Health Assessment assignment 1

nurse has assessed the breath sound of an adult client... best way to document

"bilateral lung sounds clear"

Working Phase

- data-gathering phase - verbal skills for this phase include your questions to the patient and your responses to what the pt has said -use both open and close-ended questions

introducing the interview

-address person with surname, shake hands if appropriate -introduce self -give reason for interview/visit -ask open-ended questions

Closing the Interview

-give pt the opportunity to ask questions and add anything else; final opportunity for self-expression -signal closing -give summary: recapitulation of what you have learned during the interview basically: -signals that the interview is ending and gives pt a last chance to share concerns and self-expression

light palpation

1-2 cm

moderate palpation

1-2 cm with circular motion

high pitched sounds by using stethoscope with __

1.5 inch diaphragm

what are the 3 phases of the interview?

1.introducing the interview 2.the working phase 3. closing the interview

deep palpation

2.5-5 cm

if patient answers yes to __ out of __ questions during CAGE assessment, its clear that it is likely that the client has a problem and should seek assistance additionally

3 out of 4

direct percussion

Direct percussion helps assess an adult's sinuses for tenderness and elicits sounds in a child's thorax

indirect percussion

Indirect percussion helps reveal the size and density of underlying thoracic and abdominal organs and tissues

diaphragm of stethoscope

Larger end of stethoscope used to detect breath sounds, normal heart sounds, and bowel sounds

dorsal surface of hand

Part of examiner's hand used to feel for temperature

ulnar surface or palm of hand

Part of examiner's hand used to feel for vibration, thrills, or fremitus

when asked to explain similarities and differences between objects... what is cognitive ability is being tested?

abstract reasoning

health history interview with angry adult client? nurse should __

allow the client to ventilate his or her feelings

nursing diagnostic phase

analysis of subjective and objective data to make a professional nursing judgement

before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to

arrive at conclusions about the client's health

while interviewing about nutrition habits, nurse should

ask the client for a 3-day recall of food intake

the nurse is interviewing a 78 year old client for the first time ... the nurse should __

assess the client's hearing

evaluation

assessing whether outcome criteria have been met and revising the plan of care if necessary

the nurse is preparing to meet a client in the clinic for the first time.. after reviewing the client's record the nurse should

avoid premature judgements about the client

preparing to document assessment findings?

avoid slang terms or labels unless they're direct quotes

during a client interview the nurse uses nonverbal expressions appropriately when the nurse

avoids excessive eye contact

alert

awake and oriented

stupor

awakens to painful stimuli and then goes back to sleep; has motor response of withdrawal, groans or mumbles

lithotomy position

back lying position with hips at edge of examining table and feet supported in stirrups; used for examination of female genitalia, reproductive tract and rectum

supine position

back lying position- examination of abdomen (small pillow under head and another under knees) ... allows easy access for palpitation of peripheral pulse

bimanual palpation

both hands

implementation

carrying out the plan of care

to arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data... after proposing possible nursing diagnoses, the nurse should __

check for the presence of defining characteristics

prone position

client lies on abdomen with head turned to one side; may be used to assess back and mobility of hip joint

nursing diagnosis

clinical judgment about individual, family, or community responses to actual or potential health problems and life processes

nursing assessment

collection of subjective and objective data

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed __

comprehensive exam

nursing assessment phase precedes other phases and is also __

continuous

during palpation of client's organs... the nurse palpates the spleen by applying pressure between 2.5 and 5cm... this is __

deep palpation

geriatric depression scale is used because

depression often mimics signs and symptoms of early dementia

planning

developing a plan of nursing care and outcome criteria

examine a client... nurse plants to palpate temperature of skin by using

dorsal surface of hand

error while documenting findings?

draw a line through error, write "error", initial

the nurse is interviewing a client in the clinic for the first time... when the client tells the nurse that he smokes two packs of cigs a day, the the nurse should __

encourage the client to quit smoking

assessment form commonly used in long-term care facilities is the nursing minimum data set... advantage of this form?

