Assessment Quiz 1
What is OLDCARTS?
Use when talking to someone about their pain Onset Location Duration Characteristics Aggravating / alleviating factors Related symptoms (palpations, sob, vomitting) Treatments by pt Severity (intensity, strength, use scales)
individual's genetic makeup influences psycho-social health a. true b. false
a
rn is caring for a 3yo child who has been hospitalized for internal fixation of a fx arm. the rn is considering non-pharmacological pain management techniques. What interventions should be included in the care plan a. sit with the child and blow bubbles b. offer a glucose coated paci c. explain to the child the cause of the pain d. teach the use of guided imagery
a
the physical signs of stress include all of the following except what? a. decreased reflexes b. increased hr c. decreased blood clotting time d. elevated glucose levels
a
the rn is caring for a teenage who reports having abd pain. When the rn asks for a description of the pain the pt says "It just hurts. Why can't I have something for the pain?" Which of the following actions should the rn take? a. provide questions that require yes or no answers related to pain b. ask the pt what they would like to have for pain c. continue with the assessment d. leave the room and come back later
a
which of the following is not a characteristic of a pt who is at risk for suicide? a. 14 year old boy who did bad at school b. 24yo male w/ drinking prob c. 34 yo female whose father and sister committed suicide d. 44yo male who lost wife to cancer
a
which of the following is true about pain in regards to nursing? a. pain is whatever the experiencing person says it is b. pain must be validated by the rn to determine the cause of the pain c. pain is defined as unpleasent sensations, typically experienced upon movement d. pain is subjective so observations must be used to assess pain level and intensity
a
What does diagnosis mean?
analyze data
how many minutes should you wait to take a temp after smoking, eating or drinking?
at least 10 mins
2 pt's had been in an mva and both undergo abd surgeries. Both ask for pain meds, but one pt is in more distress than the other. Which pain theory is used to explain this phenomenon? a. specificity b. gate control c. stress d. pattern
b
a 7yo pt was just admitted to the hospital following an appt at the ped oncology clinic. his mother is crying and asking "what did I do wrong? why does he deserve this? why can't it be me?" the rn understands that this indicates which of the following? a. ineffective coping b. spiritual distress c. emotional emptiness d. psychologic anxiety
b
nb's and infants have anatomic, physiologic and biochemical elements necessary for pain transmission a. false b. true
b
the HOPE approach assessment is used to assess which of the following? a. self-concept b. spirituality c. role development d. cognition
b
which of the following assessment data will be most accurate of the pt's pain after triple bypass a. family reports b. response from the pt based on a pain scale c. observation of the pt's behavior while asleep d. measurement of vs
b
you are the rn taking care of 25yo male in the hospital. As you enter the roomyou notice his posture is relaxed, he is not displaying any facial expressions or guarding and he is laughing hard at something his friend said. When you assess his pain he states it is 10/10. How do you correctly document this? a. pt states 10/10 but doesn't appear to be in pain b. pt complains of 10/10 pain c. pt has no pain d. pt is drug seeking
b
18yo male is in the hospital after surgery. His parents are at his edside during most of the day. The rn notices that the pt never asks for pain meds during the day, but requests them every 4 hrs during the night. The most probable explanation is a. the night rn had more time to spend with the pt b. pt must be afraid or lonely at night and is trying to get attention c. pt may bot report pain in the presence of his parents based on their influence or cultural beliefs d. pt was asking for meds to help him sleep
c
a nursing student tells you that her pt was exhibiting visceral pain. how do you explain it to her? a. a feeling of pain at the source that extends to nearby tissues b. paint that is felt in a part of the body that is considerably removed from the tissue causing pain c. results from stimulation of pain receptors in the abd cavity, thorax + cranium. it is diffuse and feels like a burning sensation, aching or pressure d. current or past damage to the peripheral or central nervous system and may not have a stimulus
c
a pt complains of chest pain, but on assessment she is rubbing her arm. What is the pt most likely experiencing in her arm? a. phantom pain b. intractable pain c. radiating pain d. cutaneous pain
c
external factors that help contribute to psycho social well being include all except a. geography b. culture c. self-concept d. family
c
the rn has gathered assessment data on a pt admitted for attempted suicide. the rn developsappropriate nursing diagnoses and formulates goals to achieve client outcomes. which step of the nursing process is being utilized? a. implementation b. evaluation c. planning d. assessment
c
what does assessment mean?
