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NUR 3065 Health Assessment Latest Exam 2 -
Daytona State College 2024/2025 | Questions
and Correct Answers | Latest Version | Verified
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With which part of the hand would you best palpate for temperature? back This is generally the first technique that any assessment begins with. inspection If a nurse is listening to heart sounds with a stethoscope, they are using this technique. auscultation One of the 4 main assessment techniques where clinicians uses touch for assessment. palpation A standard stethoscope has 2 parts, which include the... diaphragm and bell This technique uses tapping with the fingers to assess the density of underlying structures. percussion A nurse is doing a CVA tenderness check. What organs (in the urinary system) can we assume that they are assessing? kidneys
What is the communication process with healthy history collection? sending and receiving What is sending in the communication process? what type of communication (verbal or nonverbal); What is receiving in the communication process? may not initially understand, physical and emotional states play a role, listener may have preconceived notions Empathy vs. Sympathy In empathy, we understand the feelings of others. In sympathy, we feel the feelings of others. What can the nurse do during the interview to help the patient open up? thank patients for sharing, show interest, encourage your patient, be supportive What are the internal aspects of the interview environment? confidentiality, open, receptive, non-judgemental What are the external aspects of the interview environment? personal distance (2x arms length away); 90-degree angle than face-to-face; eye-level; equal status seating; presence of others, geographic privacy, avoiding distractions, interruptions How would you interview special need patients? advice and recommendations may ned to be repeated several times, or written down What are closed-ended questions? a question only requiring a "yes" or "no" answer, ex. do you have diabetes
etiquette, space and distance, gender, sexual orientation, eye contact- nonverbal behavior The nurse makes which adjustment in the physical environment in order to promote the success of an interview? A. Reduces the distance between the interviewer and the patient to 2 feet or less B. Arranges seating across a desk or table to allow the patient some personal space C. Provides a dim light that makes a room cozier and will help the patient relax D. Reduces noise by turning off televisions and radios D. Reduces noise by turning off televisions and radios What is gravida? number of times been pregnant What is para? number of birth, carried pregnancy to term What is A? abortions; incomplete pregnancies What is T? term What is P? preterm What is L? living children What type of information is the complete health history? all subjective information
What is C/C? chief complaint, reason for seeking care What is HPI? history of present illness What is PHx? past history What is FHx? family history What is SHx? social history What is ROS? review of systems What does biographical data refer to? story, name, DOB/age, gender What is chief complaint or concern (CC)? patient's own words, reason for seeking care, usually a symptom, quote or paraphrase What is PQRSTU? provocative or palliative factors; quality or quantity; region or radiation; severity scale; timing; understand patient's perception
What are the five rights of medical administration? right patient, right drug, right time, right does, right route What is family history (FHx)? record of medical condition of each relative, relationship to patient, alive, deceased-when and how, illnesses What is social history (SHx)? self-esteem/self-concept (education, religious practices), coping/stress management, drugs, alcohol, tobacco ("yes"- positive findings)- how much, what kind, how long); activity level, sleep, nutrition/elimination, relationships, habits; environmental and occupational hazards What is PPD? packs per day How do you determine pack yrs. ppd x years smoking What is review of systems (ROS)? not physical, health history (subjective) what is reported NOT found through examination, extension of past history What is UTD? up to date The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? A. To provide an opportunity for interaction between patient and nurse B. To provide a form for obtaining the patient's biographic information C. To provide a database of subjective information about the patient's past and current health. D. To document the normal and abnormal findings of a physical assessment C. To provide a database of subjective information about the patient's past and current health. What SDH? social determinants of health What are some SDH? availability of nutritious food, clean air/water, access to education, safe homes/neighborhoods, freedom from racism; poverty is #1 SDH influence How do you incorporate cultural practices within the context of health assessments? don't assume, ASK- heritage, health practices, communication, family roles, social orientation, nutrition
How do you incorporate beliefs within the context of health assessments? use questions and statements to start conversation There are 3 patients in the waiting room of a clinic who are waiting to be seen. Patient 1 has arrived for a follow-up visit, post-tonsillectomy, and is reporting mild difficulty swallowing and pain in the throat and neck. Patient 2 is experiencing nausea, diarrhea, and vomiting after eating sushi containing uncooked fish. Patient 3 is experiencing difficulty swallowing after being stung by a bee while mowing grass. Which of the following patients should the triage nurse see first? patient 1 How do you become a culturally competent practitioner? no one fits into a box; understand and attend to contextual aspects of care including status, culturally sensitive (basic knowledge and attitudes), culturally appropriate What are some cultural considerations for nutritional assessments? diets- restrictions, fasting What is spirituality? board term; something larger What is religion? organized system of beliefs How do you use professional interpretation services in interviews and communications? used for official encounters, patients have legal rights to have materials in their language, translation systems What is IAPP? inspection, auscultation, percussion, palpation What is inspection? concentrated watching, observation What do you begin an assessment with? inspection What are we inspecting? symmetry, posture, gait, facial expression, dress, color, contour
What is a resonant percussion sound? clear, hollow; air in lung What is a tympanic percussion sound? high pitched, drum-like sounds- air and fluid in viscous organ (stomach) What is a dull percussion sound? medium pitch; dense organs (liver or spleen) What is a flat percussion sound? solid (bone, mass, muscle) What is auscultation? listening to body sounds through a stethoscope What is the diaphragm stethoscope? used most often, press firmly on skin, high pitched sounds (breathe, bowel, heart) What is the bell stethoscope? used less often; press lightly on skin, low pitch sounds (murmurs, extra heart sounds) What to look for in stethoscopes? some only have one end, warm it, minimize external noises, skin, ask patient to displace body parts or ask permission use back of hand What is the order of assessment for pediatrics and infant persons? leased invasive first; say ahh, lungs, ROM (Simon says), are they ticklish? What should you consider for teens when using a stethoscope? independent, awkwardness What should you consider for older adults when using a stethoscope? lighting, sounds, limit position changes, consider how much deep breathing they can tolerate What are some general principles of assessment? consider emotional state of pt (anxiety), maintain privacy and respect, use ppe when needed, explain everything you are doing, avoid examination in public spaces or hallways What should you do when you examine an ill person? altar your position, consider comfort level, do focused assessment until pt is able to do full assessment What is the difference between official and unofficial interpretation?
official- certified healthcare interpreter and certified interpreter systems, official documents unofficial- non certified interpreter can speak in language asking about ADLs or their day, etc
