Nurs 335 Exam 1

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Health Assessment Exam 1, includes Jarvis Ch. 1,2,3,4,5,8, & 9

According to the biomedical model, a narrow definition of health is:

the absence of disease.

What type of data base is most appropriate when a rapid collection of data is required and often compiled concurrently with life-saving measures?

Emergency

A medical diagnosis is used to evaluate:

the cause of disease.

An example of subjective data is:
A) decreased range of motion.
B) crepitation in the left knee joint.
C) left knee has been swollen and hot for the past 3 days.
D) arthritis.

C) left knee has been swollen and hot for the past 3 days.

What type of database is most appropriate for an individual who is admitted to a long-term care facility?

Complete

Which of the following is considered an example of objective data?
A) Alert and oriented
B) Dizziness
C) An earache
D) A sore throat

A) Alert and oriented

An example of objective data is:
A) complaints of left knee pain.
B) crepitation in the left knee joint.
C) left knee has been swollen and hot for the past 3 days.
D) report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion.

B) crepitation in the left knee joint.

A nursing diagnosis is best described as:

a concise statement of actual or potential health concerns or level of wellness.

A complete data base is:

used to perform a thorough or comprehensive health history and physical examination.

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) Risk for infection
C) Impaired gas exchange
D) Readiness for enhanced spiritual well-being

C) Impaired gas exchange

Define Assessment

the collection of data about the individual's health state

Define Subjective Data

what the person says about himself or herself during history taking

Define Objective Data

what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination

What is diagnostic reasoning?

the process of analyzing health data and drawing conclusions to identify diagnoses

What are the 6 phases in the nursing process?

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

What is assessment?

collecting data from clinical record, health history, physical exam, functional assessment, and risk assessment,

What is diagnosis?

Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state.

What is outcome identification?

Individualized goals for each patient that are culturally appropriate and realistic. Needs to be measurable so that goals can be evaluated.

What is planning?

Care planning is setting priorities, develop outcomes, and setting timelines.

What is implementation?

Putting that plan into action, implementing nursing interventions.

What is evaluation?

Make sure that plan is working, that everything is progressing towards the outcomes.

Medical diagnosis vs. Nursing diagnosis

the medical diagnosis is used to evaluate the etiology (cause) of disease. The nursing diagnosis is used to evaluate the response of the whole person to actual or potential health problems. .

First level priorities:

are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing. Airway problems,Breathing problems, Cardiac/circulation problems, & Vital sign concerns (e.g., high fever).
Exception: With cardiopulmonary resuscitation (CPR) for cardiac arrest, begin chest compressions immediately.

Second-level priorities:

next in urgency—those requiring your prompt intervention to forestall further deterioration, for example, mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security.

Third level priorities:

are important to the patient's health but can be addressed after more urgent health problems are addressed.

Four Assessment Types:

1) Complete
2)Focused or Problem-Centered
3)Follow-up
4)Emergency

Complete or Total Health Database

a complete health history and a full physical examination. It describes the current and past health state and forms a baseline against which all future changes can be measured.

Focused or Problem Centered database

This is for a limited or short-term problem. Here, you collect a "mini" database, smaller in scope and more targeted than the complete database. It concerns mainly one problem, one cue complex, or one body system.

Follow-up Database

The status of any identified problems should be evaluated at regular and appropriate intervals. What change has occurred? Is the problem getting better or worse? What coping strategies are used? This type of database is used in all settings to follow up short-term or chronic health problems

Emergency Database

This calls for a rapid collection of the data, often compiled concurrently with lifesaving measures. Diagnosis must be swift and sure.

holistic health

views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Health depends on all these factors working together.

Each culture has its own healers who usually:
A) speak at least two languages.
B) own and operate specialty community clinics.
C) cost less than traditional or biomedical providers.
D) recommend folk practices that are dangerous.

C) cost less than traditional or biomedical providers

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?
A) Good is hot.
B) Evil is hot.
C) The humors must be balanced.
D) The phlegm will be replaced with dryness.

C) The humors must be balanced.

Before determining whether cultural practices are helpful, harmful, or neutral, nurses must first understand:
A) the logic of the traditional belief systems.
B) the beliefs of the patient’s family.
C) their personal belief models.
D) the risk of disease in the patient’s ethnic group.

