli, and changes in weather or physical activity.

For older adults postoperative patients, poorly controlled acute pain places them at higher risk for: A. Atelectasis B. Increased myocardial oxygen demand C. Impaired wound healing D. All the above

All of the above

STROKE VOLUME -

Amount of blood pumped out of the heart with each heartbeat

Which of the following children is at risk of recurrent otitis media?

An 18-month-old infant who has had three episodes of ear infections in a 5-month period. A first episode of otitis media (OM) that occurs within 3 months of life increases risk of recurrent OM. Recurrent OM is 3 episodes in past 3 months or 4 episodes within the past year.

Which of the following groups of individuals need to be tested for the presence of color blindness (deficiency)?

Color blindness is an inherited recessive X-linked trait affecting about 8% of white males and 4% of black males. Test only boys for color vision, once between the ages of 4 and 8 years.

Medication reconciliation

Comparison between and old and current list of media\

Stage III Pressure Ulcer

full-thickness- extends into subcutaneous tissue -may see subcutaneous fat, but not muscle, bone, or tendon

c

What can be determined when the nurse clusters data as part of the critical thinking process? a. this step identifies problems that may be urgent and require immediate action. b. this step involves making assumptions in the data. c. the nurse recognizes relevant information among the data. d. risk factors can be determined so the nurse knows how to offer health teaching.

Pterygium

triangular opaque tissue on the nasal side of the conjunctiva that grows toward the center of the cornea

Questions asked in a Health Assessment (set B)

What do you know about this condition? Does it interfere with your daily life? When did it first start (onset)? What does it feel like? Do you feel safe at home? Do you have enough money for food? Is there anything else you are concerned about?

bde

Which of the following changes in aging adults affect nutritional status? (Select all that apply.) a) Increased muscle mass b) Poor dentition c) Increased saliva production d) Decreased visual acuity e) Slowed GI motility

c

Which of the following is an example of objective data? a. a sore throat b. an earache c. alert and oriented d. dizziness

b

Which of the following is an example of subjective data? a. Blood glucose 126 md/dL b. Pain rated at 7 out of 10 c. Heart rate of 76 bpm d. Bruising on lower leg

What symptom is greatly influenced by a person's cultural heritage?

pain

what is movement of tongue muscles?

hypoglossal

c

Which would be considered a risk diagnosis? a. identifying existing levels of wellness b. evaluating previous problems and goals c. Identifying potential problems the individual may develop d. focusing on strengths and reflecting an individual's transition to higher levels of wellness

c

Which would be included in a holistic model of assessment? a. nursing goals for the patient b. anticipated growth and development patterns c. a patient's perception of his or her health status d. the nurse's perception of disease related to the patient

2. Name the borders of two regions in the neck - the anterior triangle and the posterior triangle.

Anterior triangle - the anterior triangle lies in front, between the sternomastoid and the midline of the body, with its base up along the lower border of the mandible and its apex down at the suprasternal notch. Posterior triangle - the posterior triangle is behind the sternomastoid muscle, with the trapezius muscle on the other side and with its base along the clavicle below.

Name the borders of two regions in the neck

Anterior triangle- in Front between the sternomastoid/ up and lower mandible Posterior Triangle - Trapezoid muscle base along the clavicle.

A patient with atrial fibrillation requests a cup of chamomile tea. The nurse denies the patient's request because of the medication the patient is taking. What is the medication? Calcium channel blocker Beta-adrenergic blocker Cardiac glycoside Anticoagulants

Anticoagulants

The nurse records that the patient's pulse is 3+ or full and bounding. Which of the following could be the cause? Dehydration Shock Bleeding Anxiety

Anxiety A full, bounding pulse (3+) reflects an increased stroke volume, as with anxiety and exercise.

State a useful phrase to use as a closing when ending the interview

Any more questions. Do you have anything you'd like to add A summary of the interview

State 3 clinical laboratory findings that are used to detect or monitor alcohol use.

Appearance - unsteady gait, incoordination Behavior - impaired social or occupational functioning

Body Build-Proportions are:

Arm span equals height, Body length from crown to pubis roughly equal to length from pubis to sole of foot

Closed question

Ask for specific information.

How would you modify interview for someone hearing-impaired?

Ask the client their preferred method of communication, make sure their hearing aid is properly adjusted, include a sign-language interpreter when conducting a complete history interview. If they prefer lip reading, speak slowly and use appropriate hand gestures. Make sure the client understands the questions.

Recall questions for an initial pain assessment.

Ask the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors

Open ended questions

Asks for narrative information. States the topic to be discussed only in general terms.

SPICES

Assessment for older adults with focus on "marker conditions" for increased death rates, hospitalization, costs: Sleep problems Problems with eating/feeding Incontinence Confusion Evidence of falls Skin breakdown

Written Material

At a 5th grade level

The location in the brain where optic nerve fibers from the temporal fields of vision cross over is identified as the:

At the optic chiasm, nasal fibers (from both temporal visual fields) cross over.

6. For serial weight measurement, what time of the day would you instruct the person to have weight measured?

At the same time each day

For serial weight measurement, what time of the day would you instruct the person to have weight measured?

At the same time each day

Which of the following tests provides a precise quantitative measure of hearing?

Audimeter test. An audiometer gives a precise quantitative measure of hearing by assessing the person's ability to hear sounds of varying frequency.

The external structure of the ear is identified as the:

Auricle. The auricle or pinna is the external structure of the ear.

The Doppler technique A. is used to assess the apical pulse. B. amplifies Korotkoff sounds during blood pressure measurement. C. measures arterial oxygenation saturation. D. provides an easy and accurate measurement of the diastolic pressure.

B amplifies Korotkoff sounds during blood pressure measurement. The Doppler technique may be used to locate peripheral pulse sites and for blood pressure measurement to augment Korotkoff sounds. A stethoscope is used to assess an apical pulse. The systolic blood pressure is more easily identified with the Doppler technique than the diastolic pressure. A pulse oximeter measures arterial oxygenation saturation.

Select the best description of the secretion of the eccrine glands. A) Thick, milky B) Dilute saline solution C) Protective lipid substance D) Keratin

B. Eccrine glands are coiled tubules that open directly onto the skin surface and produce a dilute saline solution (sweat). The evaporation of sweat reduces body temperature. Eccrine glands are widely distributed through the body and are mature in the 2-month-old infant. Apocrine glands produce a thick, milky secretion and open into the hair follicles.

Functions of the skin include: A) production of vitamin C. B) temperature regulation. C) production of new cells by melanocytes. D) secretion of a drying substance called sebum.

B. Functions of the skin include protection, prevention of penetration, perception (of touch, pain, temperature, and pressure), temperature regulation, identification, communication, wound repair, absorption and excretion, and production of vitamin D. The skin produces vitamin D, not vitamin C. The basal cell layer of the epidermis forms new skin cells. Melanocytes produce melanin, which gives brown tones to the skin and hair. Sebum is produced by the sebaceous glands to lubricate the skin and hair.

Herpes zoster infection (shingles) is characterized by: A) A bacterial cause B) Lesion on only one side of body; does not cross midline C) Absence of pain or edema D) Pustular, umbilicated lesions

B. Herpes zoster (shingles): Small grouped vesicles emerge along route of cutaneous sensory nerve, then pustules, then crusts. Caused by the varicella zoster virus (VZV), a reactivation of the dormant virus of chickenpox. Acute appearance, unilateral, DOES NOT cross midline. Commonly on trunk; can be anywhere. If on ophthalmic branch of cranial nerve V, it poses risk to eye. Most common in adults older than 50 years. Pain is often severe and long lasting in aging adults (postherpetic neuralgia)

The dorsa of the hands are used to determine: A) vibration. B) temperature. C) position of an organ. D) fine tactile discrimination.

B. The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for vibration. A grasping action of the fingers and thumb is the best way to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination.

The examiner should use handwashing instead of an alcohol-based hand rub: A) if the patient has an infection with Mycobacterium tuberculosis. B) if the patient has an infection with Clostridium difficile. C) if the patient has an infection with hepatitis B virus. D) if the patient is HIV positive.

B. The examiner should use the mechanical action of soap-and-water handwashing when hands are visibly soiled and when patients are infected with spore-forming organisms (e.g., C. difficile or Bacillus anthracis). An alcohol-based hand rub would be effective against M. tuberculosis. An alcohol-based hand rub would be effective against hepatitis B virus. An alcohol-based hand rub would be effective against HIV.

Anorexia Nervosa -

a psychological disorder characterized by somatic delusions that you are too

Causes of Hyperthermia

increased metabolic rate trauma infection sunburn hyperthyroidism

Fine tactile discrimination is best achieved with the: A) opposition of the fingers and thumb. B) fingertips. C) back of the hands and fingers. D) base of the fingers.

B. The grasping action of the fingers and thumb is used to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination such as skin texture, swelling, pulsation, and presence of lumps. The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for detecting vibration.

When performing percussion, the examiner: A) strikes the flank area with the palm of the hand. B) strikes the stationary finger at the distal interphalangeal joint. C) strikes the stationary finger at the proximal interphalangeal joint. D) taps fingertips over bony processes.

B. To perform percussion, the examiner strikes the stationary finger at the distal interphalangeal joint (just behind the nail bed).

Assessing a patient's skin turgor is done to assess which clinical finding? A) Edema B) Dehydration C) Vitiligo D) Scleroderma

B. Poor skin turgor is evident in severe dehydration or extreme weight loss; the pinched skin recedes slowly or "tents" and stands by itself. Edema is fluid accumulating in the interstitial spaces; it is not present normally. Vitiligo, an acquired condition, is the complete absence of melanin pigment in path areas of white or light on the face, neck, hands, feet, and body folds and around orifices. Scleraderma ("hard skin") is a chronic connective tissue disorder associated with decreased mobility.

Which of the following is a normal range for a patient's temperature measured using an oral thermometer? A. 37.5° C to 39.2° C B. 35.8° C to 37.3° C C. 36.2° C to 38.2° C D. 34.0° C to 34.9° C

B. 35.8° C to 37.3° C This is the correct range for oral temperature. This range is the expected range for temperature measured using a rectal thermometer. A patient with an oral temperature in this range should be evaluated for other signs of hyperthermia (increased fever). An oral temperature less than 36.0° C is considered hypothermia.

Which of the following respiratory rates recorded for an infant without chronic illness would require further interventions and assessment by the nurse? A. 27 B. 45 C. 35 D. 30

B. 45 The nurse would need to complete further assessments and notify the physician for a respiratory rate of 45 breaths per minute. The normal range for respirations for an infant (up to 1 year) is 24 to 38 breaths per minute.

15. The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?

B. An increased respiratory rate and a shallower inspiratory phase are possible findings.

7. Select the best description of an accurate assessment for a patient's pulse.

B. Begin counting with zero; count for 30 seconds.

Which of the following would be most appropriate when weighing an infant? A. If the infant can sit up, he/she can be weighed on a standard upright scale. B. The infant should be weighed undressed on a platform-type scale. C. It's okay to weigh the infant fully dressed. D. Weigh the mother then have her hold the infant and subtract the mother's weight from the result.

B. The infant should be weighed undressed on a platform-type scale. Infants should be weighed undressed on a platform-type scale. A digital scale is preferred as they are usually more accurate. Using the process of weighing the mother then subtracting her weight after weighing her holding the infant, is an inaccurate procedure. Weight measurements of infants and children must be accurate to appropriate assess their growth patterns. In order to obtain the most accurate weight measurement of an infant, they should be weighed without clothes or diaper. It is inappropriate to weigh an infant using an upright scale. A platform-type scale placed on a counter is the safest and most accurate way to measure an infant's weight.

The tympanic membrane thermometer (TMT) A. senses the infrared emissions of the cerebral cortex. B. provides an accurate measurement of core body temperature. C. accurately measures temperature in 20 to 30 seconds. D. is not used in unconscious patients.

B. provides an accurate measurement of core body temperature. The TMT accurately measures core body temperature. The TMT senses the infrared emissions of the tympanic membrane; the tympanic membrane shares the same vascular supply that perfuses the hypothalamus. The TMT is used with unconscious patients or patients in the emergency department, recovery areas, and labor and delivery units. The temperature is displayed in 2 to 3 seconds.

Which technique would the nurse use to noninvasively assess arterial oxygen saturation? A. Arterial blood gas B. Pulse oximeter C Blood Pressure D. Respiratory rate

B. pulse oximeter The pulse oximeter is a noninvasive method to assess SpO2. Respiratory rate is only a measure of the rate of a person's breathing, not SpO2. Blood pressure is an assessment of the force of blood pushing against the side of the vessel, not SpO2. Arterial blood gas is an invasive measure to assess oxygen saturation.

Stress-

BP is elevated

Weight-

BP is higher in obese persons

3. Note aspects of normal gait

Base is as wide as the shoulder width. Foot placement is accurate, walk is booth, coordinated, even and well balanced, symmetrical arm swing present

Describe the rationale and components of cultural care.

Because immigration occurs at high levels and immigrants with limited English proficiency (LEP) have particular needs, the Office of Minority Health published the National Standards for Culturally and Linguistically Appropriate Services in Health Care. • EFFECTIVE CARE results in positive outcomes and satisfaction for the patient. • RESPECTFUL CARE takes into consideration the values, preferences, and expressed needs of the patient. • CULTURAL AND LINGUISTIC COMPETENCE is a set of congruent behaviors, attitudes, and policies that come together in a system among professionals that enables work in cross-cultural situations

__________ is the force of blood pushing against the side of the vessel wall

Blood Pressure

12. Define and describe the relationships among the terms blood pressure, systolic pressure. Diastolic pressure, pulse pressure, and mean arterial pressure.

Blood Pressure - Force of blood pushing against the side of the vessel wall

Bruit

Blowing, swooshing sound heard through the stethoscope over and area of abnormal blood flow

What is the source of deep somatic pain? A) Skin and subcutaneous tissues B) Bones and joints C) Pancreas D) Intestine

Bones and joints

A person is known to be blind in the left eye. What happens to the pupils when the right eye is illuminated by a penlight beam?

Both pupils constrict

Equal status seating

Both you and the client should be comfortably seated at eye level. Placing the chairs at 90 degrees allows to look face to face or forward. DO NOT STAND.