establishes comparability of nursing data across clinical populations

anxious client during first interview? nurse should __

explain the role and purpose of nurse / why she's there

alleviate client's anxiety during a comprehensive assessment by

explaining each procedure being performed and the reason for each

nurse is interviewing a client who is being treated for depression... enters room and client is sitting slumped/sad ... nurse should

express interest in the neutral/slumped manner

what factors indicate score of Glasgow coma scale

eye opening, appropriateness of verbal and motor responses

personality and spirituality

factors affecting mental health

sedentary lifestyle, substance abuse, exposure to violence

factors that may affect mental health

objective data

findings directly observed or indirectly observed through measurements (temperature)

assessing only one part of a client?

focused assessment

an assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a __

focused or problem-oriented assessment

medical examination

focuses on physiological status

result of nursing assessment is the __

formulation of the nursing diagnoses

the CAGE assessment is used by nurse to determine if

further assistance is needed

flatness

heard over bone

dullness

heard over fluid or solid organs

resonance

heard over lungs... hyper inflated with air

while interviewing adult client about stress/coping with stress... nurse should ask

how do you manage your stress

the nurse has interviewed a hispanic client with limited English skills... the nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation... the nurse should __

indicate acceptance of the client's cultural differences

most common percussion method

indirect percussion

during comprehensive assessment primary technique used by nurse is

inspection technique

for a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have __

knowledge of his or her own thoughts and feelings about these issues

while recording subjective data of an adult client who complains of pain in lower back... nurse should include ___ and ___

location of pain and pain relief measures

while interviewing a client for the first time, the nurse is using a standardized nursing history form... the nurse should

maintain eye contact while asking the questions from the form

after taking SLUMS tool to test mental status... nurse calculates score of 12... nurse should

make referral to primary health care provider for rather eval.

advantage for an institution to use an integrated cued/checklist type of assessment form

may be easily used by different levels of caregivers which enhances communication

while performing a physical exam on an older adult, nurse should use

minimal position changes

mental health

necessary for total health

Tympany

normally heard over abdomen / stomach

lethargy

opens eyes and answers questions but falls back asleep

level of consciousness ... what's lost first, what's lost last

orientation to time is usually lost first, orientation to person is lost last

information documented following SLUMS test

orientation, memory, speech, cognitive function

finger pads

part of examiner's hand used to feel for fine discriminations: pulses, texture, size, consistency, shape and crepitus

subjective data?

perception of pain

collaborative problem

physiological complications that nurses monitor to detect their onset or changes in status

sitting position

position used during much of physical examination... including examination of head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities

standing position

position used to examine male genitalia and to assess gait, posture, balance

using cued or checklist type of assessment form

prevents missed questions during data collection

referral problem

problem that requires the attention or assistance of other health care professionals

nurse is interviewing a client who has demonstrated manipulative behaviors during past clinic visits... nurse should

provide structure and set limits with the client

the depth and scope of nursing assessment has expanded significantly over the past several decades because of __

rapid advances in biomedical knowledge and technology

during the interview of an adult client, the nurse should

read each question carefully from the history form

nurses should clarify a client's statements by

rephrasing the client's statements

disadvantage of open-ended assessment form?

requires a lot of time to complete

to prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first __

review the client's healthcare record

subjective data

sensations or symptoms that can be verified by the client only (pain)

female client is assessed to have a score of 8points on the AUDIT ... this would indicate that

she has a hazardous drinking problem

sims' position

side-lying position used during rectal exam

obtunded

slow response, mumbles and incoherent, opens eyes to loud voice

bell of stethoscope

smaller end of stethoscope used to detect low-pitched sounds (abnormal heart sounds and bruits)

WHO definition of health

state of complete, physical, mental, and social well-being and not merely the absence of disease of infirmity

percussion

tapping surface to determine differences in density of underlying organs/tissues

during client interview, nurse asks questions about past health history.. primary purpose of asking about health history is __

to identify risk factors to the client and his or her significant others

mental disorder

underlying psychobiological dysfunction

coma

unresponsive to all stimuli

the nurse is interviewing a client in the clinic for the first time... the client appears to have a very limited vocabulary... the nurse should plan to __

use very basic lay terminology

blunt percussion

used to detect tenderness over organs by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface

keep an interview from going off course by

using close-ended questions

nurse plans to assess a newly admitted client... while gathering data nurse should --

validate all data before documentation of said data

object vinding?

vital sign

before physical exam

wash hands with soap and water

during an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals... this occurs during the working phase

working phase