A) the logic of the traditional belief systems.

On the basis of median age:
A) the non-Hispanic white population tends to be younger.
B) the Hispanic population tends to be older.
C) the Asian population tends to be younger.
D) minorities tend to be older than non-Hispanic white populations.

C) the Asian population tends to be younger.

Spirituality is defined as:

a personal effort to find meaning and purpose in life.

Which of the following is true regarding language barriers and health care?
A) There are laws addressing language barriers and health care.
B) Limited English proficiency is associated with a higher quality of care.
C) English proficiency is associated with a lower quality of care.
D) Patients with language barriers have a decreased risk of non-adherence to medication regimens.

A) There are laws addressing language barriers and health care.

What is the yin/yang theory of health?

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

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

What symptom is greatly influenced by a person's cultural heritage?
A) hearing loss
B) pain
C) breast lump
D) food intolerance

B) pain

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.

Title VI of the Civil Rights Act of 1964

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

Religious beliefs and practices influence explanation for:

Cause of illness, perception of severity, choice of healers.

Spirituality

Focuses more on self and includes belief systems other than religion.

Religion

Organized system of beliefs and practices in a higher power

Culturally sensitive

implies that caregivers possess some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting in which they are practicing.

Culturally appropriate

implies that the caregivers apply the underlying background knowledge that must be possessed to provide a given person with the best possible HEALTH CARE.

Culturally competent

implies that the caregivers understand and attend to the total context of the individual's situation, including awareness of immigration status, stress factors, other social factors, and cultural similarities and differences.

Culture

it is the thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups.

culture has four basic characteristics

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

Ethnicity

pertains to a social group within the social system that claims to possess variable traits such as a common geographic origin, migratory status, religion, race, language, shared values, traditions, or symbols, and food preferences.

Socialization

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

Acculturation

the process of adapting to and acquiring another culture

Assimilation

the process by which a person develops a new cultural identity and becomes like the members of the dominant culture

Biculturalism

dual pattern of identification and often of divided loyalty

biomedical or scientific theory of illness causation

based on the assumption that all events in life have a cause and effect, that the human body functions more or less mechanically (i.e., the functioning of the human body is analogous to the functioning of an automobile), that all life can be reduced or divided into smaller parts (e.g., the reduction of the human person into body, mind, and spirit), and that all of reality can be observed and measured (e.g., intelligence tests and psychometric measures of behavior).

naturalistic or holistic perspective theory of illness causation

believe that human life is only one aspect of nature and a part of the general order of the cosmos. The people may believe that the forces of nature must be kept in natural balance or harmony.

Germ Theory of illness causation

hat microscopic organisms such as bacteria and viruses are responsible for specific disease conditions.

yin/yang theory of illness causation

health is believed to exist when all aspects of the person are in perfect balance. Yin energy represents the female and negative forces, yang forces are male and positive

hot/cold theory of health and illness

The four humors of the body—blood, phlegm, black bile, and yellow bile—regulate basic bodily functions and are described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors.

magicoreligious perspective of illness causation

The basic premise is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the action of supernatural forces for good or evil.

Pain

very private, subjective experience that is greatly influenced by cultural heritage

culture-bound syndrome

a condition that is culturally defined

Guide to Cultural Care

R.E.S.P.E.C.T.
Realize that you MUST know and understand your heritage and that of your patient.
Examine the patient within the context of his or her cultural HEALTH and ILLNESS practices.
Select questions that are not complex, and do not ask questions rapidly.
Pace questions throughout the physical examination.
Encourage the patient to discuss the meanings of health and illness with you.
Check for the patient's understanding and acceptance of recommendations, and build on cultural HEALTH practices when indicated.
Touch the patient within the cultural boundaries of his or her heritage—manners are a vital component of the nurse-patient relationship.

When preparing the physical setting for an interview, the interviewer should:
A) set the room temperature between 64 and 66° F.
B) reduce noise by turning the volume on the television or radio down.
C) conduct the interview at eye level and at a distance of 4 to 5 feet.
D) stand next to the patient to convey a professional demeanor.