List the effects of alcohol on 4 traumatic or disease conditions.

Breast Cancer - up to 1 alcoholic drink per day increases risk of breast cancer 4%, more than 3 per day can increase risk by up to 40-50% Liver Cirrhosis - alcohol abuse is the number one cause for this disorder Hypertension - moderate drinking leads to hypertension by stimulating the nervous system, which can later cause cardiomyopathy Atrial Fibrillation - moderate to heavy drinking increases risk of atrial fibrillation in people over 55yrs old with cardiovascular disease and diabetes

Discuss bruising in children and how it relates to their development level.

Bruising is not typical in infants under 9months old if they are not yes "cruising", usually bruising in infants younger than 9 months, should alert you to possible abusive mechanisms to the injury or an underlying medical illness. Children who are walking bruise on bony prominences on the front of their body (atypical places include butt, hands, feet, and abdomen). With children younger 4, bruising on torso, ears, and neck as well as any bruising on pre-cruising infants correlates with abuse.

Facial characteristics of hyperthyroidism

Bulging eyeballs goiter

The tympanic membrane of a child with acute otitis media would be:

Bulging with a distinct red color. The tympanic membrane would be bulging and red with acute otitis media.

State convenient ways to assess a person's recent memory within the context of the initial health history.

By the 24-hour diet recall or by asking the time the person arrived at the agency.

Identify the blood vessel that runs diagonally across the sternomastoid muscle A Temporal artery B Carotid artery C External jugular vein D Internal jugular vein

C External jugular vein

Risk factors that may lead to skin disease and breakdown include: A) loss of protective cushioning of the dermal skin layer. B) decreased vascular fragility. C) a lifetime of environmental trauma. D) increased thickness of the skin.

C. Accumulating factors that place an aging person at risk for skin disease and breakdown include thinning of the skin, decrease in vascularity and nutrients, loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, social changes of aging, an increasingly sedentary lifestyle, and the chance of immobility. Aging results in the loss of protective cushioning of the subcutaneous layer of the skin. Aging results in decreased vascularity of the skin. Aging results in thinning of the skin.

A funduscopic examination is an examination of the: A) inner ear. B) pharynx. C) internal structures of the eye. D) nasal turbinates.

C. An ophthalmoscope is used for a funduscopic examination, which is an examination of the internal structures of the eye. An otoscope is used to visualize the ear canal and tympanic membrane. A flashlight or penlight and tongue depressor are used to examine the pharynx. An otoscope may also be used with a short, broad speculum to view the nasal turbinates and nares.

A configuraation of individual lesions arranged in circles or arcs, as occurs with ringworm, is described as a: A) Linear lesion B) Clustered lesion C) Annular lesion D) Gyrate lesion

C. Annular, or circular, lesion - begins in center and spreads to periphery. Linear lesion - a scratch, streak, line or stripe. Clustered lesion - grouped. Gyrate lesion - twisted, coiled spiral, snakelike

An area of thin shiny skin with decreased visibility of normal skin markings is most likely: A) Lichenification B) Plaque C) Atrophy D) Keloid

C. Atrophy - the resulting skin level is depressed with loss of tissue; a thinning of the epidermis. Lichenification - prolonged, intese scratching eventually thickens skin and produces tightly packed sets of papules; looks like surface of moss (or lichen). Plaque - papules coalesce to form surface elevation wider than 1cm; a plateaulike, disk-shaped lesion. Keloid - a benign excess of scar tissue beyond sites of original injury; looks smooth, rubbery, shiny and "claylike"; feels smooth and firm; higher incidence in Blacks, Hispanics and Asians.

You examine the nail beds of a patient. Which finding indicates a normal angle? A) 60 degrees B) 100 degrees C) 160 degrees D) 180 degrees

C. Normal angle of nail bed: ~160 degrees. Curved nail bed: <160 degrees. Early clubbing: 180 degrees.

An example of a primary lesion is a(n): A) erosion. B) ulcer. C) urticaria. D) port-wine stain.

C. Urticaria is a primary lesion; a primary lesion is one that develops on previously unaltered skin. Erosions are secondary lesions; a secondary lesion is one that changes over time or changes because of a factor such as scratching or infection. Ulcers are secondary lesions; a secondary lesion is one that changes over time or changes because of a factor such as scratching or infection. A port-wine stain is a vascular lesion.

The "A" in the ABCDE rule for skin cancer stands for: A) Accuracy B) Appearance C) Asymmetry D) Attenuated

C. Danger signs: abnormal characteristics of pigmented lesions are summarized by ABCDE: - Asymmetry (NOT regularly round or oval, two halves of the lesion do not look the same) - Border irregularity (notching, scalloping, ragged edges, poorly defined margins) - Color variation (areas of brown, tan, black, blue, red, white, or combination) - Diameter >6mm (i.e. size of pencil eraser), although early melanomas may be diagnosed at a smaller size - Elevation or Evolution

A risk factor for melanoma is: A) Brown eyes B) Darkly pigmented skin C) Skin that freckles or burns before tanning D) Use of sunscreen products

C. Risk factors for melanoma are UV radiation from sun exposure and indoor tanning and family history.

5. Which changes regarding height and weight occur during the 80s and 90s?

C. Both decrease

12. Mean arterial pressure is:

C. Diastolic pressure plus one third of the pulse pressure.

2. You are assessing a patient's gait. What do you expect to find?

C. Gait is as wide as the shoulder width.

14. A patient is being seen in the clinic for complaints of "fainting episodes that started last week." How should you proceed with the examination?

C. Record the blood pressure in the lying, sitting, and standing positions.

4. Which changes in head circumference measurements in relation to chest measurements will occur from infancy through early childhood?

C. The newborn's head will be 2 cm larger than that chest circumference, but between 6 months and 2 years, the chest size will increase and remain the way.

Endogenous obesity is A. characterized by evenly distributed excess body fat. B. due to inadequate secretion of cortisol by the adrenal glands. C. caused by excess adrenocorticotropin (ACTH) production by the pituitary gland. D. a result of excessive secretion of growth hormone in adulthood.

C. caused by excess adrenocorticotropin (ACTH) production by the pituitary gland. Endogenous obesity is caused by either the administration of adrenocorticotropin or excessive production of adrenocorticotropin by the pituitary. Adrenocorticotropin stimulates the adrenal cortex to secrete excess cortisol and causes Cushing syndrome, which is characterized by weight gain and edema with central trunk and cervical obesity. Excessive catabolism causes muscle wasting with thin arms and legs. Body fat is evenly distributed in exogenous obesity because of excessive caloric intake. Acromegaly is caused by an excessive secretion of growth hormone in adulthood.

The general survey consists of four distinct areas. These areas include A. gait, range of motion, mental status, and behavior. B. level of consciousness, personal hygiene, mental status, and physical condition. C. physical appearance, body structure, mobility, and behavior. D. mental status, speech, behavior, and mood and affect.

C. physical appearance, body structure, mobility, and behavior. The general survey is a study of the whole person, covering the general health state and any obvious physical characteristics. The four areas of the general survey are physical appearance, body structure, mobility, and behavior. A general survey does not include assessment of mental status and physical condition.

The six muscles that control eye movement are innervated by cranial nerves

CN 3, CN 4, CN 6, Oculomotor, Trochulear, Abducens

The corneal reflex is mediated by cranial nerves

CN 5 and CN 7 trigeminal abducens

Discuss some of the long-term consequences of child maltreatment.

Child maltreatment shown to be a predictor of negative health outcomes for children that can persist into adulthood (e.g., mental health issues, incidence of suicide attempts, substance abuse, and the risk of perpetrating abuse as an adult). It has also shown to be a predicator of youth violence.

developmental history points

Children: 1. Prenatal/perinatal history 2. Issue description and who provided the details, 3. Childhood illness, accidents and shots, 4. Developmental overview, 5. Nutritional history, Consider developmental age in functional assessment. Elderly: Consider in ADL's due to having or chronic health changes. Impact or burden of the disease.

List the 9 types of examiner responses that could be used during the interview, and give a short example of each.

Clients perspective. Client leads. 1. facilitate- general clue Encourages client to go on. Examples: "go-on," shifting forward, nodding. 2. Silence- listening. provides you a chance to notice nonverbal cues. Examples: waiting for response without interruption, sitting quietly 3. Empathy- care. allows person to feel accepted. Examples: This must be very hard for you... 4. Clarification- repeat, Useful when person's word choice is confusing. Summarize person's words, simplify the statement, and ensure that you are on the right track. Example: ... is that correct. 5. Reflection- echoes client's words by repeating part of what person has just said. Can help express feeling. Mirroring clients words can help elaborate. Example: Client its hard having to stay in bed during my pregnancy. I have kids at home I'm worried about. Response: You feel worried and anxious about your children? 6.Confrontation - clarifying inconsistent info. Focusing the clients attention on an observed behavior, action, or feeling. Example: you look or you sound.... you said this but now you say this... clarify differences in nonverbal and verbal. 7. Interpretation- links events, implies cause. based on conclusion. may e incorrect but helps prompt further discussion Example: It seems when you have this... this happens... assuming an emotion. 8. Explanation- informing, factual and objective info. Example: you may not, telling what to do, rules. 9.Summary- condenses facts and validates what was discussed. signals the end of interview. both client and examiner are active participants. Example: review facts. allow client to make corrections.

A 30 year old woman reports having persistent intense pain in her right arm related to trauma sustained from a car accident 5 months ago. She states that the slightest touch or clothing can exacerbate the pain. This report is suggestive of: A. Referred Pain B. Psychogenic Pain C. Complex Regional Pain I D. Cutaneous pain

Complex regional pain I

Interview Contract

Concerns what the client needs and expects from health care and what you have to offer. Includes 1. Time and place of he interview and succeeding exam 2. Introduce yourself and a brief explanation of your role. 3. Purpose of interview. 4. How long it will take 5. Explanation of participation for each person. 6. Presence of any other people. 7. Confidentiality 8. Cost.

Summary

Condenses facts and validates what was discussed during the interview. At the end. What you and client agree health state to be.

Describe your own preparation as you encounter the patient for examination: your own dress, your demeanor, safety/Universal precautions, sequence of examination steps, instruction to patient

Consider your emotional state for the sake of the pt and try to reduce any anxiety, be self-assured, interact with pt in confident manner, make conversation, provide privacy, clean hands in the person's presence, begin with touch, avoid distractions and concentrate on one step at a time, explain to them what you are doing

10a. Fill in the labels indicated on the following illustration (neck structures).

Cricoid cartilage isthmus of thyroid sternomastoid muscle clavicle hyoid bone thyroid cartilage trachea manubrium

You note a lesion during an examination. The most complete description: A. raised, irregular lesion the size of a quarter, located on dorsum of left hand B. open lesion with no drainage or odor, approximately 1/4 inch in diameter C. pedunculated lesion below left scapula with consistent red color, no drainage or odor D. dark brown, raised lesion, with irregular border, on dorsum of right foot, 3 cm in size with no drainag

D

A scooped-out, shallow depression in the skin is called a(n): A) ulcer. B) excoriation. C) fissure. D) erosion.

D. An ulcer is a deeper depression extending into the dermis. An excoriation is a self-inflicted abrasion that is superficial. A fissure is a narrow opening of tissue or skin. An erosion is a scooped-out, shallow depression in the skin.

You note a lesion during a skin assessment. Which is the best way to document this finding? A) Raised, irregular lesion the size of a quarter, located on dorsal of left hand B) Open lesion with no drainage or odor, approximately 1/4 inch in diameter C) Pedunculated lesion below left scapula with consistent red color and no drainage or odor D) Dark brown raised lesion, with irregular border, on dorsal of right foot, 3 cm in size, with no drainage

D. Danger signs: abnormal characteristics of pigmented lesions are summarized by ABCDE: - Asymmetry (NOT regularly round or oval, two halves of the lesion do not look the same) - Border irregularity (notching, scalloping, ragged edges, poorly defined margins) - Color variation (areas of brown, tan, black, blue, red, white, or combination) - Diameter >6mm (i.e. size of pencil eraser), although early melanomas may be diagnosed at a smaller size - Elevation or Evolution

When taking the health history, the patient complains of pruritus. What is a common cause of this symptom? A) Excessive bruising B) Hyperpigmentation C) Melasma D) Drug reactions

D. Drug reactions can lead to pruritus or itching. Excessive bruising can occur in response to a traumatic event or a coagulation abnormality. It is associated with erythema, not pruritus. Hyperpigmentation is related to color changes. Melasma (also known as chloasma or the mask of pregnancy) is a facial skin discoloration related to hormones of pregnancy.

A student nurse has been assigned to teach fourth graders about hygiene. While preparing, the student nurse adds information about the sweat glands. Which of the following should be included while discussing this topic? A) There are two types of sweat glands: eccrine glands and sebaceous glands. B) The evaporation of sweat, a dilute saline solution, increases body temperature. C) Eccrine glands produce sweat and are mainly located in the axillae, anogenital area, and navel. D) Newborn infants do not sweat and use compensatory mechanisms to control body temperature.

D. Newborn infants' eccrine glands do not secrete sweat in response to heat until the first few months of life; newborn temperature regulation is ineffective. There are two types of sweat glands: eccrine glands and apocrine glands. The evaporation of sweat reduces body temperature. The apocrine glands produce a thick, milky secretion and open into the hair follicles; they are located mainly in the axillae, anogenital area, nipples, and navel.

At the end of the examination, the examiner should: A) complete documentation before leaving the examination room. B) have findings confirmed by another provider. C) compare objective and subjective data for discrepancies. D) review the findings with the patient.

D. At the end of the examination, the examiner should summarize the findings and share necessary information with the patient. The examiner may take short notes during the examination; complete documentation should occur after leaving the examination room. The examiner should have findings confirmed only if the finding is abnormal and requires confirmation from another examiner. Subjective and objective data should be compared throughout the history and physical examination.

Flattening of the angle between the nail and its base is: A) Found in subacute bacterial endocarditis. B) A description of spoon-shaped nails. C) Related to calcium-deficiency D) Described as clubbing.

D. Clubbing of nails occurs with congenital cyanotic heart disease, lung cancer, and pulmonary diseases. In early clubbing that angle straightens out to 180 degrees, and the nail base feels spongy to palpation. Then the nail becomes convex as the digit grows.

