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NSG-316 Exam 1 Questions And Correct
Answers
Describe the elements of a general survey - answer -physical appearance (age, sex, consciousness, skin color, facial features, signs of distress) -body structure (stature, nutrition, symmetry, posture, position, build, deformities) -mobility (gait, involuntary movements) -behavior (expression, mood, speech, dress, hygiene) PBMB when should you begin observing - answer the second you see the client health assessment - answer collection of data about the patient's health state complete database - answer full health history and physical examination (family practice) episodic database - answer limited or short term problem concerns 1 problem or complex or system (urgent care) follow-up database - answer status of pervious problem at regular scheduled intervals (doctors office) emergency database - answer rapid collection of data (ER) comprehensive assessment - answer health history and complete physical examination, usually conducted when a patient first enters a health care setting focused assessment - answer assessment conducted to assess a specific problem; focuses on pertinent history and body regions subjective data - answer what the person says about himself or herself during history taking objective data - answer information that is seen, heard, felt, or smelled by an observer; signs
first level priority - answer Emergent, life threatening, and immediate (ABCs) second level priority - answer Next in urgency, requiring attention so as to avoid further deterioration third level priority - answer Important to patient's health but can be addressed after more urgent problems are addressed functional assessment components - answer -basis for care planning, goal setting, and discharge planning -self care (ADLs) -self maintenance (IADLs) -physical mobility collecting subjective data for the ill person - answer information about health problem obtaining an accurate and current health history - answer -subjective data -biographical data (name,DOB,sex,race,ethnic origin) -source of history (themselves or family?) -reason for seeking care (signs/symptoms) -present health/illness (location, severity, timing, setting, relieving factors) -past health (childhood illness, hospitalizations, operations, immunizations, allergies, current meds) -family history -review of systems -functional assessment (ADLs, IADLs, AADLs) cultural competence - answer An understanding of how a patient's cultural background shapes his beliefs, values, and expectations for therapy; established through knowing your own culture first inspection - answer -begins when you first see the patient
incident acute pain - answer happens with movement chronic pain - answer -lasts 6 months or longer -slow onset -malignant -nonmalignant (arthritis, fibromyalgia, low back pain) -isn't associated with injury -BRADS (bracing, rubbing, appetite, decreased activity, sighing) breakthrough pain - answer Occurs when patient has recurrence of pain before next scheduled dose of medication visceral pain - answer large internal organs (dull, deep, squeezing, cramping) ex. appendicitis and cholecystitis somatic pain - answer Pain that originates from skeletal muscles, ligaments, or joints. (aching, throbbing) cutaneous pain - answer pain from skin surface and subcutaneous tissue (superficial, sharp, nausea, sweating, tachycardia, HTN) referred pain - answer pain felt in a part of the body other than its actual source nociceptive pain - answer -nerve fibers are stimulated -Triggered by events outside the nervous system from actual or potential tissue damage
-transduction, transmission, perception, modulation (arthritis, mechanical back pain) neuropathic pain - answer Does not adhere to the typical phases Due to a lesion or disease in the somatosensory nervous system Implies abnormal processing of the pain message from an injury to the nerve fibers Most difficult to assess, diagnose, and treat May evolve into chronic condition May be caused by diabetes, shingles, HIV, chemotherapy, stroke, MS, a tumor, etc. PQRST - answer provocative/palliative, quality, region/radiation, severity, timing Identify changes that occur when a client's pain is poorly controlled. - answer Cardiac changes: tachycardia, elevated BP, increased myocardial oxygen demand, increased cardiac input Pulmonary changes: hypoventilation, hypoxia, decreased cough, atelectasis GI changes: nausea, vomiting, ileus Renal changes: oliguria, urinary retention Musculoskeletal changes: spasm, joint stiffness Endocrine changes: increased adrenergic activity CNS changes: fear, anxiety, fatigue Immune changes: impaired cellular immunity, impaired wound healing Poorly controlled chronic pain: depression, isolation, limited mobility and function, confusion, family distress, diminished quality of life
AADLs - answer Advanced Activities of Daily Living; activities performed in the community- social or recreational, activities performed within the family Katz Index of ADL - answer -Assessment for evaluation of activities of daily living -Focus: assessment of level of independence functioning and type of assistance required in six areas of ADL: 1) bathing 2) dressing 3) toileting 4) transferring 5) continence 6) feeding syncope - answer loss of consciousness or fainting due to weakness complete skin assessment - answer - scrutinize outer surface of skin -concentrate on underlying structures and inspect thoroughly -inspect feet, toenails, and between toes -check for color, temperature, moisture, texture, thickness, edema, mobility and turgor, vascularity or bruising, and lesions what causes true pallor (skin) - answer could be due to blood loss or anemic; slowed circulation (immobility/inactivity, prolonged elevation) jaundice (skin) - answer Yellowing - decreased liver function Where is jaundice first seen? - answer In the sclera of the eye, and then the skin cyanotic (skin) - answer blue- Not enough oxygen getting to red blood cells
erythema (skin) - answer red- indicates trauma, fever or infection; vasodilation what might multiple bruises at different stages of healing indicate - answer physical abuse edema can indicate - answer heart failure Scale to Grade Pitting Edema - answer 1+ mild pitting, slight indentation, no perceptible swelling in the leg 2+ moderate pitting, indentation subsides rapidly 3+ deep pitting, indention remains for a short time, leg looks swollen 4+ very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted complete nail assessment - answer shape and contour, consistency, color, capillary refill, profile sign (160 deg) ABCDE skin assessment - answer A: asymmetry B: border C: color D: diameter E: elevation and enlargement
