health assessment chapters 1-7

Assessment

Collect the most specific and critical findings to support your problem list

HEENT

Dentures is written in what system?

Planning

Develop goals

C. Flow logically from identified diagnoses. D. Specify which steps are needed next

For each patient problem you identify you develop and record a plan. What must your plan do? Mark all that apply. A. Begin discharge planning B. Include referral to dietician C. Flow logically from identified diagnoses D. Specify which steps are needed next E. Identify timing of family involvement

B. Asking the appropriate questions

How does a nurse best facilitate the nursing health assessment? A. Maintaining privacy B. Asking the appropriate questions C. Formulating a nursing diagnosis D. Creating a nursing care plan

D. By generating plans early

How does an experienced nurse improve his or her efficiency and enhance the relevance and value of the data he or she collects? A. By conducting the assessment as rapidly as possible B. By utilizing an information source other than the patient C. By correlating medical diagnoses and nursing diagnoses D. By generating plans early

C. A question that elicits a graded response

How many steps ca you climb before you get short of breath? is an example of what kind of question? A. A question that offers multiple choices for answers B. A question that is qualitative in focus C. A question that elicits a graded response D. A question that demands an imprecise response

Skin breakdown

In what area do nurses use formalized screening and assessment tools? A. vital signs B. Skin breakdown C. Hand hygiene D. Kidney failure

1. Pre interview 2. Introduction 3. Working 4. Termination

List the phases of the interviewing process

Assessment

Subjective and objective data gathered initially during the health history and physical examination and the additional information collected on a daily basis

Well being

The primary goal of the nurse patient interview is to improve the _______ _________ of the patient

Diagnosis

Use your inferences about the structures and processes involved

Onset

When the sign or symptom began

A. past history

You are collecting data for a comprehensive health history on a patient new to your clinic. Under what component of the health history would you place data on a chronic childhood illness? a. past history b. health maintenance c. general information d. risk factors

B. None Currently

Your patient has been directly admitted from the doctors office. The only paperwork he has brought with him is his admission orders. You are gathering your admission data when ordered lab work is collected. When documenting your history, physical examination, assessment, and plan, what would you write under the heading "laboratory data"? A. Not recommended. B. None currently. C. Not relevant to patients care. D. Nothing. Enter as a late entry

D. more information regarding psychosocial issues

Your patient tells you that his chief complaint is "fatigue" When obtaining the patient history, what additional information might you want to elicit to try and pinpoint the patients "real problem" A. More information regarding family history B. More information regarding cognition C. More information from the patients peers D. More information regarding psychosocial issues

disapproval

_______ of behaviors or elements in the health history will only interfere with learning about the patient

c. proficiency

as a nursing student you learn that mastering all the components of the comprehensive history provides what? a. empathy b. avocacy c. proficiency d. authority

health

defined as a state of complete physical, mental, and social well being

psychiatric

depressed mood is written in what system?

health promotion, health education, environmental education

describe three ways in which nurses are able to influence the health of the patient

health patterns

documents personal/ social history and daily living routines

nursing presence

involves a sincere connection and sharing of human experience

spiritual assessment

involves a two tiered approach

reverse, yes, no

it can be disconcerting working with a person whose culture ___________ nodding the head for ______ and shaking the head for ______

cultural or minority

knowledge of the ________________ or ___________________ groups in your practice region will help you better understand and interpret the patients need

1. denial and isolation 2. anger 3. bargaining 4. depression or sadness 5. acceptance

list the stages of grief

respectful communication

maintaining an open inquiring attitude

standing

range of motion of the patients spine is checked in this position

primary prevention

reducing risk factors is an example of what form of prevention

sitting

reflexes are checked in this position

Evaluation

A continuing process that determines if the goal/outcomes have been attained

Relieving factors

Anything the patient has tried to make it go away

C. knowledge base and expertise

As a nurse becomes more proficient and comfortable in his or her role, what increases? A. Confidence and knowledge base B. time management and confidence C. Knowledge base and expertise D. Expertise and time management

Evaluation

Continue to monitor

Duration

How long the sign or symptom has been going on

Empathetic responses

Identify the patients feelings and then communicate understanding and acceptance

complete and congruent

Learning about the effects of the illness gives the nurse and the patient the opportunity to create a ______ and _______ picture of the problem.

