Health Assessment Exam 1

Front 1

subjective data

Back 1

what the person says about himself/herself

Front 2

objective data

Back 2

what you as the healthcare professional observes, can be measured

Front 3

judgement or diagnose

Back 3

Purpose of healthcare assessment

Front 4

diagnostic reasoning

Back 4

process of analyzing health data and drawing conclusions to identify diagnoses

Front 5

1. attending to initially available cues

2. formulating diagnostic hypothesis

3. gathering data

4. evaluating hypothesis

Back 5

Name four components of hypothetico-deductive process

Front 6

Cue

Back 6

piece of info, sign or symptom, or a piece of lab data

Front 7

hypothesis

Back 7

a tentative explanation for a cue or set of cues

Front 8

1. assessment

2. diagnose

3. plan

4. implement

5.evaluate

Back 8

name the nursing process

Front 9

Novice

Back 9

Level of experience that has no experience with a specified patient population and uses rules to guide performance

Front 10

proficient

Back 10

Level of experience that understands a patient situation as a whole rather than a list of tasks

Front 11

expert

Back 11

Level of experience that can vault over the steps and arrive at clinical judgement in one leap

Front 12

assessment

Back 12

Which part of the Nursing Process?

Collect data

Front 13

Assessment

Back 13

Which part of the Nursing Process?

document relevant data

Front 14

Diagnose

Back 14

Which part of the Nursing Process?

Compare clinical findings with normal and abnormal variation and developmental events

Front 15

DIagnose

Back 15

Which part of the Nursing Process?

Interpret Data

Front 16

Planning

Back 16

Which part of the Nursing Process?

establish priorities

Front 17

Planning

Back 17

Which part of the Nursing Process?

develop outcomes

Front 18

Planning

Back 18

Which part of the Nursing Process?

set timelines for outcomes

Front 19

Planning

Back 19

Which part of the Nursing Process?

integrate evidence based trends and research

Front 20

Nursing diagnosis

Back 20

clinical judgments about a person's response to an actual or potential health state

Front 21

North American Nursing Diagnosis Association

Back 21

What does NANDA stand for?

Front 22

First-level priority problems

Back 22

problems that are emergent, life threatening, and immediate

Front 23

Second level priority problems

Back 23

problems that require your prompt intervention to forestall further deterioration

Front 24

Third Level Priority problems

Back 24

Problems that are important to the patient care but can be addressed after more urgent health problems are addressed

Front 25

collaborative problems

Back 25

Problems in which the approach to treatment involves multiple disciplines

Front 26

1. complete

2. focused/ problem centered

3. follow-up

4. emergency

Back 26

List the four different types of data bases

Front 27

complete data base

Back 27

complete health history and full examination. Describes current and past health

Front 28

primary care

Back 28

Complete data bases are usual obtained from where

Front 29

problem centered/ focused database

Back 29

database for one problem or body system

Front 30

emergency database

Back 30

rapid collection of the data

Front 31

holistic health

Back 31

views mind, body, and spirit as interdependent and functioning as a whole within the enviroment

Front 32

1. physical appearance

2. body structure

3. mobility

4, behavior

Back 32

four areas of general survey

Front 33

health disparity

Back 33

unusual and disproportionate frequency of a health problem within a population when compared to other populations

Front 34

culturally sensitive

Back 34

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

Front 35

culturally appropriate

Back 35

implies that the caregivers apply the underlying background knowledge that must be possessed to provide a given person with the best possible Health Care

Front 36

culturally competent

Back 36

implies that the caregivers understand and attend to the total context of the individual's situation

Front 37

1. your own heritage

2. heritage of the nursing profession

3. heritage of health care system

4. heritage of patient

Back 37

Four areas you must have knowledge when dealing with cultural care

Front 38

Heritage consistency

Back 38

A concept that describes the "degree to which one's lifestyle reflects his or her own culture"

Front 39

1. learned from birth

2. shared by all members of same cultural group

3. adapted to specific conditions

4. dynamic and ever changing

Back 39

four basic characteristics of culture

Front 40

subculture

Back 40

groups that function within a large culture

Front 41

acculturation

Back 41

process of adapting to and acquiring another religion

Front 42

Assimilation

Back 42

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

Front 43

Biculturalism

Back 43

dual pattern of identification and often of divided loyalty

Front 44

1. biomedical/scientific

2. naturalistic/ holistic

3. magicoreligious perspective

Back 44

three views on disease causation

Front 45

biomedical/ scientific

Back 45

Theory of disease causation that is based on the assumption that all events in life have a cause and effect, that the human body functions more or less mechanically

Front 46

Naturalistic/ holistic

Back 46

Disease causation view that human life is part of the general order of the cosmos. balance and harmony.

