Health Assessment Test 1

Front 1

Identify the four basic characteristics of culture:

Back 1

• Learned- from birth through the processes of language acquisition and socialization
• Shared- by all members of the same cultural group
• Adapted- to specific conditions related to environmental and technical factors and to the availability of natural resources
• Dynamic- ever changing

Front 2

• Ethnicity

Back 2

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

Front 3

• Spirituality

Back 3

borne out of each person’s unique life experience and his or her personal effort to find purpose and meaning of life

Front 4

• Assimilation

Back 4

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

Front 5

Identify how an Asian immigrant may describe health

Back 5

• Asians have a way of explaining illness through a naturalistic or holistic perspective. That is, they believe that human life is only one aspect of nature and a part of the general order of the cosmos. They may believe that the forces of nature must be kept in natural balance or harmony
• Some Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. This theory states that all organisms and objects in the universe consist of yin and yang energy forces. Yin energy represents the female and negative forces, such as emptiness, darkness, and cold, whereas yang forces are male and positive, emitting warmth and fullness.
o Yin foods-cold and eaten with a hot illness
o Yang foods-hot and eaten with a cold illness
• Among people of Chinese decent, no translation for the English word “sadness” exists, therefore sometimes they convert mental experiences into bodily symptoms (complain of cardiac symptoms because their heart is aching with grief—the heart is the center of their universe)

Front 6

Describe how an individual who takes the magicoreligious perspective of illness and disease is likely to believe that their illness was caused by

Back 6

• These people believe that supernatural forces dominate the world. The fate of the world and those in it depends on the action of supernatural forces for good or evil.
• Examples of magical uses of illness include belief in voodoo or witchcraft
• Faith healing is based on religious beliefs and is most prevalent among certain Christian religions.
• It is possible to have a combination of world views, and many people are likely to offer more than one explanation for the cause of their illness
• Some techniques used for the management of chronic pain are becoming more prevalent including acupuncture, herbal therapies, hypnosis, therapeutic touch, and biofeedback

Front 7

Describe how working with children with a different cultural perspective can be especially difficult

Back 7

• Parental perceptions about the illness of the child may be partially influenced by religious beliefs. For example, some parents may believe that a transgression against a religious law is responsible for a congenital anomaly in their offspring
• Other parents may delay seeking care because they think prayer should be tried first
• Certain types of treatment (administration of blood; medications containing caffeine, pork, or other prohibited substances) and selected procedures may be perceived as cultural taboos—that is, practices to be avoided (by adults and children)

Front 8

Be prepared to give an identify hot/cold theory

Back 8

• Embraced by many Hispanic, Arab, black, and Asian groups
• The theory is based off of the ancient Greek humoral theory
o The four humors of the body are blood, phlegm, black bile, and yellow bile
o The humors regulate basic bodily functions and are described in terms of temperature, dryness, and moisture
o Illness is when the four humors are not in balance
o Thus, treatment of illness seeks to restore the balance by adding or subtracting cold, heat, dryness, or wetness
• People who follow the hot/cold theory classify beverages, food, herbs, and medicines as hot or cold according to their perceived effects on the body
• Illness caused by cold earache, chest cramps, paralysis, gastrointestinal discomfort, rheumatism, and tuberculosis
• Illness caused by overheating abscessed teeth, sore throats, rashes, and kidney disorders
• Those who embrace the theory maintain that health consists of a positive state of total well-being, including physical, psychologic, spiritual, and social aspects of the person
• This theory is a reflection of the biomedical/scientific perspective

Front 9

Be prepared to identify an example of Opening/introducing during the interview

Back 9

• Steps to the introduction:
1. Address the person using his or her surname and shake hands if that seems comfortable
2. Introduce yourself and your role in the agency
o If a student, tell the client that you are a student
3. If gathering a complete history, give the reason for the interview (this is especially important if the patient is being interviewed multiple times by different members of the health care team)
o Ex: Mrs. Sanchez, I would like to talk about your illness that caused you to come to the hospital
o Ex: Ms. Taft, I want to ask you some questions about your health so that we can identify what is keeping you healthy and explore any problems
• Keep in mind that it is best to build rapport with the client by letting him or her discuss their concern early
• You do not need small talk to build rapport

