NUR2092 Health Assessment Exam #1 COMPLETE SOLUTIONS

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NUR2092 Health Assessment Exam #1 COMPLETE SOLUTIONS Steps of the Nursing Process Correct Answer: Assessment - gather data Diagnosis - problem Outcome Identification - goals, what we want to hap... pen, expect to happen Planning - treatment plan, intervention Implementation - doing the plan Evaluation - Was it successful, meet the goals Define Subjective Data Correct Answer: What patient says about himself or herself during history taking symptoms Define Objective Data Correct Answer: Observed when inspecting, percussing, palpating, and auscultating patient during physical examination signs Factors of Diagnosis Correct Answer: -Cluster of data that seem to be associated in some way. -Validate data, confirm accuracy -Look for gaps in your information -Interpret data and identify problems -Document the diagnosis Factors of Outcome Identification Correct Answer: -Identify expected outcomes related to patient individualization -Ensure outcomes have the SMART components -Specify short-term and long-term goal measurement criteria What does SMART stand for? Correct Answer: Specific, Measurable, Attainable, Realistic, Timely Factors of Planning Correct Answer: -Establish priorities based on meeting patients care goals -Develop outcomes and set time frames for meeting outcomes -Identify relevant interventions and utilize interdisciplinary health care team members for the patient -Document plan of care Factors of Evaluation Correct Answer: -Refer to outcomes -Evaluate patient's condition and compare actual outcomes to expected outcomes -If reached outcome: does something need to be done -If NOT reached: identify reasons for not achieving -Modify plan if needed -Document in plan of care Evidence-Based Decision Making factors Correct Answer: -Best evidence from clinical review of research literature -The providers clinical expertise -Patient's preference and values -Physical examination and assessment of patient Focused Database Correct Answer: Problem-centered Used for a limited or short-term problem Smaller scope and more targeted than the complete database Complete Database Correct Answer: Includes a complete health history and full physical examination Yielding the first diagnosis Steps in Priority Problem Levels Correct Answer: 1. First-level priority: emergent, life threatening, immediate 2. Second- level: next in urgency, requires attention to prevent further deterioration 3. Third-Level: important to patient's health, but can be addressed after urgent problems What are the two parts to Communicating? Correct Answer: 1. Sending 2. Receiving In communication what are the two types in "sending"? Correct Answer: 1. Verbal: words/tone 2. Nonverbal: less conscious In communication, what does "receiving" mean? Correct Answer: Interpretation based on past experiences, culture, and self concept Physical and emotional state Communication does what with a patient? Correct Answer: -Builds a relationship -Builds rapport Key to Communication Correct Answer: Is the receiver getting the message the way it was intended? Active listening Types of questions in Therapeutic Communication Correct Answer: Open-ended: narrative answers, feelings and opinions, develops rapport Close-ended: yes/no questions, used for specific information, limits rapport In Therapeutic Communication, what are the types of responses focused on the client's frame of reference? Correct Answer: CLARIFICATION (rephrase) FACILITATION (nodding, Hmm,hmm) SILENCE (when to use) SUMMARIZE (summarize what pt stated) EMPATHY (likening to others, comfort, "I understand") In Therapeutic Communication, what are the types barriers? Correct Answer: AVOIDANCE LANGUAGE (using other words) CHANGING THE SUBJECT DISTANCING (walking to the door, avoid eye contact) BLAMING (if you didn't smoke...) FALSE REASSURANCE (you'll be fine) FAILURE TO LISTEN GIVING ADVICE Barriers in Communication include: Correct Answer: - lack of interest - physical barriers - patient's inability to hear you - safety - physiological barriers - language/use of medical jargon, or speaking above someone's educational level Substance Abuse Assessment Correct Answer: - Tolerance: carries from person to person - Watch for withdrawal symptoms - Dependence - Addiction Dependence vs Addiction Correct Answer: -Dependence: can be weeded off -Addiction: destructive behaviors with what you are doing Substance Abuse withdrawal symptoms: Correct Answer: - nausea/vomiting - tremor - paroxysmal sweats - anxiety - visual disturbances - headache - disorientation Alcohol Use assessment Correct Answer: - quick assessment: frequency use of alcohol, tobacco, prescription drug for nonmusical use, illicit drugs - AUDIT: Alcohol Use Disorders Identification Test - CAGE: Cut down, Annoyed, Guilty, Eye-opener CAGE questionnaire Correct Answer: Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)? Domestic Violence Assessment includes: Correct Answer: - need to ask every client needs to be assessed for the risk/evidence of abuse - use own words in nonjudgemental way - Abuse Assessment Screen - Walker's Cycle of Violence: tolerance, explosion, honeymoon Assessment of Intimate Partner Violence (IPV) Correct Answer: - HITS: hurt, insult, threaten, scream - 1-5 points: never to frequently - 10 or more: indicate IPV When should you report for Domestic Violence cases Correct Answer: children/elder adult- not required Warning signs of Human Trafficking include: Correct Answer: - injuries/signs of physical abuse - malnourished - disoriented - lack of identification - few personal belongings - avoids eye contact - minor appearing in relationship with older person - works long hours, lives in work environment - fearful, anxious, submissive - fearful of law enforcement - cannot freely contact friends/family Human Trafficking Screening factors: Correct Answer: - best to speak to client alone: try not to raise suspicions - treat each case as unique - assume victim is at risk of harm - do NOT start with sensitive questions [Show More]

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