Checking for skin temperature is best accomplished by using: A) The palmar surface of the hands. B) The ventral surface of the hands. C) The fingertips. D) The dorsal surface of the hands.

D. Note the temperature of your own hands. Then us the backs (dorsa) of your hands to palpate the person and check bilaterally. The skin should be warm, and the temperature should be equal bilaterally; warmth suggests normal circulatory status. Hands and feet may be slightly cooler in a cooler environment.

9. Select the best description of an accurate assessment of a patients' respirations.

D. Count for 30 seconds after pulse assessment.

The nurse is completing a general survey for an older adult and notices the patient demonstrates a wider gait with short, uneven steps. Which of the following would be the most important action of the nurse? A. Ask another nurse to assess the patient. B. Refer the patient to a geriatric health care specialist. C. Notify the physician immediately. D. Document this as normal findings.

D. Document this as normal findings. An older adult with a wider gait with short, uneven steps is a normal finding. There is no need to immediately notify the physician since these are normal findings for an older adult. There is no need to refer the patient to a geriatric health care specialist since these are normal findings. Unless the nurse is a novice and this is the first time he/she is assessing an older adult, there is no need for a second opinion.

Identify the facial bone that articulates at a joint instead of a structure? A. Zygomatic B. Maxilla C. Nasal D. Mandible

D. Mandible

The nurse is completing a general survey assessing the level of consciousness of a person. Which of the following findings are expected in this assessment? A. No signs of acute distress are present B. Facial features symmetric with movement C. Patient appears drowsy and is having difficulty answering questions. D. Patient is alert and oriented to person, place, time, and situation.

D. Patient is alert and oriented to person, place, time, and situation. The normal/expected findings for level of consciousness includes: alert and oriented to person, place, time, and situation along with patient attends to and appropriately responds to questions. A patient who is drowsy and having difficulty answering questions is demonstrating decreased level of consciousness and should be assessed further. No signs of acute distress are the expected findings when the nurse assesses overall appearance. Facial features symmetric are expected findings when completing a general survey assessing physical appearance—facial features.

1. The 4 areas to consider during the general survey include:

D. Physical appearance, body structure, mobility, and behavior

Which of the following assessments should be included as part of the body structure portion of the general survey? A. Sexual development, skin color, and overall appearance B. Gait and range of motion C. Facial expression, speech pattern, and dress D. Stature, nutrition, and symmetry

D. Stature, nutrition, and symmetry When completing the body structure assessment portion of the general survey, the nurse should assess stature, nutrition, symmetry, posture, position, and for physical deformities. Sexual development, skin color, and overall appearance are included in physical appearance portion of the general survey assessment. Gait and range of motion are included as part of the mobility portion of the general survey assessment. Facial expression, speech pattern, dress, mood and affect, and personal hygiene should be included in the behavior portion of the general survey assessment.

Select the symptome that is least likely to indicate a possible malignancy. A Hx of radiation Tx to head neck upper ches B. Hx of using chewing tobacco C. Hx of large alcohol consumption D. Tenderness

D. Tenderness

11. The examiner suspects a patient has coarctation of the aorta. Which assessment finding supports this suspicion?

D. The pressure is lower than in the arm.

Providing resistance while the parient shrugs the choulders is a test of the statis of CN: A. II B.V C.IX D.XI

D. XI

An adult patient's pulse is 46 beats per minute. The term used to describe this rate is A. weak and thready. B. tachycardia. C. sinus dysrhythmia. D. bradycardia.

D. bradycardia. A heart rate of less than 50 beats per minute in an adult is bradycardia. A heart rate of greater than 90 beats per minute in an adult is tachycardia. Weak and thready describes the force of the pulse reflecting a decreased stroke volume. Sinus dysrhythmia is a pulse that is irregular; the heart rate varies with the respiratory cycle.

Physical appearance includes statements that compare appearance with A. mood and affect. B. nutrition. C. gait. D. stated age.

D. stated age. Physical appearance includes statements that compare appearance with age, sex, level of consciousness, skin color, and facial features. Behavior is compared with mood and affect. Mobility is compared with gait. Body structure is compared with nutrition.

Which entity regulates medicinal herbs? FDA Dietary Supplement Health and Education Act of 1994 (DSHEA) U.S. Department of Agriculture (USDA) American Medical Association (AMA)

DSHEA

When inspecting the eyeballs of an African American individual, which of the following might the examiner expect to observe?

Dark-skinned people may normally have small brown macules on the sclera.

15. Explain the significance of phase I, phase IV, and phase V Korotkoff sounds during blood pressure movement. Phase V, Silence.

Decreased velocity of blood flow. Streamlined blood flow is silent. The last audible sound is diastolic pressure

Decreased vision in the elderly may be due to which of the following conditions?

Decreased vision in the elderly is most commonly caused by cataracts, glaucoma, or macular degeneration.

Hypopituitary Dwarfism -

Deficiency in growth hormone in childhood results in retardation of growth below the 3rd percentile, delayed puberty, hypothyroidism, and adrenal insufficiency.

Identify the most common mental health problems that result from intimate partner violence.

Depression, suicidality, posttraumatic stress disorder (PTSD) symptoms, and problems with substance abuse.

________ is the elastic recoil, or resting pressure that the blood exerts constantly between each contraction

Diastolic pressure

Pulse pressure -

Difference between the systolic and diastolic and reflects the stroke volume

dysphagia

Difficulty in swallowing

Normal age- related finding in the lower extremities of an 80-year-old woman would be: A. Crepitus B. Joint Swelling C. Diminished strength bilaterally D. Unilateral muscle atrophy

Diminished strength bilaterally

Reflection

Echoes client's words by repeating part of what person has just said.

Acromegaly -

Disease characterized by enlarged features, especially the face and hands, caused by hypersecretion of the pituitary hormone after puberty, when normal bone growth has stopped; most often caused by a pituitary tumor

Achondroplastic Dwarfism -

Due to genetic disorder in converting cartilage to bone. Congenital skeletal malformation. relatively large head with frontal bossing midplace hypoplasia short stature short limbs often thoracic kyphosis, prominent lumbar lordosis, abdominal protrusion

c

During the evaluation phase of the nursing process, which action would be included? a. validating the nursing diagnosis b. establishing priorities related to patient care c. including the patient and family members d. establishing a timeline for planned outcomes

First Level Priority

Emergent, life threatening, and immediate (someone is going to die)

Which theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage?

Heritage consistency

4. Discuss the rationale for obtaining a family history.

Highlights those diseases/conditions that a particular patient may be at increased risk for.

_______ is also known as cushing syndrome ----> is due to excess cortisol secretion by adrenals. ----> Endogenous or exogenous ACTH stimulates the adrenals to release cortisol ---->It is characterized by central trunk and cervical obesity

Endogenous Obesity

Describe the unique nutritional needs for adolesence

Energy and protein requirements increase, calcium and iron requirements increase during this time. Careful meal and snack planning is essential to meet the increase nutrient demands.

The labyrinth of the inner ear is responsible for maintaining the body's:

Equilibrium. The labyrinth maintains the body's equilibrium.

10. Describe 3 qualities to consider when assessing the pulse.

Exercise, Emotion, Illness

Religious beliefs amy influence the person's

Explanation of the cause of illness Perception of its severity Choice of healers

Open posture

Extension of large muscle groups shows relaxation, physical comfort and willingness to share

Marfan's Syndrome -

Inherited condition that results in excessive cartilage formation at the growth plates, forming long arms and legs.

List the facial structures that should appear symmetric when inspecting the head

Eyebrows Ears Eyes Nose Mouth

Which of the following behaviors demonstrated by an individual may be indicative of hearing loss?

Frequently asking for the question to be repeated

Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include:

Functional assessment measures a person's self-care ability. The areas assessed under the self-esteem and self-concept section of the functional assessment include education, financial status, and value-belief system.

_________ is the hypersecretion of growth hormone from the anterior pituitary before puberty, leading to abnormal overgrowth of body tissues

Gigantism

A patient presents with acute pain of the abdomen. After the initial examination, how would you proceed? A. Withhold analgesic until diagnostic testing is completed B. Give patient medications as ordered C. Withhold analgesic until pain subsides. D. Determine what type of pain it is and proceed accordingly

Give pain medication as ordered.

Silence

Gives time to think, observe nonverbal cues.

Cultural and Linguistic competence

a set of congruent behaviors, attitudes, and policies that come together in a system among professionals that enables work in cross cultural situations

medicine really does not have a good taste; I swallow it down quickly in great haste. ( Nerve, name & #)

Glossopharyngeal, #IX

5. Define a pedigree or genogram.

Graphic family tree in at least 3 generations such as parents, grandparents, and siblings.

Questions asked in a Health Assessment (set A)

Have you noticed any changes? Do you have and chronic illnesses? Are you in pain now? What is your family health history? Any recent surgeries? Are you on any medications? Do you self exam? Any recent trauma?

Craniosynostosis is a severe deformity caused by:

premature closure of the sutures. Craniosynostosis is marked asymmetry caused by a severe deformity caused by premature closure of the sutures resulting in a long, narrow head.

9. Describe the facial characteristics that occur with down syndrome.

Head and face characteristics may include upslanting eyes with inner epicanthal folds; flat nasal bridge; small, broad, flat nose; protruding, thick tongue; ear dysplasia; short, broad neck with webbing; and small hands with single palmar crease.

What is the yin/yang theory of health?

Health exists when all aspects of hte person are in perfect balance

Discuss special considerations when interviewing an older adult.

Hearing May take more time Proper name

BRADYCARDIA -

Heart rate fewer than 50 or 60 beats per minute in the adult (depending on agency)

TACHYCARDIA

Heart rate great than 95 beats per minute in adult

What is tachycardia?

Heart rate great than 95 beats per minute in adult

While discussing the treatment plan, the nurse infers that the patient is uncomfortable asking the physician for a different treatment because of fear of the physician's reaction. In this situation, the nurse's verbal interpretation:

Helps the patient understand personal feelings in relation to his or her verbal message

The position of the tympanic membrane in the neonate is more ________________, making it more difficult to visualize with the otoscope.

Horizontal. The position of the eardrum is more horizontal in the neonate, making it more difficult to see completely and harder to differentiate from the canal wall.

Which of the following has been found to influence pain sensitivity in women? A) Age B) Hormonal changes C) Parity D) Weight

Hormonal changes

Which of the following findings is associated with Horner syndrome?

Horner syndrome is caused by a lesion of the sympathetic nerve. An individual with Horner syndrome will have a unilateral, small, regular pupil that does react to light and accommodation. There will be unilateral ptosis and absence of sweat on the same side.

Define the hot and cold theory of health and illness, and relate this to different types of foods and illnesses.

Hot/cold theory is an explanatory model with origins in the ancient Greek humoral theory. Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not on their physical characteristics. Illnesses believed to be caused by cold entering the body include earache, chest cramps, paralysis, gastrointestinal discomfort, rheumatism, and tuberculosis. Among illnesses believed to be caused by overheating are abscessed teeth, sore throats, rashes, and kidney disorders.

Gigantism -

Hypersecretion of growth hormone from the anterior pituitary before puberty, leading to abnormal overgrowth of body tissues

10. Contrast the facial characteristics of hyperthyroidism versus hypothyroidism.

Hyperthyroidism- exophthalmos (bulging eyeballs), thin silky hair and skin, infrequent blinking, and a staring appearance. Hypothyroidism- Note puffy, edematous face, especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows.

I hit the palate and places inside your mouth; even difficult words I help you to pronounce. ( nerve, name &#)

Hypoglossal, #XII

__________ is a deficiency in growth hormone in childhood results in retardation of growth below the 3rd percentile, delayed puberty, hypothyroidism, and adrenal insufficiency.

Hypopituitary Dwarfism

The first step in the nursing process?

INSPECTING (percussing, palpate, and auscultate)

State three purposes of a nutritional assessment

Identify individual nutritional requirements Provide information for designing a nutrition plan of care that will optimize nutrition and meet individual nutrient requirements. Establish a baseline data for evaluating the efficacy of nutritional care.

Describe the role that cultural heritage and values may play in an individual's nutritional intake.

Immigrants commonly maintain traditional eating customs long after the language and manner of dress of an adopted country become routine. Occupation, class, religion, gender, and health awareness also have a great bearing on eating customs. Cultural food preferences are often interrelated with religious dietary beliefs and practices. Other issues are fasting and other religious observations that may limit a person's food or liquid intake during specified times

Third Level Priority

Important to patient's health but can be addressed after more urgent problems are addressed (is it urgent and can it wait to address more life-threatening issues)

differentiate norms of traditional heritage and modern heritage

In a traditional heritage, people live within the norms of the traditional culture and in a modern heritage people live according to the norms of the dominant society

Discuss the rationale for obtaining a family history.

In the age of genomics an accurate family history highlights diseases and conditions for which a particular patient may be at increased risk.

Complete Total Health Database

Includes complete health history and full physical examination Describes current and past health state and forms baseline to measure all future changes

Describe the unique nutritional needs for various developmental periods throughout the life cycle.

Infants & Children: Breastfeeding is recommended for full-term infants for the first year of life because breast milk is ideally formulated to promote normal infant growth and development and natural immunity. Because cow's milk may cause gastrointestinal (GI) and kidney problems and is a poor source of iron and vitamins C and E, it is not recommended for infants until 1 year of age; fat (calories and essential fatty acids) is required for proper growth and central nervous system development. Adolescents: Caloric and protein requirements increase to meet this demand, and because of bone growth and increasing muscle mass (and in girls the onset of menarche), calcium and iron requirements also increase. Pregnancy: To support the synthesis of maternal and fetal tissues, sufficient calories, protein, vitamins, and minerals must be consumed during pregnancy. In particular, iron, folate, and zinc are essential for fetal growth, and vitamin and mineral supplements are often required. Adulthood: During adulthood growth and nutrient needs stabilize; the adult years are an important time for education to preserve health and prevent or delay the onset of chronic disease. Aging adult: Important nutritional features of the older years are a decrease in energy requirements caused by loss of lean body mass (the most metabolically active tissue) and an increase in fat mass. Because protein and vitamin and mineral 183needs remain the same or increase (e.g., vitamin D and calcium), nutrient-dense food choices (e.g., milk, eggs, cheese, and peanut butter) are important to offset lower energy/calorie needs.