Reassurance

Must be realistic. Avoid assuring the patient that everything will be alright

Treatments

Nursing interventions that are recommended

Implementation/interventions

Nursing interventions that help to achieve the goals stated

cultural

Remember that ______________________ background and individual taste influence preferences about interpersonal space

religion

a system of beliefs or a practice of worship

Breasts

abnormal nipple discharge is written in what system?

focused assessment

addresses specific concerns or symptoms is what type of assessment?

review/ physical comfort

before beginning the physical examination _______ the measures that promote the patients _____________ __________________ and make any adjustments needed in the lighting and surrounding environment

supine

cardiac auscultation is checked in this position

follow up history

carried out by a second shift nurse who is addressing a problem identified by an earlier nurse is what type of assessment?

objective data

considered to be the signs

comprehensive assessment

creates platform for health promotion through education and counseling is what type of assessment

emergency history

data collection is focused on the patients emergent problem is what type of history

cultural/ anxiety/ fear/ sadness

decreased eye contact may be ________ or may suggest _________,____________, or _____________________

secondary prevention

early treatment of diseases is an example of what form of prevention

hematologic

easy bruising is written in what system?

the nursing assessment

entails both a comprehensive health history and a complete physical examination

follow up history

gathering data to evaluate the outcomes of the plan of care is what type of assessment

Neck

goiter is written in what system?

religious practices

has being sick (or what has happened to you) made a difference in your practice of praying?

follow up history

having a problem or treatment plan evaluated is what type of assessment?

primary prevention

health education is an example of what form of prevention

respiratory

hemoptysis is written in what system?

standing

inspection for varicose veins is checked in this position

supine

inspection, auscultation, and percussion of the abdomen is checked in this position

Self awareness

intuitively knowing members of one's own group

different body systems

involvement of __________ _____________ _______________ may help toy to cluster the clinical data

partnering

making the relationship collaborative

family history

may include a genogram

dying patients

may not wish to confide in everyone they meet

holistic

nursing has long recognized and practiced _____________ care of the patient and attention to culture is a part of caring for the whole patient

chief complaints

one or more major symptoms or concerns

supine

palpation of femoral and popliteal pulses is checked in this position

tertiary prevention

rehabilitation programs are an example of what form of prevention

past history

risk factors are found in

subjective data

the basis for symptoms

collect data

the nurses initial role in health assessment is to ____________ ______

wasting/ rigid/ discomfort

the skillful nurse is thorough without ____________________ time, systematic without being ______________ gentle yet not afraid to cause _______________ should this be required

neurological

unilateral weakness is written in what system?

c. blood borne pathogens

universal precautions are primarily designed to protect the health care worker from what? A. STD's B. musculoskeletal injuries c. blood borne pathogens d. respiratory diseases

cultural humility

what concept is an approach to caring for patients from culturally diverse backgrounds? A. cultural humility b. ethnic sensitivity c. spiritual awareness d. cultural values

relation between spiritual beliefs and health

what do you think is going to happen to you?

a. listening

what is an important part of being present with a patient? a. listening b. understanding c. spiritual awareness d. cultural knowledge

sitting

assessment of cranial nerve function is checked in this position

focused assessment

assesses symptoms restricted to a specific body system is an example of what type of assessment?

primary prevention

focuses on improving overall wellness and protecting from disease or disability

Planning

Charting the best course to achieve the patients optimal wellness and comfort

Guided questioning

Options for expanding and clarifying the patients story

cardiovascular

paroxysmal nocturnal dyspnea is written in what system?

steps of clinical reasoning

1. identify abnormal or positive findings 2. Cluster the findings 3. Interpret findings in terms of probable process 4. Make hypothesis about the nature of patients problem 5. Test the hypotheses and establish a working nursing diagnosis 6. Develop a plan agreeable to the patient

B. Summarization

A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask the patient next. What is a useful interview technique for the student to use at this point? A. Transition B. Summarization C. Reassurance D. Terminiation

purpose

how much history to gather varies by the _______________ of the patient encounter