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

Parents or caretakers 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

Which of the following statements, if made by the interviewer, would be an appropriate response?
A) "I know just how you feel."
B) "If I were you, I would have the surgery."
C) "Why did you wait so long to make an appointment?"
D) "Tell me what you mean by 'bad blood'."

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

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:
A) affects the nurse-physician relationship.
B) impedes further discussion.
C) helps the patient understand personal feelings in relation to his or her verbal message.
D) helps the nurse understand his or her own feelings in relation to the patient's verbal message.

C) helps the patient understand personal feelings in relation to his or her verbal message.

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

avoidance language.

When addressing a toddler during the interview, the health care provider should:
A) ask the child, before the caretaker, about symptoms.
B) use nonverbal communication.
C) use short, simple, concrete sentences.
D) use detailed explanations.

C) use short, simple, concrete sentences.

Nonverbal communication is the primary form of communication for which group of individuals?

Infants

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

empathy

An example of an open-ended question or statement is:
A) "Tell me about your pain."
B) "On a scale of 1 to 10, how would you rate your pain?"
C) "I can see that you are quite uncomfortable."
D) "You are upset about the level of pain, right?"

A) "Tell me about your pain."

The most appropriate introduction to use to start an interview with an older adult patient is:
A) "Mr. Jones, I want to ask you some questions about your health so that we can plan your care."
B) "David, I am here to ask you questions about your illness; we want to determine what is wrong."
C) "Mr. Jones, is it okay if I ask you several questions this morning about your health?"
D) "Because so many people have already asked you questions, I will just get the information from the chart."

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

Results of a successful interview

establish rapport, patient teaching, and health promotion, identify health strengths and problems, and is a bridge to the physical exam

The contract (interview) term include

Time and place of interview and physical exam
Introduction of and explanation of health care provider's role
Purpose of interview
How long it will take
Expectation of participation of each person
Presence of other (family, friends, etc.)
Confidentiality and to what extent it may be limited
Any costs that the patient must pay

Communication

all behavior, conscious and unconscious, verbal and nonverbal.

Challenges of note taking:

Breaks eye contact
Shifts attention away from person, diminishing importance
Interrupts patient's narrative flow
Impedes observation of patient's non-verbal behavior
May be threatening to patient's discussion of sensitive issues

open-ended question

asks for narrative information. It states the topic to be discussed but only in general terms

Closed or direct questions

ask for specific information. They elicit a short, one- or two-word answer, a "yes" or "no," or a forced choice.

Facilitation

These responses encourage the patient to say more, to continue with the story ("mm-hmm, go on, continue, uh-huh"). Also called general leads, these responses show the person you are interested and will listen further.

Silence

Silence is golden after open-ended questions. Your silent attentiveness communicates that the patient has time to think, to organize what he or she wishes to say without interruption from you. This "thinking silence" is the one health professionals interrupt most often.

Reflection

This response echoes the patient's words. Reflection is repeating part of what the person has just said. In this example, it focuses further attention on a specific phrase and helps the person continue in his own way

Empathy

An empathic response recognizes a feeling and puts it into words. It names the feeling and allows the expression of it.

Clarification

Use this when the person's word choice is ambiguous or confusing, also is used to summarize the person's words, simplify the words to make them clearer, and then ask if you are on the right track.

Confrontation

you have observed a certain action, feeling, or statement and you now focus the person's attention on it. You give your honest feedback about what you see or feel.

Interpretation

This statement is not based on direct observation as with confrontation, but it is based on your inference or conclusion. It links events, makes associations, or implies cause

Explanation

With these statements, you inform the person. You share factual and objective information.

Summary

This is a final review of what you understand the person has said. It condenses the facts and presents a survey of how you perceive the health problem or need. It is a type of validation in that the person can agree with it or correct it. Both you and the patient should participate.

Ten Traps of Interviewing:

1. Providing false assurance or reassurance.
2. Giving unwanted advice.
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using "why" questions

Nonverbal skills:

Physical appearance
Posture
Gestures
Facial expressions
Eye contact
Voice
Touch

telegraphic speech

usually a combination of a noun and a verb and includes only words that have concrete meaning

Cross-cultural communication

refers to the process occurring between a health care professional and a patient, each with different cultural backgrounds, in which both attempt to understand the other's point of view

Etiquette

refers to the conventional code of good manners that governs behavior and varies cross-culturally.