collect data
a 90yo woman comes in for back pain and is asking about pain meds. You know that when it comes to meds in the elderly: a. it is safe to give the same dose as most adults b. an increased dose is usually needed c. pain meds are contraindicated in the elderly d. a decreased dose is usually needed
d
the rn is assessing a pt prior to his physical exam. the pt complains of frequent aches/pains and abdominal discomfort. The rn may suspect which of the following factors that impacts physical health? a. income b. ethnicity c. occupation d. stress
d
you are interviewing an underwt teen who looks at the floor and speaks softly. you identify a problem with the pt's self-concept. which of the following findings would support your conclusion? a. increased desire to form lasting relationships b. decreased ability to form attachments with others c. inability to maintain stable employment d. feelings of worthlessness, anxiety and depression
d
what does planning mean?
develop a plan/ strategies to attain outcomes
What is percussion used for and what types are there?
evaluate size, boarders + consistency of internal organs - tenderness + extent of fluid in body cavity - direct + indirect
what does evaluation mean?
evaluates progress toward desired outcome
what is a episodic / follow up assessment?
follow up from a specific problem - diabetes follow up - pneumonia follow up
What is blood pressure?
force of blood against arterial walls
what is the single most important action to reduce transmission of infections?
hand hygiene
what does identification (outcome) mean?
identify expected outcomes for a plan
What is referred pain?
in an area away from the area of injury or dz often with visceral pain because many abd organs have no pain receptors
how is the heart rate assessed?
indirectly by palpating the pulse
what is persistent (chronic) pain?
intermittent / continuous more than 6mos
What is auscultation? what are you listening for?
listening through a stethoscope intensity, pitch, duration + quality
what is health protection?
motivated by the desire to avoid illness and detect early
what is the respiratory rate?
# of cycles (inhalation + exhalation) in 60 seconds
when should pain be reassessed?
- 30 mins after IV meds - 60 mins after oral meds
8 techniques to enhance data collection
- active listening - facilitation = encourage talking - clarification = ask about vague statements - restatement = repeat to confirm - reflection = restate as question - confrontation = w/ inconsistencies - interpretation = conclusions from data - summary = condense + order to clarify sequence of events
what are the 6 types of pain?
- acute - persistent (chronic) - nociceptive - neuropathic - referred - phantom
what are 7 physiological factors that affect bp?
- age - gender - wt - race - pregnancy - emotions - pain
during general inspection what are we looking for with physical appearance + hygiene?
- age - skin - general hygiene
what causes pain tolerance to go up?
- alcohol - meds - warmth - distraction
during general inspection what are we looking for with emotional status, disposition + behavior?
- allertness - facial expressions - tone + affect - eye contact - clothing + behavior appropriate
What is light palpation used for?
- approx 1cm - skin pulsations - tenderness
what is deep palpation used for?
- approx 4cm w/ 1 or 2 hands - size + contour of organs
during general inspection what are we looking for with body movement?
- balance - smooth - assistive devices - range of motion
components of a health hx
- bio data = age, name, gender etc - chief complaint - hx of present illness - present health status - past health hx - family hx - personal / psychosocial hx - review of symptoms
5 types of health assessments
- comprehensive - problem based / focused - episodic / follow up - shift - screening / exam
what causes pain tolerance to go down? 4 things
- exposure - fatigue - boredom - sleep deprevation
what are your PPE?
- gloves - mask - face shield - eye protection - gown
6 standard precautions
- hand hygiene - PPE - managing contaminated equipment - environmental controls - cough etiquette - pt placement
4 components of a health assessment
- health hx - physical exam - other info from record - documenting finding
3 phases of a pt interview
- intro = introduce yourself - discussion = pt centered discussion - summary = allow pt to clarify + communicate understanding of info to pt
what makes up a physical exam? what it is and 5 things it includes.
- objective data - insepection - palpation - percussion - auscultation - vital signs + ht + wt
what types of questions should be asked during a pt interview?
- open ended
what are the 5 ways to take a temp?