Validating

Acknowledging the legitimacy of the patients emotional experience

B. Observable signs and symptoms

As the nurse caring for a patient you have completed the collection of the subjective data. On what do you base your decision to do an entire head to toe physical assessment or a systems specific assessment? A. The patients answers B. Observable signs and symptoms C. Your knowledge base and expertise. D. The patients chief complaint

respectful and open

Being consistently _______________ and ___________ to individual differences is one of the clinical challenges

Active Listening

Closely attending to what the patient is communicating

Nonverbal communication

Communication that occurs continuously and provides important clues to feelings and emotions

A. Appear attentive B. Give brief encouragement to the patient E. Watch the patient closely for nonverbal cues

During one of your clinical placements you encounter a patient who becomes silent during the nursing interview. What would be appropriate for you to do? Mark all that apply. A. Appear attentive B. Give brief encouragement to the patient C. Change the subject you are asking about D. Ask your question again E. Watch the patient closely for nonverbal cues

reproductive

HPV is written in what system?

Diagnosis

Has a nursing focus and is based on real or potential health problems or human responses

B. Facilitating the patients fullest communication

How would the nursing instructor explain the goal of guided questioning to his or her students? A. Providing the most plausible answer to the patient B. Facilitating the patients fullest communication C. Developing a basis for accurate health promotion activities D. Creating an opportunity for the early generation of a plan

Occurrences

Inquire about past __________ of a symptom and ask what treatments were previously used and their results

D. Gives them the opportunity to create a complete and congruent picture of the problem

Learning about the effects of the illness does what for the nurse and the patient? A. Gives them the basis to establish a trusting relationship B. Gives them each a better understanding of the other C. Gives them the ability to communicate better D. Gives them the opportunity to create a complete and congruent picture of the problem

History of present illness

The _________ ___ _________________ ________________ should reveal the patients responses to his or her symptoms and what effect the illness has had on the patients life

communication and relational

The interviewing process that actually generates the pieces of health information is much more fluid and demands effective ___________________ and ______________________ skills

Implementation

The performance of nursing interventions

B. At the beginning of the interview

The principle of confidentiality is pf paramount importance in the nurse patient relationship. When should you inform the patient of with whom his or her information will be shared? A. When the patient asks B. At the beginning of the interview C. At the end of the interview D. Whenever it seems appropriate

D. Assessing

Using both verbal and nonverbal clues given by the patient, what is the nurse constantly doing? A. diagnosing B. Intervening where necessary C. formulating a discharge plan D. Assessing

1. any unexplained injuries 2. is the patient delayed in treatment for trauma? 3. Repeated history of "accidents" 4 Does the patients family have any history of alcohol or drug abuse 5 Does the partner try to dominate the interview

What are the clues to physical abuse?

1. Identify data and source of history 2. Reliability 3. Chief complaint 4. History of present illness 5. Past history 6. Family History 7. Review of systems 8. Health patterns

What are the eight main components of a comprehensive health history?

D. Areas in need of health adjustments

What are the nurses able to detect through the health assessment? A. Areas that need continuous care B. Areas that need in hospital care C. Areas that need referral to a specialist D. Areas in need of health adjustments

Associated Manifestations

What else is going on when the patient experiences the sign or symptom

C. Source of information

What information aids the nurse in assessing possible biases in the data collected in the health history 1. ethnicity of patient b. gender of patient c. source of information d. socioeconomic status of patient

D. Self treatment

What is a key element of the history of present illness A. initiating a problem list b. obtaining an accurate history c. developing accurate nursing diagnoses d. self treatment

A. Your clinical reasoning process

What is pivotal to determining how to move from each patient problem to its goals? A. Your clinical reasoning process. B. Your positive interpretation of the patients history. C. Your process in collecting physical data. D. Your evaluation as an accurate historian of the patient

B. Assessment

What is the foundation of nursing practice? A. Planning B. Assessment C. Evaluation D. Intervention

B. To decide the best overall care

What is the primary function of the health care team? A. to work together to obtain maximum coverage B. To decide the best overall care. C. To guide the patients care throughout times of crisis D. To develop an individual focus for each member,

b. patients nonverbal communication

as a novice nurse caring for a patient from a different culture, what may you find confusing or upsetting? a. patients level of motivation b. patients nonverbal communication c. patients family members d. patients ethnicity

A. Planning for follow up care

What occurs during the termination phase of an interview? A. Planning for follow up care B. Addressing topics that have not yet been addressed. C. Assessing the patients mental status D. Letting the patient know you understood all he or she has told you.