Intimate Zone

0-1 1/2 feet

Personal Zone

1 1/2 - 4 feet

Social distance

4 - 12 feet

Public distance

12+ feet

Which of the following is included in documenting a history source?
A) Appearance, dress, and hygiene
B) Cognition and literacy level
C) Documented relationship of support systems
D) Reliability of informant

D) Reliability of informant

A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about:

aggravating factors.

The CAGE test is a screening questionnaire that helps to identify

excessive or uncontrollable drinking

The "review of systems" in the health history is:

an evaluation of past and present health state of each body system

When recording information for the review of systems, the interviewer must document:
A) physical findings, such as skin appearance, to support historic data.
B) "negative" under the system heading.
C) the presence or absence of all symptoms under the system heading.
D) objective data that supports the history of present illness.

the presence or absence of all symptoms under the system heading.

Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include:
A) education, financial status, and value-belief system.
B) exercise and activity, leisure activities, and level of independence.
C) family role, interpersonal relations, social support, and time spent alone.
D) stressors, coping mechanisms, and change in past year.

education, financial status, and value-belief system.

PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to:

symptoms

The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to:
A) review previous medical records.
B) rephrase the same questions later in the interview.
C) ask the patient if there is someone who could verify information.
D) call a family member to confirm information.

B) rephrase the same questions later in the interview.

When taking a health history from an adolescent, the interviewer should:
A) ask about violence and abuse before asking about alcohol and drug use.
B) have at least one parent present during the interview.
C) interview the youth alone with a parent in the waiting area.
D) ask every youth about the use of condoms.

C) interview the youth alone with a parent in the waiting area.

What information is included in greater detail when taking a health history on an infant?
A) nutritional data
B) history of present illness
C) family history
D) environmental hazards

A) nutritional data

Health History Sequence (adult)

1. Biographical data
2. Source of history
3. Reason for seeking care
4. Present health or history of present illness
5. past health
6. Family history
7. Review of systems
8. Functional assessment (ASLs)

symptom

subjective sensation that the person feels from the disorder

sign

objective abnormality that you as the examiner could detect on physical examination or in laboratory reports

PQRSTU

P: Provocative or Palliative. What brings it on? What were you doing when you first noticed it? What makes it better? Worse?

Q: Quality or Quantity. How does it look, feel, sound? How intense/severe is it?

R: Region or Radiation. Where is it? Does it spread anywhere?

S: Severity Scale. How bad is it (on a scale of 1 to 10)? Is it getting better, worse, staying the same?

T: Timing. Onset—Exactly when did it first occur? Duration—How long did it last? Frequency—How often does it occur?

U: Understand Patient's Perception of the problem. What do you think it means?

pedigree or genogram

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, siblings

Purpose of review of systems

(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.

Functional assessment measures :

a person's self-care ability in the areas of general physical health or absence of illness; ADLs, such as bathing, dressing, toileting, eating, walking; instrumental activities of daily living (IADLs), or those needed for independent living, such as housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances; nutrition; social relationships and resources; self-concept and coping; and home environment.

CAGE

Have you ever thought you should Cut down your drinking?

Have you ever been Annoyed by criticism of your drinking?

Have you ever felt Guilty about your drinking?

Do you drink in the morning?

HEEADSSS method

interviewing focuses on assessment of the Home environment, Education and employment, Eating, peer-related Activities Drugs, Sexuality, Suicide/depression, and Safety from injury and violence. The tool minimizes adolescent stress because it moves from expected and less-threatening questions to those that are more personal.

A full mental status examination should be completed if the patient:
A) has a change in behavior and the family is concerned.
B) develops dysphagia.
C) is newly diagnosed with type 2 diabetes mellitus.
D) complains of insomnia.

A) has a change in behavior and the family is concerned.

Aphasia is best described as:

a language disturbance in speaking, writing, or understanding.

A patient who was recently diagnosed with a seizure disorder plans to continue a career as a pilot. At this time in the interview, the nurse begins to question the patient's:
A) thought process.
B) judgment.
C) perception.
D) intellect.

B) judgment.