Front 47

1. Yin/Yang

2. hot/ cold theory

Back 47

Two theories that go with Holistic/naturalistic disease causation

Front 48

magicoreligious

Back 48

View of causation of disease where the world is seen as an arena in which supernatural forces dominate

Front 49

culture-bound syndrome

Back 49

condition that is culturally defined

Front 50

1. gather complete/ accurate data

2. establish trust

3. teach patient about the health state

4. build rapport for continuing relationship

5. begin teaching for health promotion and prevention

Back 50

You know you have had a successful interview when you have covered these 5 things

Front 51

verbal

Back 51

communication with the words you speak, tone of voice

Front 52

nonverbal

Back 52

communication with body language, facial expressions, eye contact

Front 53

1. liking others

2. empathy

3. ability to listen

Back 53

Three internal factors that the examiner should bring to the interview

Front 54

1. introducing the interview

2. working phase

3.closing the interview

Back 54

three parts of the interview

Front 55

1. facilitation

2. silence

3. clarify

4. reflect

5. empathy

6.confront

7. interpretation

8.explanation

9. summary

Back 55

Nine types of verbal responses

Front 56

1.providing false reassurance

2. giving unwanted advice

3. using authority

4. using avoidance language

5. engaging in distancing

6. using professional jargon

7.using biased questions

8. talking too much

9. interrupting

10. using "why" questions

Back 56

ten traps of interviewing

Front 57

parent

Back 57

when you have a patient that is 1-6 years old, focus more on the

Front 58

1. intimate zone

2. personal distance

3. social distance

4. public distance

Back 58

4 distance zones

Front 59

name, address, phone number, DOB, birthplace, gender, marital status, race, ethnic origin, and occupation

Back 59

biographic data should include

Front 60

symptom

Back 60

subjective sensation that the person feels from the disorder

Front 61

sign

Back 61

objective abnormality that you as the examiner detect on physical examination or lab reports

Front 62

P- provocative or palliative

Q-quality or quantity

R-region or radiation

S- severity scale

T-timing

U-understand patient's perception

Back 62

your final summary of a patient's symptom should include these characteristics

Front 63

childhood illness, accidents/ injuries, serious or chronic illness, hospitilizations, operations, obstetric history, immunizations, last examination date, allergies, current meds

Back 63

Past health history should include (10)

Front 64

pedigree/ genogram

Back 64

family tree that uses symbols to depict the gender, relationship, and age in at least three generations

Front 65

history of skin disease, pigment or color change, change in mole, excessive dryness/moisture, excessive bruising, rash, or lesion

Back 65

skin assessment

Front 66

recent loss, change in texture, Nails- change in shape, color, brittleness

Back 66

Hair/ nails assessment

Front 67

any unusually frequent or severe headache, any head injury, dizziness

Back 67

Head assessment

Front 68

difficulty with vision, eye pain, diplopia, redness, swelling, watering or discharge, glaucoma or cataracts

Back 68

eye assessment

Front 69

wears glasses/ contacts, last vision check, how coping with vision loss

Back 69

Health promotion of eyes

Front 70

earaches, infections, discharge

Back 70

ear assessment

Front 71

discharge, frequent colds, , sinus pain, nasal obstruction, nosebleeds, allergies, change in sense of smell

Back 71

Nose and sinus assessment

Front 72

mouth pain, frequent sore throat, bleeding gums, toothache, lesion, dysphagia, hoarseness, altered taste

Back 72

mouth and throat assessment

Front 73

pain, limitation of movement, lumps, swelling, enlarged nodes, goiter

Back 73

Neck assessment

Front 74

pain, lump, nipple discharge, rash, history of breast disease, any surgery of breasts

Back 74

breast assessment

Front 75

tenderness, swelling, rash

Back 75

axilla assessment

Front 76

history of lung disease, chest pain with breathing, wheezing, noisy breathing, shortness of breath, cough, sputum, hemoptysis,

Back 76

respiratory system assessment

Front 77

precordial or retrosternal pain, palpitation, cyanosis, dyspnea on exertion, edema, history of heart murmur

Back 77

cardiovascular assessment

Front 78

coldness, numbness, tingling, discoloration in hands and feet, ulcers, swelling of legs