A. Asking a series of questions, one at a time B. Using reflection E. Offering multiple choices for answers

What techniques encourage patient disclosures while minimizing the risk for distorting the patients ideas or missing significant details? choose all that apply A. Asking a series of questions one at a time B. Using reflection C. Asking only one ended questions D. Encouraging with repetition E. Offering multiple choices for answers

Characteristic symptoms

What the symptom feels like

A. A healthy environment

When assisting a patient with health promotion, what must the nurse also nurture? A. A healthy environment B. Knowledge of the healthy people 2020 indicators C. family communication D. school/work attendance

A. Therapy. C. Patient education. E. Diagnosis

When constructing a nursing care plan, what should you reference? Select all that apply A. Therapy B. Healthy people 2020 health indicators C. Patient education D. Input from the patients physician E. Diagnosis

A. Thyroid isthmus barely palpable, lobes not felt

When documenting clinical data after an assessment of the patients neck, what might you write in the physical assessment? A. Thyroid isthmus barely palpable, lobes not felt. B. Apical impulse indiscrete and tapping C. Thorax symmetric without equal excursion D. Extraocular movements full and equal on exam

B. Eye contact C. Gestures D. Posture

When interacting with a patient, what conveys the extent of interest, attention, acceptance, and understanding of the nurse? Mark all that Apply. A. Cultural reassurance B. Eye contact C. Gestures D. Posture E. Restatement

Location

Where the sign or symptom is

a. strengthens the nurse patient relationship. b. provides baselines for future assessments c. creates platform for health promotion though education and counseling

Which of the following are aspects of the comprehensive health history? select all that apply a. strengthens the nurse patient relationship b. provides baselines for future assessments c. creates platform for health promotion through education and counseling d. obtains data to evaluate the outcomes of the plan of care e. is appropriate for established patients

A. An increasing sense of connectedness

While interviewing a new patient, you notice that he is mirroring your position. What can this signify? A. an increasing sense of connectedness. B. a desire to be on an equal power level C. A desire for increased rapport D. The patient does not take you seriously

C. to achieve the best results

Why is the nurse always reassessing the patient for changes? A. To never make a mistake when providing care B. To always have the best nursing care plan C. To achieve the best results D. To update the nursing diagnosis

C. Identify the patients problems

You are the office nurse admitting a new patient to the clinic. You have gained your patients trust, gathered a detailed history, and finished your portion of the physical exam. What is your next step in caring for this patient. A. Formulate nursing diagnoses B. Order the appropriate lab tests C. Identify the patients problems. D. Notify the physician of your findings

C. The blockage of further disclosures by the patient

Your new patient becomes visibly anxious during the nursing interview. You respond by telling her, "don't worry, everything will be okay." What might this premature reassurance cause? A. A feeling of closeness between the patient and the nurse B. The nurse to shorten the interview process C. The blockage of further disclosures by the patient D. A noticeable lessening of the patients anxiety.

b. do you experience blackouts when drinking? d. do you have seizures while drinking e. do you have any legal problems?

Your patient has two affirmative answers to the CAGE questionaire. what other questions should you ask? mark all that apply. a. what OTC medications do you take? b. do you experience blackouts when drinking? c. how would you describe your level of nutrition d. do you have seizures while drinking e. do you have any legal problems?

spiritual

____________________ distress may be a response to illness or health issues

healthy people 2020

a framework that identifies risk factors, health issues, and diseases of concern in the united states

fatigue

a nonspecific sense of weariness with many causes

b. health maintenance

a nurse at the local free clinic is collecting data on 16 year old boy who has come to the clinic. under what component of the health history would the nurse place data on whether the teen routinely uses seat belts when in a vehicle? a. general information b. health maintenance c. risk factors d. initial information

d. chief complaint

a patient states that the reason he has come into the clinic is for a routine annual physical. in what section of the health history would you document this information? a. initial information b. history of present illness c. health maintenance d. chief complaint

emergency history

a systematic prioritization of need in an urgent context is what type of assessment?