What would you say to someone who tells you that infants do not remember pain and that they are too little for the pain to have any damaging effect?

Infants have the same capacity for pain as adults it is a myth that infants do not remember pain studies have shown infants remember pain

Explanation

Informing person, sharing data

Define and describe the technique of the 4 physical examination skills: Inspection, Palpation, Percussion., Auscultation

Inspection: concentrated watching of the individual as a whole and then of each body system Palpation: applying your sense of touch to assess texture, temperature, moisture, organ location and size or swelling, vibration or pulsation. Use fingertips, grasping actions, dorsa of hands and fingers, base of fingers Percussion: tapping skin with short, sharp strokes to assess underlying structures Auscultation: listening to the sounds in the body

SPHYGMOMANOMETER -

Instrument for measuring arterial blood pressure

Communication

Is exchanging information so each person clearly understands the other. Based on behavior conscious and unconscious and all behavior has meaning.

State a useful phrase for closing the interview.

Is there anything we missed or anything you would like to add?

Define the term mental disorder.

It is a clinically significant behavioral, emotional, or cognitive syndrome that is associated with significant distress (a painful symptom) or disability (impaired functioning) involving social, occupational, or key activities.

One of the critical-thinking skills is identifying assumptions. Explain how the following statement contains an assumption. How would you get the facts in this situation? "Ellen, you have to break up with your boyfriend. He is too rough with you. He is no good for you."

It is an assumption because the person speaking is placing his or her subjective opinion on "Ellen's" situation. For example, the person's idea of roughness could be incongruent with that of Ellen's, as could be the person's ideals of good and bad. In order to obtain the facts about the situation, one would have to state specific behaviors and occurrences in the relationship and ask Ellen whether or not she feels those behaviors are in alignment with her own ideals of health and safety.

What is the SBAR used for?

It is used for communication between healthcare providers. It contains a situation, a brief Hx, assessment, and recommendations

increase in bilirubin in the blood causing a yellow color in the skin, palate, and sclera. Dark skinned have yellow outer sclera.

Jaundice

Describe the technique for measuring head circumference and chest circumference on an infant. To measure chest circumference of the infant:

Lay the infant flat on his or her back. Use the thumb of one hand to hold the zero mark of the tape at the middle of the sternum. Use your other hand to wrap the tape snugly under the axillary area and around the back to meet at the midsternal area. Make sure the tape is at the nipple level of the chest and that it is not twisted. Read the measurement after the infant has exhaaled or during the resting phase between respirations. Read the tape measure to the nearest 1/2 inch or 0.1 centimeters.

Interpretation

Link events, may be incorrect but allows further discussion

Discuss the extra risk alcohol drinking poses to the aging adult.

Liver metabolism and kidney function are decreased, increasing bioavailability of acohol in the blood for longer, muscle mass decreases which means increased BAC levels, and increased risks of falls, depression, or GI problems. Also, risk of dementia is 5x higher in those who are alcoholics than those who are not.

4. Describe the characteristics of lymph nodes often associated with: acute infection, chronic inflammation, cancer.

Lymphadenopathy- enlaragement of the lymph nodes(>1cm) from infection, allergy, or neoplasm.

Formulate a response you would make to a client who has spoken in a sexually aggressive way.

Make it clear that that is inappropriate and unacceptable. Make professional relationship clear

Most facial bones articulate at a suture. Which facial bone articulates at a joint?

Mandible. The facial bones articulate at sutures (nasal bone, zygomatic bone, and maxilla), except for the mandible. The mandible articulates at the temporomandibular joint.

Matching: Color Change A. Intense redness of the skin due to excess blood in the dilated superficial capillaries B. Bluish mottled color that signifies decreased perfusion C. Absence of red-punk tones from the oxygenated hemoglobin in blood D. Increase in bilirubin in the blood causing a yellow color in the skin Descriptor: 1. ___ Pallor 2. ___ Erythema 3. ___ Cyanosis 4. ___ Jaundice

Matching: Color Change 1. C 2. A 3. B 4. D

Matching: Skin Color Change A. Harlequin B. Erythema toxicum C. Acrocyanosis D. Physiologic jaundice E. Carotenemia F. Café au lait spot G. Cutis marmorata Descriptor: 1. ___ Tiny, punctate red merciless and papules on the cheeks, trunk, chest, back, and buttocks. 2. ___ Lower half of body turns red, upper half blanches. 3. ___ Transient mottling on trunk and extremities. 4. ___ Bluish color around the lips, hands, fingernails, feet, and toenails. 5. ___ Large round or oval patch of light brown usually present at birth. 6. ___ Yellowing of skin, sclera, and mucous membranes due to increased numbers of red blood cells hemollyzed after birth. 7. ___ Yellow-orange color in light-skinned persons from large amounts of food containing carotene.

Matching: Skin Color Change 1. B 2. A 3. G 4. C 5. F 6. D 7. E

Matching: Skin Layers A. Epidermis B. Dermis C. Subcutaneous Descriptor: 1. ___ Basal cell layer 2. ___ Aids protection by cushioning 3. ___ Collagen 4. ___ Adipose tissue 5. ___ Uniformly thin 6. ___ Stratum corneum 7. ___ Elastic tissue

Matching: Skin Layers 1. A 2. C 3. B 4. C 5. A 6. A 7. B

Systolic pressure -

Maximum pressure felt on the artery during left ventricular contraction, or systole

_________ is the pressure-forcing blood into the tissues, averaged over the cardiac cycle. ----->Close to diastolic pressure plus one-third of pulse pressure

Mean arterial pressure (MAP)

HEEADSSS

Method of interviewing adolescents that focuses on: Home environment Education/employment Eating Activities, peer-related Drugs Sexuality Suicide/depression Safety from injury/violn

Emotions-

Momentarily rises with fear, anger and pain as a result of stimulation of the sympathetic nervous system

Differentiate abuse from neglect.

Neglect is a "failure to provide the necessary care, aid or guidance to dependent adults or children by those responsible for their care." Types of abuse include: Physical abuse - such as punching, hitting, slapping, burning etc. Sexual abuse - forcing someone to take part in sexual activity against their will.

Petechiae

a small red or purple spot caused by bleeding into the skin.

hematoma

a solid swelling of clotted blood within the tissues.

While taking a history, the patient describes a burning, painful sensation that moves around the toes and bottoms of the feet. These symptoms suggest: A. Nociceptive pain B. Neuropathic Pain C. Visceral Pain D. Muscular Pain

Neuropathic pain

Second Level Priority

Next in urgency, requiring attention so as to avoid further deterioration (something needs to be done so that there is no further deterioration)

Identify the differences between nociceptive and neuropathic pain. Which word will people use to describe nociceptive and neuropathic pain?

Nociceptive are specialized nerve endings, design to detect painful sensations from the periphery and transmit them to the CNS. Nociceptive are located primarily within the skin, joints, CT, muscle, and thoracic, abdominal, and pelvic viscera. Neurophatic: Is pain that does not adhere to the typical and rather predictable phases in nociceptive pain. It is pain "caused" by a lesion or disease of the somatosensory nervous system

7. Describe the characteristics of normal cervical lymph nodes during childhood.

Not normally palpable in infants. Child's nodes are palpable (3 mm normal) and feel more prominent than an adult's until after puberty with tissue atrophy. They should move easily, and are not tender.

Explain the clinical changes associated with each type of malnutrition: obesity, marasmus, kwashikor, marasmus-kwashikor mix

Obesity: Obese appearance Marasmus: Starved appearance Kwashiorkor: Well-nourished appearance Marasmus-kwashiorkor mix: Emaciated appearance

sense of smell?

Olfactory

when you have a cold, I do not do well; A running nose really affects my sense of smell. (Nerve, name & #)

Olfactory, #I

Contrast open-ended versus closed questions, and explain the purpose of each during the interview

Open ended- require a story, or narrative, begins a new topic. starts conversation Closed questions- are more detailed, and direct questions. asks for specific information.

Open-ended vs Closed questions: explain the purpose of each during an interview.

Open-ended questions: asks for longer narrative information; unbiased; leaves the person free to answer in any way. These are good to use to begin the interview or to gain more information when a new topic is brought up during the interview. Closed questions: questions that ask for specific information and elicit a short, one- or two- word answer, a "yes" or "no," or a forced choice. These are good to ask when filling in details that might have been missed in the clients' narrative. They are good to speed up the interview.

Define optimal nutritional status.

Optimal nutritional status is achieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands caused by growth, pregnancy, or illness

Differentiate organic brain disorder from psychiatric mental disorder.

Organic Disorder: caused by brain disease of known specific organic cause (e.g., delirium, dementia, alcohol and drug intoxication, and withdrawal). Psychiatric Mental Disorder: in which an organic etiology has not yet been established (e.g., anxiety disorder or schizophrenia).

PQRSTU

P - provocative or palliative Q - quality or quantity R - region or radiation S - severity scale T - timing/onset U - understand patient's perception

PQRSTU Mnemonic

P = Provocative or palliative Q = Quality or quantity R = Region or radiation S = Severity scale: 1 to 10 T = Timing or onset U = Understand patient's perception of problem

You must be aware of traditional folk practices and assess them

PAtients may seek help from biomedical health professions as wella s traditional healers

10c. Fill in the labels indicated on the following illustration (neck lymph nodes).

Posterior auricular occipital jugulodigastic superficial cervial posterior cervical supraclavicular preauricular submandibular submental Deep cervial chain

2. Describe normal posture and body build?

Posture-a person stands comfortably erect as appropriate for age

What occurs during transduction (the first phase of nociceptive pain)? A) Pain signals move from the site of origin to the spinal cord. B) The pain impulse moves from the spinal cord to the brain. C) The brain interprets the pain signal. D) Chemical mediators are neutralized to decrease the perception of pain.

Pain signals move from the site of origin to the spinal cord.

What disease is characterized by a flat, expressionless, or mask-like face, a staring gaze, oily skin, and elevated eyebrows?

Parkinson disease. Facial characteristics of Parkinson disease include a flat and expressionless face that is "mask-like" with elevated eyebrows, a staring gaze, oily skin, and drooling.

Which of the following is the most reliable indicator for chronic pain? A) Magnetic resonance imaging (MRI) results C) Patient self-report D) Tissue enzyme levels D) Blood drug levels

Patient self-report

At which phase does the individual become aware of a painful sensation? A. Modulation B. Transduction C. Perception D. Transmission

Perception

Pain issues should be anticipated in a cognitively impaired older adult with a history of: A. Constipation B. Peripheral vascular disease C. COPD D. Parkinson Disease

Peripheral vascular disease

List the significant information considered in each of the 4 areas of a GENERAL SURVEY.

Physical Appearance, Body structure, Mobility, and Behavior.

Describe the technique for measuring head circumference and chest circumference on an infant. To measure head circumference of an infant:

Position the infant on the examination table or ask the parent to hold the infant. Use a thumb or finger to hold the zero mark of the tape measure against the infant's forehead just above the eyebrows. Use your other hand to bring the tape around the infant's head, just above the ears, over the occipital bone at the back of the head, and back to the forehead to move the zero mark on the tape. Pull the tape snug to compress the hair, but not too tight. Read the tape measure to the nearest 1/2 inch to 0.1 centimeters. Record the reading.

When using the ophthalmoscope, you would

remove your own glasses and approach the patient's left eye with your left eye

Mean arterial pressure -

Pressure-forcing blood into the tissues, averaged over the cardiac cycle. Close to diastolic pressure plus one-third of pulse pressure

CRIES is an inappropriate pain assessment tool for: A. Cognitively impaired older adults B. Children ages 2 to 8 years C. Infants D. Preterm and term neonates

Preterm and term neonates

Facial characteristics of hypothyroidism

Puffy face around the eyes dry skin dry course hair dry facial hair

________ is the difference between the systolic and diastolic and reflects the stroke volume

Pulse pressure

c

Question 1 of 10 Obesity in adults is defined as a) excess body fat placed predominately within the hips and thighs. b) excessive body fat leading to body weight 5% above ideal. c) a body mass index of 30 or greater. d) overnourished.

b

Question 2 of 10 Which of the following is the reason for increased caloric and protein requirements during adolescence? a) Decreased dependence on parents. b) Rapid physical growth and increasing muscle mass c) Changes in diet d) Change in cognitive and psychological factors

c

Question 3 of 10 A dietary practice to restrict meat on certain days such as Ash Wednesday and Fridays during Lent is an example of what type of nutritional influence? a) Ethnic b) Economic c) Religious d) Cultural

c

Question 4 of 10 Nutritional status is best determined by a) triglycerides. b) 24-hour diet recall. c) serum albumin. d) clinical manifestations.

b

Question 5 of 10 In order for a weight-loss program to be effective, what fat intake would be considered a low-fat diet? a) Mostly trans-fatty acid or saturated fat b) Between 20% and 25% of the total calorie intake c) Between 10% and 20% of the total calorie intake d) Less than 300 mg per day

b

Question 6 of 10 For optimum health, infants and children up to 2 years of age should receive whole milk. What component of whole milk is essential for neurologic development? a) Fortified vitamin D b) Fat c) Pasteurized protein d) Lactose

c

Question 7 of 10 A comprehensive nutritional assessment always includes a) a direct observation of feeding and eating processes. b) a comprehensive metabolic panel. c) anthropometric measures. d) a work history.

a

Question 8 of 10 Which of the following is the most accurate and easy to implement nutritional assessment method? a) Food diary b) 24-hour recall c) Food frequency questionnaire d) Direct observation

ade

Question 9 of 10 Which of the following signs and symptoms would indicate malnutrition? (Select all that apply.) Select all that apply. A) Lips cracked and pale pink, tongue beefy red. b) Skin color appropriate for race, intact, without evidence of dryness c) Erect posture with symmetric gait and muscle tone appropriate for age d) Hair dull and dry e) Bleeding gums

Discuss the impact that racial and cultural diversity of individuals has on the U.S. health care system.

Racial and cultural diversity is continuously expanding in the U.S. - "In 2043 the United States is expected to become a majority-minority nation". Because the U.S. is such a "melting pot" of people, not one single approach is beneficial to every person. With that being said, in order to provide truly holistic health care, one must take into consideration ones racial and cultural backgrounds in order to provide them with the best care. It is also important to know how to treat people of different cultures, so healthcare workers across the country are traveling all over the globe to learn how to effectively meet health needs and treat people by means of their cultural backgrounds.