Back 78

peripheral vascular assessment

Front 79

appetite, food intolerance, dysphagia, heart burn , indigestion, abdominal pain, nausea, vomiting, flatulence, frequency of bowel movement, constipation, diarrhea, rectal bleeding, black stools

Back 79

gastrointestinal assessment

Front 80

frequency, urgency, nocturia, dysuria, polyuria, narrowed stream, urine color, incontinence, pain in groin/subpubic region/ lower back

Back 80

urinary system assessment

Front 81

penis or testicular pain, sores, lesions, penile discharge

Back 81

male genital system assessment

Front 82

menstrual history, vaginal itching, discharge, age at menopause, post menopausal bleeding

Back 82

Female genital assessment

Front 83

history of arthritis, gout. In the joints: pain, stiffness, swelling, cramps, weakness. In the back: pain, limitation of movement

Back 83

musculoskeletal system assessment

Front 84

history of seizure disorder, stroke, fainting, paralysis, tremor, tic, weakness, coordination problems, memory disorder, nervousness, hallucinations

Back 84

Neurologic system assessment

Front 85

HEEADSSS

Back 85

what is the psychosocial interview used for adolescents

Front 86

Home
Education/ Employment

Eating

Activities

Drugs

Sexuality

Suicide/ depression

Safety

Back 86

What does HEEADSSS stand for?

Front 87

1. age

2. sex

3. level of consciousness

4.skin color

5. facial features

Back 87

(5) things looked at under physical appearance

Front 88

appears older than stated age, as with chronic illness, chronic alcoholism

Back 88

abnormal findings with age

Front 89

delayed or precocious puberty

Back 89

abnormal findings with sex

Front 90

confused, drowsy, lethargic

Back 90

abnormal findings of level of consciousness

Front 91

pallor, cyanosis, jaundice, erythema, lesions

Back 91

abnormal findings in skin color

Front 92

immobile, masklike, assymetrical drooping

Back 92

abnormalities in facial features

Front 93

1. stature

2. Nutrition

3.symmetry

4. posture

5. position

6. body build

Back 93

(6) things to look at under body structure

Front 94

excessively short/tall

Back 94

abnormalities in stature

Front 95

cachetic, obesity with even distribution, centripetal obesity- cushing's syndrome

Back 95

abnormalities in nutrition

Front 96

unilateral atrophy/ hypertrophy

Back 96

abnormalities in symmetry

Front 97

rigid spine and neck, stiff and tense, fidgety, shoulders slumped

Back 97

abnormalities in posture

Front 98

tripod-leaning forward with one arm braced on chair (chronic pulmonary disease), sitting straight up and refusing to lay down (congestive heart failure), curled in fetal position (abdominal pain)

Back 98

abnormalities in position

Front 99

elongated arm span, arm span greater than height (marfan syndrome, hypogonadism), missing exremeties, webbed digits, shortened limbs

Back 99

abnormalities in body build

Front 100

1. gait

2. range of motion

Back 100

(2) things to look for under mobility

Front 101

exceptionally wide base, staggered, stumbling, shuffling, dragging, nonfunctional leg, limping with injury, difficulty stopping

Back 101

abnormal findings in gait

Front 102

limited join range of motion, paralysis -absent movement, uncoordinated, seizures, tremors, tics

Back 102

abnormal findings in range of motion

Front 103

1. facial expression

2. mood and affect

3. speech

4. dress

5. personal hygeine

Back 103

(5) things to look for under behavior

Front 104

flat, depressed, angry, sad, anxious

Back 104

abnormalities in facial expression

Front 105

hostile, distrustful, suspicious, crying

Back 105

abnormal findings in mood/ affect

Front 106

dysarthria, dysphagia, speech defect, monotone, garbled

Back 106

abnormalities of speech

Front 107

clothing too large and new holes in belt suggests weight loss, clothing too tight suggests obesity or ascites, long sleeves to cover up, Velcro fasteners may indicate chronic motor dysfunction

Back 107

abnormalities of clothes

Front 108

19-25

Back 108

healthy BMI is between

Front 109

temperature

pulse

respiration

blood pressure

Back 109

vital signs

Front 110

99 F

Back 110

deep core body temp

Front 111

hypothalamus

Back 111

temperature is regulated in the

Front 112

98.6 F

Back 112

normal oral temp

Front 113

-diurnal cycle, trough in the early morning and peak in late afternoon

-menstruation cycle

-exercise

-age

Back 113

normal temp is influenced by