goal/ minimize/ position

as the nurse develops his or her own sequence of examination, an important ______________ is to ______________ how often you ask the patient to change _______________

error

almost all clinical information is subject to ____________

d. the decision makers for the family

an elderly chinese man is touring the united states and has a heart attack. when admitting this patient to the coronary care unit, what would be important to note in the family history? a. chronic childhood illnesses b. quality of family relationships c. reliability of information source. d. the decision makers for the family

focused assessment

appropriate for established patients is what type of assessment?

musculoskeletal

arthritis is written in what system?

empowering the patient

reinforcing the patients primary responsibility for his or her health

spiritual care

being present during unpleasant experiences, listening to the patient, providing opportunities for the patient to practice religious rituals, or referring the patient to a religious leader of the patients choice

endocrine

change in glove or shoe size is written in what system?

peripheral vascular

change in glove or shoe size is written in what system?

skin

changes in hair or nails is written in what system?

secondary prevention

communicable disease control is an example of what form of prevention

collaborative partnerships

communication based on trust, respect, and a willingness to re examine assmptions

spirituality

culture specific is part of what concept?

emergency history

immediate priorities are the ABCs of airway, breathing, and circulation is what type of assessment

tertiary prevention

decreasing the effects of a disease or disability by preventing complications and additional loss that happens when a defect is permanent

c. lungs

during the physical examination of your patient you auscultate the sound of the patients breathing. hat area of the patient are you assessing? a. abdomen. b. neck c. lungs d. back

secondary prevention

early detection and treatment of a disease when it is curable or has few complications or disabilities

d. examining the tongue

equipment used in conducting a physical examination includes a 2 x 2 gauze pad. what is this used for? a. testing facial sensation b. invoking the blink reflex c. inverting the eyelid d. examining the tongue

identifying data

establishes source of referral

urinary

flank pain is written in what system?

primary prevention

improving the overall wellness and protection from disease or disability

present illness

includes patients though and feelings about the illness

1. communication and language 2. kinship and social networks 3. educational background and learning style 4. nutrition 5. child bearing and rearing practice 6. high risk factors 7. health care beliefs and practices 8. health care practitioners 9. spirituality

list several of the aspects of culture relevant to health assessment

supine

palpation of the breasts is checked in this position

primary prevention

periodic selective examinations are an example of what form of prevention

stressful

problems may relate to _________________ events in the patients life

comprehensive assessment

provides fundamental and personalized knowledge about the patient is what type of assessment

summarization

providing a general overview of what the patient has said

primary prevention

provision of adequate housing is an example of what form of prevention

tertiary prevention

provision of hospital and community facilities is an example of what form of prevention

relevant

risk factors and other pertinent information related to the symptom are frequently ___________________, such as risk factors for coronary artery disease in a patient with chest pain, or current medications that may have side effects similar to the complaint

standing

romberg test is checked in this position

secondary prevention

self examination is an example of what form of prevention

tertiary preventions

sheltered communities are an example of what form of prevention

comprehensive assessment

strengthens the nurse patient relationship due to its broad scope is what type of assessment?

review of systems

systemic documentation of presence or absence of common symptoms

transitions

telling the patient when you are changing directions during the interview

goal/ visualize/ body

the _________________ of the nurse is to _________________ one area of the ________ at a time

the nursing process

the broad systematic framework that supplies a methodical base applicable to the practice of nursing

c. a cultural bound syndrome

the evil eye is an example of what? a. a spiritually defined illness b. a psychosocial condition c. a cultural bound syndrome d. an ethnic belief

personal or social

the health pattern section provides a guide for gathering ___________ or _____________ history from the patient and daily living routines that may influence health and illness

process/objective

the physical examination is a _____________________ to obtain _____________ data through patient assessment

reflex/ gauge

the strength of a ______________ is used to ______________ central and peripheral nervous system disorders

cultural bound symptoms

there are ______________________ __________ ___________________ which are illnesses defined by a particular culture but that have no corresponding illness in western medicine

gastrointestinal

trouble swallowing is written in what system?