8. List the conditions associated with parotid gland enlargement.

Rapid painful inflammation of the parotid occurs with mumps, blockage of a duct, abscess, or tumor. Note swelling anterior to lower ear lobe. Stensen duct obstruction can occur in aging adults dehydrated from diuretics or anticholinergics.

Describe 3 qualities to consider when assessing the pulse.

Rate: normal range is 50-90 Rhythm: even tempo Force: shows strength of heart's stroke volume

Define the Pitch of sound wave. Amplitude, Quality, Duration of the following percussion notes: Resonance, Hyperresonance, Tympany, Dull, Flat

Resonance: medium-loud, low, clear, hollow, moderate duration, over normal lung tissue Hyperresonance: Louder, lower, booming, longer duration, over child's normal lung, abnormal in the adult Tympany: loud, high, musical drum-like, sustained longest duration, over an air-filled viscus Dull: soft, high, muffled thud, short, relatively dense organ as liver or spleen Flat: very soft, high, a dead stop of sound, absolute dullness, very short duration, over thigh muscles or bone or tumor

11. Relate the qualities of normal respirations to the appropriate approach for counting them.

Relaxed, -Regular, Automatic, Silent, Count without the patient being aware

What is the best description of the consumer safety precautions for herbal supplements? Reliable data on product efficacy is scarce. Medicinal herbs are under strict U.S. Food and Drug Administration (FDA) control. Herbs in tamper-resistant containers are safe. The package labeling clearly states product safety.

Reliable data on product efficacy is scarce.

Religion and spirituality may be a source of comfort for patients and their significant others

Religion and spiritual leaders may strongly influence the perception of health, illness, and practices

Teach Back

Repeat in own words what you just stated. Allows assessment of clients understanding.

Anger

Response to own feelings of anxiety or helplessness

Differentiate routine universal screening from indicator-based screening.

Routine universal - asking all adult patients each time they are in the healthcare system, no matter what their problem or concern, whether they have experienced IPV Indicator-based - this screening is used after abuse has been indicated to determine how recent and how frequent the abuse takes place; designed to know more specific details about abuse

stage II hypertension

S: more than 160 D: more than 100

________ is an instrument for measuring arterial blood pressure

SPHYGMOMANOMETER

_______ is the amount of blood pumped out of the heart with each heartbeat

STROKE VOLUME --> 70 mL in the average adult

The major neck muscle are the:

Sternomastoid and Trapezius

How would you modify your interviewing technique when working with a hearing-impaired person?

Simple sentence Sign language if needed. Face them so that they can see your mouth. Write things down if needed. Slow and supplement your voice Allow more time

_______ is the maximum pressure felt on the artery during left ventricular contraction, or systole

Systolic pressure

Most common non-English languages spoken at home

Spanish, Chinese, French, German, Tagalog

Internal factors

Specific to examiner.

Clarification

Summarize person's words, simply the statement, and ensure that you are on the right track.

Which is considered a common physiologic change that occurs with pain? A. Polyuria B. Hyperventilation C. Hyperactive Bowel Sounds D. Tachycardia

Tachycardia

Normal cervical lymph nodes are: a. smaller than 1 cm b. warm palpation. c fixed d. firm

a. smaller than 1 cm

Cephalhematoma is associated with: a. subperiosteal hemorrhage b. increased intracranial pressure c. down syndrome d. mental retardation

a. subperiosteal hemorrhage

Collaborative Problems

approach to treatment involves multiple disciplines (try new things)

The normal color of the optic disc is:

The color of a normal optic disc will range from creamy yellow-orange to pink.

c

The concept of health and healing has evolved in recent years. Which is the best description of health? a. Health is the absence of disease. b. Health is a dynamic process toward optimal functioning c. Health depends on an interaction of mind, body, and spirit within the environment. d. Health is the prevention of disease.

Diastolic pressure -

The elastic recoil, or resting pressure that the blood exerts constantly between each contraction

b

The expert nurse differs from the novice nurse by acting without consciously thinking about the actions. This is referred to as a. deductive reasoning b. intuition c. the nursing process d. focused assessment

The extraocular muscles consist of four straight or ________ muscles and two slanting or ______ muscles.

The four straight, or rectus, muscles are the superior, inferior, lateral, and medial rectus muscles. The two slanting, or oblique, muscles are the superior and inferior muscles.

While evaluating the health history, the nurse determines that the patient subscribes to the hot/cold theory of health. Which of the following will most likely describe this patient's view of wellness?

The humors must be balanced

Describe the 4 sources of error that may occur when using the 24 hour diet recall

The individual or family member may not be able to recall type of amount of food eaten. intake within the past 24 hours may be atypical of usual intake. The individual of family member may alter the truth or a variety of reasons. Snack items and the use of gravies, sauces, and condiments may be underrreported.

The lens of the eye functions as a:

The lens serves as a refracting medium, keeping a viewed object in continual focus on the retina.

Identify the most common physical health problems that result from intimate partner violence.

The most obvious health problem caused by abuse from IPV is injury; including lacerations and choking. Abused women also suffer from significantly higher neurologic, gastrointestinal, and gynecologic symptoms and chronic pain. Reproductive health is also significantly affected in abused women.

d

The nurse uses health promotion activities with a new patient. What would this focus include? a. the nurse would try to change the patient's perception of disease. b. the nurse would search for identification of biomedical model interventions c. the nurse would help to identify negative health acts of the patient d. the nurse would empower the patient to choose a healthier lifestyle.

Data collection for the general survey begins: at the first encounter. at the beginning of the physical examination. while taking vital signs. during the mental status examination.

at the first encounter. The general survey is initiated at the first encounter with the patient.

The most reliable indicator of pain in the adult is: A. The degree of physical functioning B. Nonverbal behaviors C. The MRI findings D. The patient's self-reporting

The patient's self-report

While caring for a preterm infant, you are aware that: A. Inhibitory neurotransmitters are in sufficient supply y 15 weeks gestation. B. The fetus has less capacity to feel pain C. Repetitive blood draws have minimal long-term consequences. D. The preterm infant is more sensitive to painful stimuli.

The preterm infant is more sensitive to painful stimuli.

State the purpose of the complete health history.

The purpose of the health history is to collect subjective data; what the person says about himself or herself. The history is combined with the objective data from the physical examination and laboratory studies to form the database. The database is used to make a judgment or a diagnosis about the health status of the individual.

Discuss the rationale for obtaining a systems review.

The purposes of this section are (1) to evaluate the past and present health state of each body system, (2) to double-check in case any significant data were omitted in the Present Illness section, and (3) to evaluate health promotion practices. The order of the examination of body systems is roughly head to toe.

Describe the environmental conditions to consider in preparing the examination setting

The room should be warm and comfortable for the pt and private. Remove any distracting items, make sure it is quiet, and make sure there is good lighting. Have your equipment near by for your convenience and for you pt to see

1. The major neck muscles are the:

The sternomastoid and the trapezius; they are innervated by cranial nerve IX, the spinal accessory.

Define the use of prescription opioid pain relievers for a nonmedical use.

The use of prescription opioid drugs for a nonmedical use can be defined as using it over the prescribed amount, getting the drug from a friend or relative for recreational use, or buying it off of a friend/relative or drug dealer. This is the 2nd most common form of illicit drug use.

List and define 3 major theories about how people view the causes of illness.

Theories of causation have been formulated on the basis of ethnic identity, religious beliefs, social class, philosophic perspectives, and level of knowledge. Biomedical: assumes that all events in life have a cause and effect, that the human body functions more or less mechanically, that all life can be reduced or divided into smaller parts (e.g., body, mind, and spirit), and that all of reality can be observed and measured (e.g., intelligence tests and psychometric measures of behavior). Naturalistic: Found most frequently among American Indians, Asians, and others who believe that human life is only one aspect of nature and a part of the general order of the cosmos. These people believe that the forces of nature must be kept in natural balance or harmony. Magicoreligious: The basic premise is that the world is an arena in which supernatural forces dominate.

Which of the following is true regarding language barriers and health care?

There are laws addressing language barriers and health care

What would you say to a colleague who remarks that the individual with Alzheimer disease does not feel pain and therefore does not require an analgesic?

There are no studies that show older adults or people with diminished cognitive abilities have less pain.

Which mental function is the Four Unrelated Words Test intended to test?

This tests New Learning in cognitive function and the person's ability to lay down new memories.

9. Describe the tympanic membrane and temporal artery thermometers, and compare their use with other forms of temperature measurements.

Tympanic membrane and temporal artery thermometer are fast and comfortable. Oral and rectal thermometers are unsafe.

Describe the provisions of Title VI of the Civil Rights Act of 1964.

Under the provisions of Title VI of the Civil Rights Act of 1964, when people with LEP seek health care in settings such 14as hospitals, nursing homes, clinics, daycare centers, and mental health centers, services cannot be denied to them.

Self- Awareness

Understand own biases, prejudices and stereotypes.

Pain in the aging adult is considered to be: A. Part of the normal degenerative process B. Perceives to lesser degree C. An expected finding D. Unrelated to the aging process

Unrelated to the aging process

Differentiate among light, deep, and bimanual palpation

Use light palpation first to detect surface characteristics and accustom pt to being touched them perform deep palpation by using intermittent pressure to get a sense of what you are feeling. Bimanual palpation required you to use both hands to envelop/capture certain body parts

List the two end pieces of the stethoscope and the condition for which each is best suited

Use the diaphragm to listen to high-pitched sounds like breath, bowel, and normal heart sounds. Use the bell to listen to low-pitched sounds like extra heart sounds or murmurs

8. What changes in height and weight distribution would you expect from an adult in his or her 70s or 80s.

Weight-Body weight decreases. Muscles shrinkage. Sucutaneous fat is lost from face and periphery. Additional fat deposited on abdomen and hips. Height-Shorter. Shorter trunk with longer extremities

A patient is requesting pain medication and expresses a pain level of 9/10; however, the patient is up and smiling. How should you proceed? A. Complete a full physical examination. B.Check to see when the patient last received the pain medication and administer it if the time is appropriate. C. Call the provider and suggest a substance abuse consult. D. Use therapeutic communication Technique to determine the patient's current prescription drug use.

Use therapeutic communication Technique to determine the patient's current prescription drug use.

Receiving

Uses his or her own interpretations on your words. Based on past experiences, culture and self-concept.

Which of the following statements is true in regard to the results obtained from use of the Snellen chart?

Using the Snellen chart, the larger the denominator, the poorer the vision.

Sending

Verbal commnication, words you speak, vocalizaiton, the tone of voice. Nonverbal- body language- posture, gestures, facial expression, eye contact foot tapping, touch, where you place your chair.

cranial nerve VIII?

Vestibulocochlear

Empathy

Viewing the world from the others person. Recognition and acceptance. Feeling with the person, rather than feeling like the person. Ability to understand how he or she perceives his or her world.

During the physical examination, your patient is diaphoretic and pale and complains of dull pain in the LUQ of the abdomen. This is what type of pain? A. Cutaneous Pain B. Somatic Pain C. Visceral Pain D. Psychogenic Pain

Visceral Pain

Subjective data

What the person says about him or herself.

b

What type of database is most appropriate for an individual who is admitted to a long-term care facility? a. focused b. complete c. emergency d. follow up

d

What type of database is most appropriate when rapid collection of data is required and often compiled concurrently with lifesaving measures? a. complete b. focused c. follow up d. emergency

Objective date

What you obtain through physical examination Example: posture, physical appearance, ability to carry on a conversation, and demeanor

What is bradycardia?

When heart rate is fewer than 50 or 60 beats per minute in the adult (depending on agency)

6. Describe the tonic neck reflex in the infant.

When supine and the head is turned to one side (extension of same arm and leg, flexion of opposite arm and leg). The tonic neck reflex disappears between 3 and 4 months, and then the head is maintained in the midline; beyond 5 months may indicate brain damage.

a

Which best describes evidence based nursing practice? a. combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances. b. appraising and looking at the implications of one or two articles as they relate to the culture and ethnicity of the patient c. completing a literature search to find relevant articles that use nursing research to encourage nurses to use good practices. d. finding value based resources to justify nursing actions when working with patients of diverse cultural backgrounds.

d

Which is an example of objective data? a. patient's history of allergies b. patient's use of medications at home c. last menstrual period one month ago d. 2- x 5 cm scar present on the right forearm.

b, c, e

Which of the following actions/behaviors in the critical-thinking process are important for the novice nurse to remember? (Select all that apply.) a. disregard initial cues b. Approach assessment with a nonjudgmental attitude c. Cluster associated assessment data d. Perform assessment in whatever manner works for you. e. Avoid making assumptions

d

Which would be included in the database for a new patient admission to a surgical unit? a. all subjective and objective data gathered by a health practitioner from a patient b. all objective data obtained from a patient through inspection, percussion, palpation, and auscultation. c. A summary of a patient's record, including laboratory studies. d. All subjective and objective data, data gathered from a patient, and the results of any laboratory or diagnostic studies completed.

Which of the following statements regarding cultural/racial differences in the treatment of pain is true? A) White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms. B) Black and Hispanic individuals have been found to have a higher pain tolerance than white individuals. C) Pain modulation is more highly developed in black and Hispanic individuals. D) Neurotransmitters are more concentrated in white individuals than in black and Hispanic individuals.

White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms.

When an otoscope examination is performed on an older adult client, the tympanic membrane may be:

Whiter than that of a younger adult. During otoscopy the tympanic membrane of an older adult may be whiter in color than that of a younger adult. The tympanic membrane may also appear more opaque and dull.

14. Related the use of the wrong size blood pressure cuff to the possible findings that might be obtained.

Wider cuffs deliver false low reading and narrow cuffs give a false high reading (because it takes extra pressure to compress the artery.

Closed position

With arms and legs crossed, looks defensive and anxious.

While examining the broken arm of a 4-year-old boy; select the appropriate assessment tool to evaluate his pain status. A. 0 to 10 numeric rating scale B. Wong-Baker Scale C. Simple descriptor scale D. 0 to 5 numeric rating scale

Wong-Baker Scale

Define the yin yang theory of health and illness, and relate this to different types of foods.