nodule/tumor - answer Nodule: solid, round or oval elevated lesion 1 cm or more in diameter, extends deeper into dermis Tumor: larger than few cm, extends deep into dermis, benign or malignant wheal/urticaria - answer small, round, raised area on the skin that may be accompanied by itching; usually seen in allergic reactions -urticaria is a lot of wheals -hives/mosquito bite vesicle/bulla - answer Vesicle: A membrane bound sac that contains materials involved in transport of the cell; fluid filled up to 1cm (chickenpox, shingles) Bulla: larger than 1cm, single chambered, superficial in epidermis; large blister (blister, burns) cyst - answer sac containing fluid, elevates skin pustule - answer elevation of skin containing pus, circumscribed and elevated (acne, impetigo) scale - answer dry silvery, white, dead excess of keratin cells (eczema, psoriasis) secondary lesions - answer result from the changes that take place in the primary lesion due to infection, scratching, trauma, or various stages of a disease crust, scale, fissure, erosion, ulcer, excoriation, scar, atrophic scar, lichenification, keloid
vascular lesions - answer Hemangiomas Telangiectases Purpuric lesions Lesions caused by trauma or abuse pressure ulcer- stage 1 - answer skin is unbroken, localized (light) redness, patient is in pain pressure ulcer- stage 2 - answer skin is broken, loss of 1st layer, open blister, red and pink wound color, nerve endings are exposed pressure ulcer- stage 3 - answer expands into subcutaneous layer, may be crater-like, patient is not in pain pressure ulcer- stage 4 - answer may be deeper than it appears, all layers to supporting structures; could be down to the bone clubbing - answer profile sign of heart/lung disease, due to reduction of amount of oxygen in the blood; nail curves subjective data includes - answer signs what does a data base consist of - answer subjective and objective data, patient records, lab studies what does HIPAA stand for - answer Health Insurance Portability and Accountability Act
assimilation - answer developing a new cultural identity and becoming members of that culture open ended questions - answer begins the interview or helps to move on to a new topic close ended questions - answer Questions that can be answered in short or single word responses; to get the most relevant info in the dedicated time with the client; to know specific info what is included in health history - answer -biographical data -source of history -reason for seeking care -present health or illness -past health -systems review
- Family history
- ADLs what is a "reliable" person/statement - answer when they give the same answers after the questions are repeated or rephrased later on PQRSTU - answer P: Provocative or palliative- what makes pain better/worse Q: Quality or quantity- describe the pain R: Region or radiation- where is the pain, does it spread
S: Severity scale- how bad is it, has it gone away or gotten better (usually numerical scale) T: Timing: onset, duration, frequency U: Understand patient's perception edema: 1+ pitting - answer mild, slight indentation, no observable swelling edema: 2+ pitting - answer indentation goes away quickly edema: 3+ pitting - answer deep and stays for short time; observable swelling edema: 4+ pitting - answer very deep pitting that lasts for a long time; appears very swollen complete health history (well person) - answer lifestyle, exercise, diet, substance use, risk reduction, health promotion complete health history (ill person) - answer info about health problems spiritual resource questions - answer FICA -Faith (do you consider yourself a religious or spiritual person?) -Influence (how does your faith influence the way you see health) -Community (are you part of any religious/spiritual community?) -Address (would you like me to address any religious/spiritual concerns)
loss ecchymosis - answer bruise purpura - answer red-purple skin lesion due to blood in tissues from breaks in blood vessels angioma - answer tumor composed of blood vessels stages of bruising - answer Red/Blue or Purple within 24 hours of trauma 1-5 days Blue/purple Green 5- Yellow 7- Brown 10- confluent lesions - answer lesions that run together (urticaria-hives) discrete lesions - answer distinct, individual lesions that remain separate (skin tags, acne) grouped lesions - answer lesions that appear in clusters (contact dermatitis) gyrate lesions - answer twisted, coiled spiral, snakelike lesions (scabies) polycyclic lesions - answer annular lesions grow together
zosteriform lesions - answer linear arrangement along a unilateral nerve route, will cause a lot of pain (herpes zoster) target lesions - answer annular, but have specific red center (Lyme disease) what cultural practice is common among Turkish people - answer hanging a glass blue eye in the home acculturative stress (societal dimensions) - answer legal status, discrimination, political forces acculturative stress (environmental) - answer unemployment, language barriers culture - answer learned from birth, shared by all members, dynamic, adapted to specific conditions naturalistic beliefs - answer Beliefs that consider illness as the result of disequilibrium between hot and cold; or yin and yang (illness occurs because of imbalance of body's 4 humors what tests should be used to assess religion/spirituality - answer FICA and R-cope (coping) which instrument is used to examine the ear and the nose - answer otoscope which exam visualizes neurochemical changes in the brain caused by nociception - answer
informal support - answer help from people who care about them (family, close friends, usually free of charge) formal support - answer help from associations and institutions (welfare, social service, health care delivery agencies) where do nociceptors carry the pain to - answer CNS HEEDSSS - answer H- home environment E- education/employment E- eating D- drugs S- sexuality S- suicide/depression S- safety from injury/violence what can cause false pallor - answer vasoconstriction- fear/anger, chilly room, smoking how to assess a deaf patient - answer - use an interpreter
- always look at the patient
- allow them to pick the method of communication/learning style how do you assess pain - answer palpation