- oral - axiallary - tympanic - temporal - rectal
What are transmission based precautions? List 3 types
- precautions used when caring for infected or suspected - used in addition to standard precautions - airborne precautions - droplet precautions - contact precautions
what are the 3 types of health promotion?
- primary = prevent dz - secondary = screening efforts - tertiary = treatment = decrease the disability from dz
what is context of care?
- setting / environment - physical - psychological - socioeconomic circumstances - expertise of the rn
during general inspection what are we looking for with body structure + position?
- stature - nourishment - body symmetry - posture
what are the 5 types of sounds you will hear doing percussion?
- tympany = abdomen - resonance = healthy lung tissue - hyperresonance = over inflated lungs - dullness = liver - flatness = bone + muscle
what is bimanual palpation?
- using 2 hands - 1 anterior + 1 posterior - entrap mass / organ - uterus, kidney, large breast
5 ways to diminish data collection
- using medical terms - judgement - interrupting - being authoritarian - using "why" questions
respiratory rate range for an adult
12-20
when is the ht of an adult taken?
18-20years old
how far in should a rectal thermom be placed?
1in -> 1.5in (2.5 ->3.8cm)
how long should you wash your hands?
40-60 seconds
heart rate range for an adult
60-100
what is the normal temp range for adults?
96.4 -> 99.1
What is neuropathic pain?
Abnormal processing of pain message-feels like it is burning or shooting
What is the nursing process?
Assessment Diagnosis (Identification) Planning Implementation Evaluation
What is pain tolerance?
Duration or intensity of pain that an individual will tolerate before responding outwardly
for non verbal adults what pain assessment tool do we use?
F - facial expressions A - activity / movement G - guarding Physiologic 1 - VS Physiologic 2- skin, pupillary response, sweating
pain assessment tool for critically ill + kids
F - facial expressions L - leg movement A - activity C - cry C - consolability score 0-10 in each catergory
What is a comprehensive assessment?
Health history and complete physical - done at well care visit or admission
4 basic techniques of physical assessment
Inspection Palpation Percussion Auscultation
what is the acronym to identify info about a pt's pain
OLDCARTS
exam for evaluating pain Old Ladies Mean Always I Pray
Old Ladies Mean Always I Pray observe = posture, face, behavior to relieve pain listen = sounds pt makes measure = BP + palpate pulse assess = res rate + pattern inspect = site of pain (appearance) palpate = site of pain (tenderness)
What is nociceptive pain?
Stimulation of somatic structures (bones, muscles, skin, connective tissue) or visceral organs. normal neural systems
What makes up a health hx?
Subjective data - info from pt ex: symptoms - info from others
what are signs
objective data observed - felt, heard, measured
what is general inspection? 6 things you are looking for.
observing + looking for clues of possible problems - appearance - hygiene - body structure - movement - emotional status - behavior
What is phantom pain?
pain that seems to come from a limb that has been amputated
What is pain threshold?
point at which a stimulus is perceived as pain
what does implementation mean?
putting the plan into action
What is acute pain?
recent onset less than 6mos
Define standard precautions
reduce the risk of transmission of infection from body fluid to non-intact skin
if you have a regular heart rate how should you count it vs an irregular heart rate?
regular = 30 second x 2 irregular = 1 full minute
what is a shift assessment?
rn will do an assessment at the beginning of their shift to check for changes to baseline
what is a screening / exam assessment?
short and focused on dz detection - tb test -sti screenings
what is a problem based / focused assessment?
specific problem (sprained ankle) - ED or urgent care
what is direct percussion?
striking a finger / hand directly on a persons body - sinus + kidney
what are symptoms?
subjective data reported by pt
bp range for adult
systolic = 110-139 diastolic = 60-79
how do you find the pulse pressure?
systolic pressure - diastolic pressure = normal is 30-40 difference
What is health promotion?
the process of enabling people to increase control over, and to improve, their health
what is indirect percussion?
uses both hands tap on your hand on the persons body - palm down + tap back of hand w. fist (kidney) - end of middle finger down tap between nail + 1st joint w/ other middle finger
how and why do palpation
using 2 hands to feel texture, size, consistency, pulsation + location - finger pads + palm for vibration - dorsal / back of hand for temp
what are you looking for during inspection? 3 things
visual examination of the body - movement - posture - smell