Yin/Yang theory is the view that health exists when all aspects of the person are in perfect balance. It states that all organisms and objects in the universe consist of yin and yang energy forces. Yin energy represents the female and negative forces such as emptiness, darkness, and cold, whereas yang forces are male and positive, emitting warmth and fullness. Foods are classified as hot (yang) and cold (yin) in this theory and are transformed into yin and yang energy when metabolized by the body. Cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness.

c

You are reviewing assessment data of a 45- year - old male patient and note pain of 8 on a scale of 10, labored breathing, and pale skin color on the electronic health record. This documentation is an example of a. hypothetical reasoning b. diagnostic reasoning c. data cluster d. signs and symptoms

a

You are reviewing concepts related to steps in the nursing process for determining prioritization and developing patient outcomes. To what are these actions attributed? a. planning b. assessment c. implementation d. diagnosis

second

___________-level priority problems require prompt intervention to prevent further deterioration and may include mental status change, acute pain, or abnormal laboratory values.

first

____________-level priority problems are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing.

evidence based practice

_____________ ______________ _________________ is a systematic approach to practice that uses research evidence, clinical expertise, clinician knowledge, and the patient's preferences and values to make decisions about care and treatment.

critical thinking

_____________ ______________ is the multidimensional thinking process needed for sound diagnostic reasoning and clinical judgment.

third

_____________-level priority problems are important to the patients health but can be addressed after more urgent problems. Examples include lack of knowledge or family coping.

objective

_______________ data includes information obtained by the health care provider through observation and inspecting, percussing, palpating, and auscultating during the physical examination.

diagnostic reasoning

__________________ __________________ is the process of analyzing health data and drawing conclusions to identify diagnoses. (consists of attending to cues, formulating hypothesis, gathering data, and diagnosis)

assessment

___________________ is the collection of subjective and objective data about a patient's health.

collaborative

_____________________ problems are certain physiologic conditions in which the approach to treatment involves multiple disciplines.

complete

a ______________ database includes a complete health history and full physical examination, yielding the first diagnosis.

follow up

a _______________ database evaluates the status of any identified problem at regular intervals (short term and chronic)

focused

a _______________ database is used for a limited or short term problem. It is smaller in scope and more targeted than the complete database.

Title VI of the Civil Rights Act of 1964

a federal law that mandates that when people with limited English proficiency (LEP) seek health care settings such as hospitals, nursing homes, clinics, daycare centers , and mental health centers, services cannot be denied to them

Glaucoma

a group of eye diseases characterized by increased intraocular pressure

Spirituality is defined as

a personal effort to find meaning and purpose in life

The practitioner, entering the examining room to meet a patient for the first time, states: Hello, I'm M.M,. and I'm here to gather some information from you and to perform your examination. This will take about 30 minutes. D.D. is a student working with me. If it's all right with you, she will remain during the examination." Which of the following must be added to cover all aspects of the interview contract. a. A statement regarding confidentiality, patient costs, and the expectations of each person. b. the purpose of the interview and the role of the interviewer. c. Time and place of the interview and a confidentiality statement. d. An explicit purpose of the interview and a description of the physical examination, including diagnostic studies.

a. A statement regarding confidentiality, patient costs, and the expectations of each person.

List the barriers to evidence-based practice, both on an individual level and on an organizational level.

a. Can take up to 17yrs to implement findings into practice b. As individuals, nurses lack research skills in evaluating quality of research studies, are isolated from other colleagues knowledgeable in research, and lack confidence to implement change. c. Nurses lack time to go to the library to read research; health care institutions have inadequate library research holdings; and organizational support for EBP is lacking when nurses wish to implement changes in patient care.

List three health care interactions you have experienced yourself with another person from a culture or ethnicity different from your own. You may have been the patient or the provider—it makes no difference.

a. It is common for people of Hispanic or Caribbean descent to physically discipline their children. This often conflicted with the services we were supposed to provide. b. It was unethical as a counselor to share a meal in the home of our clients, but it was seen as disrespectful to deny food from clients that either came from the south (I worked in MA), or families from a Hispanic culture. This had to be taken into consideration when building a rapport and establishing a positive therapeutic relationship. c. This next example is not necessarily my own interaction but one I had facilitated. Sometimes, working with parents raised in another country and their children brought up here, as a therapist we had to facilitate their own interactions because although they had the same descent, the children adopted the American culture which made things difficult in the household.

For the following situations, state the type of data collection you would perform (i.e., complete database, focused or problem-centered database, follow-up database, emergency database). OxyContin overdose ______________; ambulatory, apparently well individual who presents at outpatient clinic with a rash ______________; first visit to a health care provider for a checkup ______________; recently placed on antihypertensive medication ______________.

a. OxyContin overdose: Emergency b. Rash: Focused c. Check-up: Complete d. Recently placed on new med: Follow-up

Differentiate subjective data from objective data by placing an S or an O after each of the following: complaint of sore shoulder ________; unconscious ________; blood in the urine ________; family has just moved to a new area ________; dizziness ________; sore throat ________; earache ________; weight gain ________.

a. Sore shoulder: S b. Unconscious: O c. Blood in urine: O d. Family moved to new area: S e. Dizziness: S f. Sore throat: S g. Earache: S h. Weight gain: O

What does active listening NOT include? a. Taking detailed notes during the interview. b. Watching for clues in body language. c. Repeating statements back to the person to make sure you have understood. d. Asking open-ended questions to explore the persons perspective.

a. Taking detailed notes during the interview.

List 8 items of information that should be communicated to the client concerning the terms or expectations of the interview.

a. Time and place of the interview/physical examination b. Introduction of myself and my role as the healthcare provider c. Purpose of the interview d. Duration of the interview e. Expectations of client/people involved f. Presence of anyone else during the interview g. Confidentiality agreement between myself/patient h. Any costs to the client

_________ is exhibiting an accurate understanding of the other person's feeling within a communication context. a. empathy b. liking others c. facilitation d. a nonverbal listening technique

a. empathy

It is normal to palpate a few lymph nodes in the neck of a healthy person what are the characteristics of these nodes? a. mobile, soft, non tender b. large clumped tender c. matted. fixed, tender, hard d. matted fixed non tender

a. mobile, soft, non tender

Bells palsy is characterized by a. unilateral paralysis of half the face. b. bulging eyeballs c. a face that appears mask like d. a puffy, edematous face

a. unilateral paralysis of half the face.

During an interview, a patient denies having any anxiety. The patient frequently changes position in the chair, holds his arms folded tight against his chest, and has little eye contact with the interviewer. The interviewer should. a. use confrontation to bring the discrepancy between verbal and nonverbal behavior to the patient's attention. b. Proceed with the interview. Patients usually are truthful with health care practitioners c. Make a mental note to discuss the behavior after the physical examination is completed. d. Proceed with the interview and examination as outlined on the agency assessment form. The patient's behavior is appropriate for the circumstances.

a. use confrontation to bring the discrepancy between verbal and nonverbal behavior to the patient's attention.

turns eye laterally?

abducens

Microaneurysm

abnormal finding of round red dots on the ocular fundus that are localized dilations of small vessels

tumor -

abnormal growth of tissue,

Cotton-wool area

abnormal soft exudates visible as gray-white areas on the ocular fundus

Macrocephalic

abnormally large head

Microcephalic

abnormally small head

15. Explain the significance of phase I, phase IV, and phase V Korotkoff sounds during blood pressure movement. Phase IV,

abrupt muffling. Sound mutes to a low pitched, cushioned murmur, blowing quality. Artery no longer closes in any part of cardiac cycle. Chang in quality, not intensity

Accommodation

adaptation of the eye for near vision by increasing the curvature of the lens

An older adult patient with dementia has a pain rating of 5 on the Pain Assessment in Advanced Dementia (PAINAD) scale. The nurse should: A) reassess the pain level in 3 to 4 hours. B) administer prescribed pain medication. C) ask the patient to verify the pain rating. D) use only nonpharmacologic pain relief interventions.

administer prescribed pain medication.

Pain signals are carried to the central nervous system by way of: A) perception. B) afferent fibers. C) modulation. D) referred pain.

afferent fibers.

Describe tonic neck reflex in infant

an Infant at two weeks can turn head from side to side

The configuration for individual lesions arranged in circles or arcs, as occurs with ringworm, is called:

annular

Fovea

area of keenest vision at the center of the macula on the ocular fundus

second largest

asians followed by blacks, american indians, alaska natives, native hawaiians, and other pacific islanders

The "A" in the ABCDE rule stands for:

asymmetry

An area of thin shiny skin with decreased visibility of normal skin markings is called:

atrophy

The use of euphemisms to avoid reality or to hide feelings is known as:

avoidance language

Knowledge of the use of personal space is helpful for the health care provider. Personal distance is generally considered to be: a. 0 to 1 1/2 feet b. 1 1/2 to 4 feet c. 4 to 12 feet d. 12 feet or more.

b. 1 1/2 to 4 feet

Children usually come for health care with a parent. At about what age should the interviewer begin to question the child himself or herself regarding presenting symptoms? a. 5 years b. 7 years. c. 9 years. d. 11 years.

b. 7 years.

With older adults, how should the examiner proceed with the interview? a. Proceed in a more organized and concise way. b. Consider the fatigue of the older person and break the interview into shorter segments. c. Ask a family member to complete some of the records while moving ahead with the interview d. Raise your voice if the patients does not appear to hear you.

b. Consider the fatigue of the older person and break the interview into shorter segments.

You conduct an admission interview. Because you are expecting a phone call, you stand near the door. Which would be a more appropriate approach? a. arrange to have someone page you so you can sit on the side of the bed. b. Have someone else answer the phone so you can sit facing the patient. c. Use this approach given the circumstances d. Arrange for a time free of interruptions after the initial physical examination is complete.

b. Have someone else answer the phone so you can sit facing the patient.

Which demonstrates a good understanding of the interview process? a. The nurse stops the patient each time something is said that is not understood. b. The nurse spends more time listening to the patient than talking. c. The nurse is consistently thinking of his or her next response so the patient will know he or she is understood. d. The nurse uses "why" questions to seek clarification of unusual symptoms or behavior.

b. The nurse spends more time listening to the patient than talking.

When interviewing a patient who does not speak English, the examiner should: a. Take advantage of family members who are readily available and willing to assist. b. Use a qualified medical interpreter who is culturally literate. c. Seek as much information as possible and then continue with the physical examination d. Wait until a qualified medical interpreter is available before starting the interview.

b. Use a qualified medical interpreter who is culturally literate.

The examiner suspects an infant's head is of abnormal size and can use which procedure to verify these findings? a. palpation b. measuring tape c. observing for symmetry of facial features d. noting absence of the tonic neck reflex

b. measuring tape

religion

belief in a divine or superhuman power or powers to be obeyed and worshipped as the creators and rulers of the universe; and a system of beliefs, practices, and ethical values

Religion

belief in a divine or superhuman power or powers to be obeys and worshipped as the creator or ruler of the universe. Spirituality is borne out of each person's unique life experience and his or her personal effort to find purpose and meaning in life

Drusen

benign deposits on the ocular fundus that show as round yellow dots and occur commonly with aging

Cultural conflicts

between nurses and patients from diverse backgrounds are related to different time and relationship perceptions

Bruit

blowing, swooshing sound heard through the stethoscope over an area of abnormal blood

Acrocyanosis

bluish color around the lips, hands, fingernails, feet, and toenails

Explain the clinical concerns associated with central obesity.

body fat that collects deep within the central abdominal area of the body is called visceral fat, is associated with increased risk for diabetes, stroke, hypertension, and cardiovascular disease. The risk of death from all causes may be higher in people with central obesity than those whose fat accumulates elsewhere in the body.

spiritualism

born out of each individuals unique life experience and his/her personal effort to find purpose and meaning in life. its an individual pursuit to discover a supreme being or some unifying truth that will give meaning, purpose, and integrity to existence.

Describe the unique nutritional needs for various developmental periods throughout the life cycle of infants and children.

breast milk is ideally formulated to promote normal infant growth and development and natural immunity. Should be receiving a daily vit. D supplement, solid foods can be introduced as the infant becomes physically able to handle them. Whole cow's milk should not be offered until the end of the first year, lower fat milk should be avoided until the age of two because it's not enough to support optimal growth and development

The meaning of health and illness is determined

by the way members of a person's culture define them. The perceived causes of illness and symptoms can be culturally based and may be viewed as biomedical (or scientific), naturalistic (or holistic), or magicoreligious.

Mr. B. tells you "Everyone here ignores me." You respond, "Ignores you?" This technique is best described as: a. Clarification b. Selective listening c. Reflecting d. Validation

c. Reflecting

A patient asks the nurse, "May I ask you a question?" This is an example of: a. an open-ended question b. A reflective question c. a closed question d. A double-barreled question

c. a closed question

Upon examination, the fontanels should feel: a. tense or bulging b. depressed of sunken c. firm slightly concave and well defined d. Pulsating

c. firm slightly concave and well defined

A throbbing unilateral pain associated with nausea vomiting and photophobia is characteristic of a. cluster headache b. subarachnoid hemorrhage c. migraine headache d. tension headache

c. migraine headache

culture- bound syndrome

condition that is culturally defined

When preparing the physical setting for an interview, the interviewer should:

conduct the interview at eye level and at a distance of 4 to 5 feet

Endogenous obesity is: due to inadequate secretion of cortisol by the adrenal glands. caused by excess adrenocorticotropin production by the pituitary gland. characterized by evenly distributed excess body fat. a result of excessive secretion of growth hormone in adulthood.

caused by excess adrenocorticotropin production by the pituitary gland. Endogenous obesity is caused by either the administration of adrenocorticotropin (ACTH) or excessive production of ACTH by the pituitary.

Bleeding into the periosteum during birth is known as:

cephalhematoma. A cephalhematoma is a subperiosteal hemorrhage resulting from birth trauma.

Explain the clinical concerns associated with Diabetes

chronic condition characterized by elevated blood glucose levels, often leads to other diseases or contributes to their development.