A major characteristic of dementia is:
A) impaired short-term and long-term memory.
B) hallucinations.
C) sudden onset of symptoms.
D) cognitive deficits that are substance-induced.

A) impaired short-term and long-term memory.

Mental status assessment documents:
A) emotional and cognitive functioning.
B) intelligence and educational level.
C) artistic or writing ability in the mentally ill person.
D) schizophrenia and other mental health disorders.

A) emotional and cognitive functioning.

Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are:
A) memory, attention, thought content, and perceptions.
B) language, orientation, attention, and abstract reasoning.
C) appearance, behavior, cognition, and thought processes.
D) mood, affect, consciousness, and orientation.

C) appearance, behavior, cognition, and thought processes.

An older adult:
A) experiences a 10-point decrease in intelligence.
B) has diminished recent and remote memory recall.
C) has a slower response time.
D) has difficulty with problem solving.

C) has a slower response time.

Which of the following statements about mental status testing of children is correct?
A) The results of the Denver II screening test are valid for white, middle-class children only.
B) The behavioral checklist is useful to assess children who are 3 to 5 years of age.
C) Abnormal findings are usually related to not achieving an expected developmental milestone.
D) Input from parents and caretakers is discouraged when assessing psychosocial development.

C) Abnormal findings are usually related to not achieving an expected developmental milestone.

Which of the following best illustrates an abnormality of thought process?
A) Lability
B) Blocking
C) Compulsion
D) Aphasia

B) Blocking

The mental status examination:
A) should be completed at the end of the physical examination.
B) will not be affected if the patient has a language impairment.
C) is usually not assessed in children younger than 2 years of age.
D) assesses mental health strengths and coping skills and screens for any dysfunction.

D) assesses mental health strengths and coping skills and screens for any dysfunction.

Mental status is:

a person's emotional (feeling) and cognitive (knowing) function.

mental disorder

significant behavioral or psychological pattern that is associated with distress (a painful symptom) or disability (impaired functioning) and has a significant risk of pain, disability, or death or a loss of freedom.

organic disorders

due to brain disease of known specific organic cause [e.g., delirium, dementia, alcohol and drug intoxication and withdrawal]

mental illness

which an organic etiology has not yet been established [e.g., anxiety disorder or schizophrenia

Consciousness

Being aware of one's own existence, feelings, and thoughts and aware of the environment. This is the most elementary of mental status functions.

Language

Using the voice to communicate one's thoughts and feelings. This is a basic tool of humans, and its loss has a heavy social impact on the individual.

Mood and affect

Both of these elements deal with the prevailing feelings; affect is a temporary expression of feelings or state of mind, and mood is more durable, a prolonged display of feelings that color the whole emotional life.

Orientation

The awareness of the objective world in relation to the self.

Attention

The power of concentration, the ability to focus on one specific thing without being distracted by many environmental stimuli.

Memory

The ability to lay down and store experiences and perceptions for later recall. Recent memory evokes day-to-day events; remote memory brings up years' worth of experiences.

Abstract reasoning

Pondering a deeper meaning beyond the concrete and literal.

Thought process

The way a person thinks, the logical train of thought.

Thought content

What the person thinks—specific ideas, beliefs, the use of words.

Perceptions

An awareness of objects through the five senses.

full mental status examination

systematic check of emotional and cognitive functioning

necessary to perform a full mental status examination when:

Patients whose initial brief screening suggests an anxiety disorder or depression.
Family members concerned about a person's behavioral changes, such as memory loss, inappropriate social interaction.
Brain lesions (trauma, tumor, brain attack [also known as cerebrovascular accident or stroke]).
Aphasia (the impairment of language ability secondary to brain damage).
Symptoms of psychiatric mental illness, especially with acute onset.

Things that can affect mental health status

Health conditions, medications, educational and behavioral level, and stress

Assess appearance

posture, body movements, dress, and grooming.

Assess behavior

Level of consciousness, facial expression, speech, mood and affect.

Asses cognitive functions

orientation, attention span, recent memory, remote memory, new learning, judgement

Assess thought processes and perceptions

thought processes, though content, perceptions, and suicide screening.

Unilateral neglect

(total inattention to one side of body) occurs following some cerebrovascular accidents.

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