reliability

varies according to the patients memory, trust, and mood

general

weakness, fatigue, or fever is written in what system?

physical, psychological, social, cultural, spiritual, developmental

what are the 6 facets of health

c. avoiding unnecessary changes in position d. enhancing clinical efficiency e. maximizing the patients comfort

what general goals do you organize your comprehensiv or focused examination around? mark all that apply a. identifying the patients medical diagnosis b. ensuring the patients compliance with treatment c. avoiding unnecessary changes in position d. enhancing clinical efficiency e. maximizing the patients comfort

A. Working with the individual patient and D. Developing the nursing care plan

what is paramount in health promotion? select all that apply. A. working with the individual patient B. demonstrating authority C. emphasizing the risks of poor health practices D. developing the nursing care plan E. limiting the involvements of the patients friends and family

a. strength of a reflex

what is used to gauge central and peripheral nervous system disorders? a. strength of a reflex b. gait c. tuning fork d. heat and cold

localizing findings

when _______ findings, be as specific as possible, bear in mind that you may have to settle for a body region, such as chest, or body system such as the musculoskeletal system

d. current medications

when collecting data on the history of the present illness, it is appropriate to include what? a. chronic childhood illnesses b. treatment recommendations c. reliability of information source d. current medications

b. how we view the world. d. how we behave in relation to other people. e. shared ideas, rules, and meanings

when culture is defined as a system, what components would be included? mark all that apply A. cognitive ability of the patient b. how we view the world. How we experience the world physically d. how we behave in relation to other people. e. shared ideas, rules, and meanings

C: identify in what areas the patient needs the most care

when doing an overall assessment of a patient, the nurse is able to utilize findings and do what? A. Identify what levels of prevention the patient is at B. Identify in what areas the patient can educate his or her family. C. Identify in what areas the patient needs the most care D. Identify the patients medical diagnosis

b. tangible lighting

when inspecting structures such as the jugular venous pulse, what would be the best lighting to use? a. direct b. tangential lighting c. diffuse lighting d. back lighting

a. become culturally skillful c. become culturally knowledgable d. seek cultural encounters

when studying campinha-bactoe'smodel of cultural competency in the delivery of health car,e you learn that cultural desire is viewed as the motivation for the nurse to want to do what? mark all that apply? a. become culturally skillful b. seek cultural compassion c. become culturally knowledgable d. seek cultural encounters e. become ethnically expert

b. patients state of hygiene

which of the following is a component of the general survey? a. patients blood pressure b. patients state of hygiene c. patients breath sounds d. patients oral temperature

a. coronary artery disease

while gathering data for the family history portion of the health history what would you ask about?

a. nutrition b. high risk behaviors e. health care practitioners

you are attending a seminar on transcultural nursing at a nursing conference. What aspects of culture relevant to health assessment would you expect to be discussed? mark all that apply. a. nutrition b. high risk behaviors c. wound care d. educational goals e. health care practitioners

c. you need to establish rapport and trust

you are caring for a 70 year old serbian woman who is in the united states visiting her family. what must occur before this patient is willing to teach you about her culture. a. the patients family must allow it. b. you need to hide your biases c. you need to establish rapport and trust d. you need to establish a clue based partnership

c. it is palliative

you are discussing hospice care with a dying patient who will be going home from the hospital tomorrow. what would be important to tell this patient about hospice care? a. it teaches CPR. b. it provides all medicine and treatment c. it is palliative d. it makes end of life decisions easier

a. cranial nerves

you are performing a physical examination on a new patient. what would you be assessing if you were testing the patients sense of smell? a. cranial nerves b. nose c. upper neuron function d. strength of nerve functioning

c. give your general impressions d. tell patient what to expect next

you have finished the physical examination, what do you immediately do after finishing? a. identify needed lab tests b. share findings with physician c. give your general impressions d. tell patient what to expect next e. perform interventions

individual

you must evaluate each patient with pain as an _______ being aware of your reaction to the patients communication style

b. percussion

your lab instructor explains that physical examination relies on what cardinal assessment technique? a. assessment b. percussion c. organization d. communication