15. Explain the significance of phase I, phase IV, and phase V Korotkoff sounds during blood pressure movement. Phase I-Soft,

clear tapping, increasing in intensity. Systolic pressure-as the cuff pressure lowers to reach intrluminal systolic pressure, the artery opens, and blood first sputs into the brachial artery. Blood is at a very high velocity because of small opening of artery and large pressure difference across opening. This creates turbulent flow, which is audible

purpose of a complete health history

collect subjective data and combine it with objective data from physical examination and diagnostic tests

plaque -

collection of papules,

Mongolian spot

common variation of hyperpigmentation in Black, Asian, American Indian, and Hispanic newborns

Lentigines

common variations of hyperpigmentation; "liver spots"

State the purpose of nutritional labelling of food products

convey information about the nutrient content of food in a standardize format, which allows comparison among goods before purchase. Provides information on energy and 13 nutrients based on stated serving size.

10b. Fill in the labels indicated on the following illustration (skull).

coronal suture frontal bone lacrimal bone nasal bone nasal septum maxilla zygomatic gone mandibular sagittal suture parietal bone lambdoid suture temporal bone sphenoid bone occipital bone temporomandibular joint external acoustic meatus mastoid process C1, Atlas C2, Axis 3rd cervical vertebra

Each culture has its own healers who usually

cost less than tradition or biomedical providers

To perform an accurate assessment of respirations, the examiner should: inform the person of the procedure and count for 1 minute. count for 15 seconds while keeping fingers on the pulse and then multiply by four. count for 30 seconds after completing a pulse assessment and multiply by two. assess respirations for a full 2 minutes if an abnormality is suspected.

count for 30 seconds after completing a pulse assessment and multiply by two. Respirations should be counted for 30 seconds (if regular) and multiplied by two. The respirations should be counted after the pulse assessment.

fissure -

crack in skin going into dermis

A-V crossing

crossing paths of an artery and vein in the ocular fundus

secondary skin lesions

crust scale fissure erosion ulcer

Describe the role cultural heritage and values play in an individual's nutritional intake

cultural definition of food, frequency and number of meals eaten away from home, form and content of cermonial meals, food preparation methods, and amount and types of foods eaten, and regularity of food consumption. Other factors to consider include fasting and other religious observations that may limit a person's food or liquid intake during specified times.

Heritage consistency includes determination of a person's

cultural, ethnic, and religious background and socialization experiences

rationale and components of cultural care nursing

culturally sensitive culturally appropriate culturally competent

Endogenous Obesity -

cushing syndrome: is due to excess cortisol secretion by adrenals. Endogenous or exogenous ACTH stimulates the adrenals to release cortisol. It is characterized by central trunk and cervical obesity

bluish, dusky blue, mottled color to skin or mucous membranes, that signifies decreased perfusion - increased amount of unoxygenated hemoglobin. Dark skinned normally have bluish lips

cyanosis

Which statement best describes interpretation as a communication technique? a. Interpretation is the same as clarification b. Interpretation is a summary of a statement made by a patient. c. Interpretation is used to focus on a particular aspect of what the patient has just said. d. Interpretation is based on the interviewer's inference from the data that has been presented.

d. Interpretation is based on the interviewer's inference from the data that has been presented.

For what or with whom should be used during the interview? a. Only with individuals from a Western culture b. As a routine way of establishing contact with the person and communication empathy c. Only with patients of the same gender d. Only if the interviewer knows the person well.

d. Only if the interviewer knows the person well.

Because of adolescents' developmental level, not all interviewing techniques can be used with them. Which techniques should be avoided. a. Facilitation and clarification b. confrontation and explanation c. empathy and interpretations. d. Silence and reflection.

d. Silence and refleciton

If the thyroid gland is enlarged bilaterally, which of the following maneuvers is appropriate? a. check for a deviation of the trachea b. listen for a bruit over the carotid arteries c. listen for a murmur over aortic area. d. listen for a bruit over the thyroid area

d.Listen for bruit over the thyroid lobes

Presbyopia

decrease in power of accommodation that occurs with aging

Heritage consistency

degree to which a person's lifestyle reflects his or her traditional heritage. A person can possess values that are consistent with the norms of the traditional culture or that are modern (or acculturated to the norms of the dominant society).

heritage consistency

degree to which a persons lifestyle reflects his or her traditional heritage, whether it is american indian, european, asian, african or hispanic

Skin turgor is assessed to determine

dehydration

Flattening of the angle between the nail and its base is:

described as clubbing

two sections of child's health history that become separate sections b/c of importance to current health status

developmental and nutritional history

Describe unique nutritional needs for adulthood

diet that is rich in fruits and vegetables, low in total and saturated fat, and high in fibre. regular snacks, meals manage their weight better than those that have more irregular or erratic eating patterns.

dysphagia

difficulty in swallowing

Mydriasis

dilate pupils

Checking for skin temperature is best accomplished by using:

dorsal surface of the hands

Diplopia

double vision

Ptosis

drooping of upper eyelid over the iris and possibly covering pupil

vesicle -

elevated cavity containing free fluid,

pustule

elevated cavity with thick, cloudy fluid.

Viewing the world from another person's inner frame of references is called:

empathy

lymphadenopathy

enlargement of lymph nodes due to infection, allergy or neoplasm

Lymphadenoapathy

enlargement of the lymph nodes due to infection, allergy, or neoplasm

Uniformly thin. Stratum corneum. The thin, tough, outer layer of the skin

epidermis

basal cell layer.

epidermis

intense redness of the skin due to excess blood in the dilated superficial capillaries, as in fever or inflammation. Dark skinned can not see erythema, so must palpate skin for warmth, edema, hardening

erythmia

Describe the unique nutritional needs for pregnancy and lactation

essential that sufficient calories, protein, vitamins, and minerals are met. Vitamin supplement containing 400mcg folic acid daily. Taking colic acid at least 3 months before pregnancy and continuing throughout postpartum period.

hot cold theory of health and illness

explanatory model with origins in the ancient greek humoral theory. the four humors of the body regulate bodily functions in terms of temperature dryness and moisture. treatment is adding or subtracting heat dryness cold or wetness to restore balance or humors. Foods and illnesses are classified as hot or cold by their perceived effects on the body not on physical characteristics

Kyphosis of the spine is common with aging. To compensate, older adults will:

extend their heads and jaws forward. The older adult may show an increased anterior cervical (concave or inward) curve when the head and jaw are extended forward to compensate for kyphosis of the spine.

cranial nerve III moves this muscle?

eye

macule -

flat skin lesion

Ophthalmoscope

for inspecting the retina and other parts of the eye

Otoscope

for visual examination of the eardrum, outter ear

holistic- (naturalistic)

found most frequently among american indians, asians, and others who believe that human life is only one aspect of nature and a part of general order of cosmos. -posits that laws of nature creates imbalances, chaos, and disease

Florance Nightingale

founder if modern nursing and a reformer of hospital sanitation methods (founder of evidence-based research and found that the key to stopping the spread of infection between patients is good hand hygiene)

Pitch

frequency of the sound, how high or how low

Stage IV Pressure Ulcer

full-thickness - involves all skin layers and extends into supporting tissue -exposes muscle, tendon, bone, slough (stringy matter attached to wound bed), eschar (black or brown necrotic tissue)

One cause of visual impairment in aging adults is:

glaucoma

movement of the thorat?

glossopharyngeal

Arcus senilis

gray-white arc or circle around the limbus of the iris that is common with aging

Describe type 2 diabetes.

has manifestations ranging from predominant insulin resistance with relative insulin deficiency to a predominant secretory defect within insulin resistance

Many new immigrants

have little understanding of the modern health care systema nd medical and nursing practices and interventions. Many also speak and understand little or no English

Torticollis

head tilt due to shortening or spasm of one sternomastoid muscle

torticollis

head tilt due to shortening or spasm of one sternomastoid muscle

National Standards for Culturally and Linguistically Appropriate SErvice in Health Care

health care organizations should ensure the patients perceive effective, understandable, and respectful care in a manner compatible with their cultural health beliefs and practices and their preferred language

yin yang theory of health and illness

health is believed to exist when all aspects of the person are in perfect balance In this theory foods are classified as hot and cold and are transformed into yin and yang energy when it's metabolize. Yin foods are cold, yang foods are hot. cold foods are eaten with a hot illness, and vice versa.

Yin Yang Theory

health is believed to exist when all aspects of the person are in perfect balance. -States that all organisms and objects in the universe consist of yin and yang energy forces. in represents the female and negative forces such as emptiness, darkness, and cold. Yang are male and positive emitting warmth and fullness. Yin foods are cold, yang foods are hot. Cold foods are eaten with hot illnesses and vice versa.

Diurnal rhythm-

high in late afternoon and declines to an early morning low

non verbal communication is the primary form of communication for which group of individuals?

infants

Binaural interaction at the level of the brain stem permits:

identification and location of the direction of the sound. The function at the brainstem level is binaural interaction which permits locating the direction of a sound in space as well as identifying the sound.

Ensure privacy

if yo can't become alone create psychological privacy using curtains Make sure patient is comfortable with people in the room

vertigo

illusory sensation of either the room or one's own body spinning; not the same as dizziness

goiter

increase in size of thyroid gland that occurs with hyperthyroidism

Standard precautions

infection control to prevent transmission

Conjunctivitis

infection of the conjunctiva, "pinkeye"

Chalazion

infection or retention cyst of a meibomian gland, showing as a beady nodule on the eyelid

Blepharitis

inflammation of the glands and eyelash follicles along the margin of the eyelids

Objective Data

information that you can prove and it evidence-based

Amplitude

intensity of the sound

Nystagmus

involuntary, rapid, rhythmic movement of the eyeball

Describe the clinical concerns associated with metabolic syndrome

is a prevalanet, multifaceted condition characterized by distinctive collection of abnormalities, including abdominal obesity, hypertension, dyslipidemia, insulin resistance, and dysglycemia. Are at risk for developing diabetes and cardiovascular disaese.

Nutritional status

is the degree of balance between intake and nutrient requirements. This balance is affected by income, education, an individual's broad physical and social environments, nutritional literacy, and access to protective foods

Cafe' au lait

large round or oval patch of light brown usually present at birth

nodule -

larger elevated skin lesion

Hispanics

largest are the largest minority in the United States

folk healer

lay healer in the persons culture apart from the biomedical/scientific health care system

Duration

length of time the sound lingers

What is the cause of the red reflex

light reflecting from the retina

Explain the clinical concerns associated with obesity.

linked to diabetes, hypertension, cardiovascular disease, and some forms of cancer.

Auscultation

listening to the sounds of the heart, lungs, and other organs in the body

A patient who takes ginseng to improve memory takes many prescription drugs as well. Which laboratory parameter should the nurse check before administering medication as a means of assessing the pharmacokinetic effect of ginseng in this patient? Liver enzymes Serum creatinine Mental status Urine bilirubin

liver enzymes

8 characteristics to describe present health

location - precise site of pain character/quality - description ex: burning, stabbing, throbbing quantity or severity - quantify symptoms, quantify pain (1-10) timing - onset, duration, frequency setting - triggers aggravating and relieving factors associated factors - symptoms that accompany the primary patient's perception - how pt feels about issue

Bitemporal hemianopsia

loss of both temporal visual fields

Ectropion

lower eyelid loose and rolling outward

Entropion

lower eyelid rolling inward

Harlequin

lower half of body turns red, upper half blanches

primary skin lesions:

macule papule plaque nodule tumor wheal vesicle pustule

Describe unique nutritional needs for older adults

more prone to undernutrition and overnutrition. after age of 50 energy requirements decrease by 5% per decade. Normal physiological changes of aging directly affect nutritional status, diminished olfactory and taste sensitivity, medication use may interact with nutrients, vitamin supplements, and other prescription drugs. Synthesis of vitamin D decreases older adults need to take daily supplement.

The cover test is used to assess for:

muscle weakness

A severe deficiency of thyroid hormone leading to nonpitting edema, coarse facial features, dry skin, and dry coarse hair is known as:

myxedema. Myxedema (hypothyroidism) is a deficiency of thyroid hormone. If severe, the symptoms include nonpitting edema or myxedema; a puffy edematous face, especially around eyes (periorbital edema); coarse facial features; dry skin; and dry, coarse hair and eyebrows.

Specialized nerve endings that are designed to detect painful sensations are: A) synapses. B) dorsal horns. C) nociceptors. D) C fibers.

nociceptors.

Describe physical examination findings that might indicate pain.

nonverbal behaviors of pain trachycardia hypertension tachypnea

cranial nerves are designated by?

number and name

Inspection

observing the patient as a whole and then each body system

movement of eye muscle?

oculomotor, Trochlear, or abducens

OD

oculus dexter, or right eye

OS

oculus sinister, or left eye

In the United States

one in eight people are immigrants. One in every three residents belongs to a group other than single-race, non-Hispanic White

Cataract

opacity of the lens of the eye that develops slowly with aging and gradually obstructs vision

cranial nerve II?

optic

vision, eyesight?

optic

Liking others

optimistic view of people- an assumption of their strengths and a tolerance of their weaknesses. atmosphere of warmth and care. Make person responsible for themselves. Respect clients choice to follow guidelines or discard them

What conditions are more likely to produce pain in the aging adult?

osteoarthritis, peripheral vascular disease, cancer, osteoporosis, angina, chronic constipation

absence of red-pink tones from the oxygenated hemoglobin in blood, excessively pale, whitish pink color to lightly pigmented skin

pallor

Optic atrophy

pallor of the optic disc due to partial or complete death of optic nerve

Stage II Pressure Ulcer

partial-thickness skin erosion - loss of epidermis and possibly dermis -looks like shallow abrasion or open blister

provisions of title VI of the civil rights act of 1964

people with limited english proficiency cannot be denied service in a hospital, daycare, nursing home, clinic, and mental health care center

Ethincity

pertains to membership in a social group that claims to possess a common GEOGRAPHIC origin, migratory status, religion, race, language, shared values, traditions or symbols, and food preferences. One's cultural background is a fundamental component of one's ethnic background

The general survey consists of four distinct areas. These areas include: mental status, speech, behavior, and mood and affect. gait, range of motion, mental status, and behavior. physical appearance, body structure, mobility, and behavior. level of consciousness, personal hygiene, mental status, and physical condition.

physical appearance, body structure, mobility, and behavior. The general survey is a study of the whole person, covering the general health state and any obvious physical characteristics. The four areas of the general survey are physical appearance, body structure, mobility, and behavior.

External factors

physical setting

German Measles (Rubella) rash

pink, papular rash (similar to Measles, but paler) Distinguished from measles by: neck lymphadenopathy no Koplik spots

Socialization

process of being raised within a culture and acquiring the characteristics of the group. Education is a form of socializations

Neuropathic pain implies an abnormal: A) degree of pain interpretation. B) processing of the pain message. C) transmission of pain signals. D) modulation of pain signals.

processing of the pain message.

Sebaceous glands

produce lipid substance secreted through hair follicles that lubricate the skin

Apocrine glands

produce thick, milky secretion opens to hair follicles secretes during emotional/sexual stimulation

Eccrine glands

produces sweat opens to skin

Cultural care

professional health care that is culturally sensitive, appropriate, and competent

Cultural care nursing

professional health care that is culturally sensitive, appropriate, and competent

List functions of the skin:

protection prevents penetration perception temperature regulation identification communication wound repair absorption and secretion production of vitamin D

Exophthalmos

protruding eyeballs

The tympanic membrane thermometer: provides an accurate measurement of core body temperature. senses the infrared emissions of the cerebral cortex. is not used in unconscious patients. accurately measures temperature in 20 to 30 seconds.

provides an accurate measurement of core body temperature. The tympanic membrane thermometer (TMT) is an accurate measurer of core body temperature.

Argyll Robertson pupil

pupil does not react to light; does constrict with accommodation

wheal -

raised skin lesion with interstitial fluid,

Sebaceous hyperplasia

raised yellow papules with a central depression

Seborrheic keratosis

raised, thickened areas of pigmentation that look crusted, scaly, warty, dark, greasy, and "stuck on"

Emergency database

rapid collection of the database, often compiled concurrently with lifesaving measures

erythemia toxicum

rash, small pustules, normal, will go away

Cup-disc ratio

ratio of the width of the physiologic cup to the width of the optic disc, normally half or less

Red reflex

red glow that appears to fill the person's pupil when first visualized through the ophthalmoscope

Measles (Rubeola) rash

red-purple maculopapular blotchy rash first appears behind ears looks coppery and does not blanch Koplik spots in mouth (red-based elevations of 1-3mm)

Actinic keratosis

red-tan plaques that increase over the years to become raised and roughened

Conjunctivitis is always associated with

reddened conjunctiva

macrocehalic

refers to abnormally large head

microcephalic

refers to abnormally small head

Normocephalic

refers to round symmetric skill that is appropriately related to body size

Define the term percent daily value.

reflects the needs of a healthy individual who consumes 2000 to 2500 calories daily. It is used to express the food's content of nutrients rather than just serving as a weight measurement.

Astigmatism

refractive error of vision due to differences in curvature in refractive surfaces of the eye (cornea and lens)

Each person responds differently to the same stimulity

regardless of the primary culture and value system

A patient is admitted to the emergency room after a motor vehicle accident. The trachea is deviated to the left side. This finding is characteristic of:

right pneumothorax. The trachea is normally midline; the trachea will deviated to the unaffected side (left) with a right pneumothorax.

Physical environment

room temp, sufficient lighting, quiet setting, 4 to 5 feet

Normocephalic

round symmetric skull that is appropriately related to body size

Macula

round, darker area of the ocular fundus that mediates vision only from the central visual field

If the tympanic membrane has white dense areas, the examiner suspects:

scarring from recurrent ear infections. White dense areas indicate scarring on the tympanic membrane from recurrent ear infections.

To assess for early jaundice, you will assess:

sclera and hard palate

Asians

second largest minority, followed by Blacks, American Indians, Alaska natives, Native Hawaiians, and other Pacific islanders

Several changes occur in the eye with the aging process. The thickening and yellowing of the lens is referred to as:

senile cataract.

When people with limited English proficiency seek health care

services cannot be denied to them

erosion

shallow depression in skin such as stage 2 of pressure ulcers.

scale -

shedded dead skin cell

Chickenpox (Varicella)

shiny vesicles on erythmatous base - become pustules, then crusts very pruritic

Causes of Hypothermia

shock cardiac arrest arterial insufficiency Reynaud disease

A risk factor for melanoma is:

skin that freckles or burns before tanning

ulcer

sloughing of necrotic, inflamed tissue such as a stage 3 pressure ulcer.

papule

small palpable skin lesion,

ethnicity

social group within the social system that claims to possess variable traits such as common geographic origin, migratory status and religion

Xanthelasma

soft, raised yellow plaques occurring on the skin at the inner corners of the eyes

movement of the neck muscles?

spinal accessory

7. Describe the items included in a functional assessment.

spiritual resources, activity/exercise, sleep/rest, nutrition/ elimination, coping/ stress management, self esteem, self concept, interpersonal relationships, personal habits, occupational health, environmental hazard, and alcohol or illicit street drugs.

Papilledema

stasis of blood flow out of the ocular fundus; sign of increased intracranial pressure

Physical appearance includes statements that compare appearance with: mood and affect. stated age. gait. nutrition.

stated age. Physical appearance includes statements that compare appearance with age, sex, level of consciousness, skin color, and facial features.

A male patient who abuses alcohol tells the nurse that he is treating himself with kava. Which instruction should the nurse include in patient teaching? Avoid using the kava with alcohol. Use another herb besides kava. Stop taking the kava now. Use either the kava or the alcohol.

stop taking kava now

aids protection by cushioning. Adipose tissue.

subcutaneous layer

Be alert to symptoms that may constitute an eye emergency. Identify the symptom(s) that should be referred immediately.

sudden onset of vision change

socialization

the process of being raised within a culture and acquiring the characteristics of that group

2. List and define the critical characteristics used to explore each symptoms the patient identifies.

symptom analysis includes: 1. Location- precise location of issue, 2. Character/quality- sharp, dull, burning, aching, etc., 3. Quantity/severity- use pain scale, dressing changes, etc, 4. Timing- onset, duration, frequency 5. Setting- issue associated location or activities, 6. Aggravating or relieving factors- what makes it worse, brings it on, or makes it better. 7. Associated factors- other related symptoms/causes, 8. Patient's perception- impacts/meaning to patients life.

P Q R S T U

symptom analysis order pneumonic: P: Provocative/palliative - What brings it on? Activity happening when you first noticed it? What makes it better? Worse? Q: Quality/quantity - How severe is it? Look, feel, sound? R: Region/radiation - Where is it? Does it spread out? S: Severity scale - Rating on scale? Is it improving/worsening? T: Timing = When did it start? How long? How often? U: Understand patients perception- What do you think it means?

Percussion

tapping body to determine condition based on sound

ethnocentrism

tendency to view your own way of life as the most desirable, acceptable, or best and to act superior to anothers culture's lifeways

On the basis of median age

the Asian population tends to be younger

Visual acuity is assessed with

the Snellen eye chart

database

the ____________ is the totality of information available about the patient, including subjective data, objective data, and the patient's medical record and laboratory studies.

holistic

the ______________ health model assesses the whole person because it views the mind, body, and spirit as interdependent and functioning as a whole within the environment.

Lid lag

the abnormal white rim of sclera visible between the upper eyelid and the iris when a person moves the eyes downward

health/illness

the balance/imbalance of the person, both within ones being and in the outside world

Mobility

the ease of skin to rise (decreased with edema, Scleroderma)

disease burden

the impact on ADL's of older adults

Before determining whether cultural practices are helpful, harmful, or neutral, nurses must first understand:

the logic of the traditional belief systems

ADOPIE

the nursing process includes six phases which can be remembered using the acronym "____________________"

The palpebral fissure is:

the open space between the eyelids

The retinal structures viewed through the ophthalmoscope are:

the optic disc, the retinal vessels, the general background, and the macula

Identify the most reliable indicator of a person's pain.

the patient's self-report

diagnosis

the purpose of assessment is to make a judgement or _________________.

Lunula

the white linear markings that are normally visible through the nail and on the pink nail bed

Use of the ophthalmoscope: an interruption of the red reflex occurs when:

there is an opacity in the cornea or lens

crust -

thick, dried-out exudate from burst vesicles or pustules like in chickenpox

Milia

tiny white papules on cheeks and forehead and across the nose and chin caused by sebum that occludes the opening of the follicles

Erythema toxicum

tiny, punctate red macules and papules on the cheeks, trunk, chest, back, and buttocks

lesion

tissue destruction

Assessing factors related to heritage

to determine the depth to which you and the patient identify with a traditional heritage, that is, cultural beliefs and practices of the family, extended family, and an ethnoreligious community

Spirituality may be used

to find meaning and purpose of illnesses

Stethoscope

to listen for internal body sounds

The Doppler technique: is used to assess the apical pulse. augments Korotkoff sounds during blood pressure measurement. provides an easy and accurate measure of the diastolic pressure. measures arterial oxygenation saturation.

ugments Korotkoff sounds during blood pressure measurement. The Doppler technique may be used to locate peripheral pulse sites and for blood pressure measurement to augment Korotkoff sounds.

Anisocoria

unequal pupil size

Diopter

unit of strength of the lens settings on the ophthalmoscope that changes focus on the eye structures

Describe facial charecteristcs that occur with Down Syndrome

upslanting eyes flat nasal bridge thick tongue flat nose

When addressing a toddler during the interview, the health care provider should:

use short, simple, concrete sentences

Diaphragm

used for listening for high pitched sounds

Bell

used for listening for low pitched sounds

Follow-up database

used in all settings to monitor progress of short-term or chronic health problems

Which descriptions apply to the market for medicinal herbs in the United States? (Select all that apply.) Select all that apply. Viewed with growing skepticism Used with traditional therapies Less than $1 million in sales annually Used by less than 40% of the population Growing in numbers of users Heavily regulated by federal law

used with traditional therapies growing in numbers of users

Palpation

using hands to examine patient's body

sensations from visceral organs?

vagus

hearing and balance?

vestibulocochlear

A common error in blood pressure measurement includes: taking the blood pressure in an arm that is at the level of the heart. waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm. deflating the cuff about 2 mm Hg per heart beat. using a blood pressure cuff whose bladder length is 80% of the arm circumference.

waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm. Waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm will result in a falsely high diastolic pressure related to venous congestion in the forearm.

Subjective Data

what the patient says

You should guard against stereotyping and should also understand culture-bound syndromes,

which may have no equivalent from a biomedical perspective

magicoreligious

world is seen as an arena in which supernatural forces dominate -voodoo (african american) -witchcraft (african american) -faith healing (christian)

Carotenemia

yellow-orange color in light-skinned persons from large amounts of foods containing carotene

Physiologic jaundice

yellowing of skin, sclera, and mucous membranes due to increased numbers of red blood cells hemolyzed following birth

jaundice

yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood

Physiologic jaundice

yellowing of the skin, sclera, and mucous membranes that develops after the 3rd or 4th day of life due to increased numbers of RBCs that hemolyze after birth

In a multicultural country,

you must accept that differences exist and be open to the importance of these practices to the patient

Before you can understand the role that beliefs and values play in a person's life

you must understand culturally dominant values and personal values

To develop cultural care, you must have knowledge of

your personal heritage, heritage of the nursing profession, the health care system, and the patient

List and describe factors related to socialization.

• Acculturation: the process of social and psychological exchanges that take place when there are ongoing encounters between individuals of different cultures, with subsequent 15changes in either or both groups. • Assimilation: to take on the characteristics of the dominant culture. • Biculturalism: biculturalism and integration are bidirectional and bi-dimensional, inducing reciprocal changes in both cultures and maintaining aspects of the original culture in one's ethnic identity.

Explain 4 factors that could affect a patient's response to the mental status examination but have nothing to do with mental disorders.

• Any known illnesses or health problems such as alcohol use disorders or chronic renal disease • Current medications with side effects that may cause confusion or depression • The usual educational and behavioral level—note that factor as the normal baseline and do not expect performance on the mental status examination to exceed it • Responses to personal history questions indicating current stress, social interaction patterns, sleep habits, drug and alcohol use

Identify important elements of assessment for an abused person.

• Completing a head-to-toe physical exam • Taking down history of the abused person • Documentation of the abuse in pictures and writing • Assessing risk of homicide

Identify risk factors that may contribute to child maltreatment.

• Disabilities or chronic illnesses in children that may increase caregiver burden • Social isolation of families • Parents' lack of understanding of children's needs and of child development • Poverty and other socioeconomic disadvantages such as unemployment and low educational achievement • Family disorganization, dissolution, and violence, including IPV • Substance abuse in family • Young, single, non-biological parents • Poor parent-child relationships and negative interactions • Parental thoughts and emotions supporting maltreatment behaviors • Parental stress and distress, including depression or other mental health conditions • Community violence

Identify commonly used screening questions for older adult abuse.

• Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids, or medical care, or from being with people you wanted to be with? • Have you been upset because someone talked to you in a way that made you feel shamed or threatened? • Has anyone made you afraid, touched you in ways you do not want, or hurt you physically?

List at least 4 questions you could ask a patient that would screen for suicide ideation.

• Have you ever felt that life is not worth living? • Have you ever felt so blue that you thought of hurting yourself? • Do you feel like hurting yourself now? • Do you have a plan to hurt yourself?

Describe the patient response level of consciousness that would be graded as: lethargic/somnolent, obtunded, stupor/semicoma, come, delirium

• Lethargic or somnolent: 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. • Obtunded: 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. • Stupor or semicoma: 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. • 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. • Delirium: 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.

List 4 situations in which it would be necessary to perform a complete mental status examination.

• Patients whose initial brief screening suggests an anxiety disorder or depression. • Family members concerned about a person's behavioral changes such as memory loss or inappropriate social interaction. • Brain lesions (trauma, tumor, stroke). • Symptoms of psychiatric mental illness, especially with acute onset.

Identify some of the important elements of the child's medical history when assessing for suspected child maltreatment.

• Previous hospitalizations • Injuries • Chronic medical conditions • Frequent hospital visits • Delays in seeking care • Financial/social stress on family

List 2 potential sources of lethality in intimate partner violence situations.

• Suicide • Homicide

Identify commonly used screening questions for intimate partner violence.

• When you and your partner argue, are you ever afraid of him or her? • Does your partner try to control you? Where you go? Who you see? How much money you can have? • Has your partner ever forced you into sex when you did not want to participate?