Front 10

Identify an example of a patient’s reason he is seeking care

Back 10

• Previously called the chief complaint
• This is a brief spontaneous statement in the person’s own words that describes the reason for the visit
• It generally states one or two signs or symptoms and their duration
• Sign: objective abnormality that the examiner detects through physical examination or laboratory results
• Symptom: a subjective sensation that the person feels from the disorder
• When documenting, enclose the reason for care in quotation marks to indicate a patient’s exact words
• Examples:
o “Chest pain” for 2 hours
o “Earache and fussy all night”
o “Need yearly physical for work”
o “Want to start jogging and need a checkup”
• The reason for seeking care is not a diagnostic statement
• If a patient is trying to self-diagnose, ask them what symptoms make them think they have their self-diagnosis
• When a patient lists many reasons for seeking care, try to focus on which is the most pressing concern by asking which one prompted them to seek help now

Front 11

• Verbal Communication

Back 11

o Includes the questions to the patient and your responses to what the patient has said
o Types of verbal responses: facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary
o Example:
 Patient: It’s so hard having to stay flat on my back in the hospital with this pregnancy. I have two more little ones at home. I’m so worried they are not getting the care they need.
Response: You feel worried and anxious about your children? (this is a reflective response)

Front 12

• Nonverbal Communication

Back 12

o Includes physical appearance, posture, gestures, facial expression, eye contact, voice (tone of voice, intensity and rate of speech, the pitch, and any pauses), and touch
o Examples of positive nonverbal communication:
 Appropriate professional appearance
 Equal-status seating
 Close proximity to the patient
 Relaxed open posture
 Leaning slightly toward a person
 Occasional facilitating gestures
 Facial animation, interest
 Appropriate smiling
 Appropriate eye contact
 Moderate tone of voice
 Moderate rate of speech
 Appropriate touch

Front 13

Define what the RN obtains during the interview portion of data collection

Back 13

Gather complete and accurate data about the person’s health state including description and chronology of any symptoms of illness
Establish rapport and trust so the person feels accepted and thus free to share all relevant data
Teach the person about the health state so that the person can participate in identifying problems
Build rapport for a continuing therapeutic relationship; this rapport facilitates future diagnoses, planning, and treatment
Begin teaching for health promotion and disease prevention

Front 14

Identify what the nurse would expect that most of the INTERVIEW will take place at which distance

Back 14

Most of the interview is done at the social distance (4-12 ft)

Front 15

13. Identify statements best describes the purpose of a health history

Back 15

Collection of subjective and objective data
Provides a complete picture of the person’s past and present health
It describes the individual as a whole and how the person interacts with the environment
The history recognizes what a person is doing right and what they are doing to stay well.

Front 16

Identify what the review of systems provides the nurse with

Back 16

the ability to evaluate the past and present health state of each body system
the ability to double-check in case any significant data were omitted in the present illness section
the ability to evaluate health promotion practice

Front 17

Identify what individuals the nurse would consider at highest risk for a suicide attempt:

Back 17

a person who expresses feelings of sadness, hopelessness, despair or grief. It is important to asses any possible risk of physical harm to him/herself <BR>Also suicide peaks in later life, being among people age 65 and older (men account for that majority)

Front 18

Identify what the technique the nurse will always perform first with a physical assessment:

Back 18

The skills requisite for the physical examination are inspection, palpitation, percussion, and auscultation. Inspection always comes first.

Front 19

What is the nurse assessing when percussing

Back 19

A nurse is trying to elicit a sound and assess underlying structures. And it has the following uses: mapping out location and size of organ, signaling density, detecting abnormal mass if fairlysuperficial, eliciting pain, and eliciting deep tendon reflex.
Two methods:
Direct (sometimes called immediate)-striking hand directly contacts the body wall (used in percussing the infant’s thorax or adult’s sinus areas)
Indirect (mediate)- used more often and involves both hands.

Front 20

When percussing over the ribs of a patient, the nurse notes a dull sound. The nurse would:

Back 20

avoid the person’s ribs and scapulae because percussing over a bone yields no data because it always sounds “dull”.

Front 21

Which technique of assessment is used to determine the presence of crepitus (crackles), swelling, and pulsations?

Back 21

Auscultation

Front 22

When performing a general survey, the examiner is...

Back 22

Looking for objective findings of the whole person, any obvious physical characteristics. Objective parameters are used to form the general survey, but these apply to the whole person, not just to one body system

Front 23

When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by:

Back 23

1) Diurnal (daily) cycles. Trough (the low point) in early morning, the peak in late afternoon/early evening
2) Menstruation in women
3) Exercise
4) Age

Front 24

When evaluating the temperature of older adults, the nurse remembers that an older adult’s body temperature:

Back 24

is usually lower than in other age groups, with a mean of 36.2 degrees C (97.2 degrees F). Normal is 98.6 F.

Front 25

What factors help to determine blood pressure?

Back 25

1. Cardiac Output – if the heart pumps more blood into the blood vessels, the pressure on the walls of the blood vessels increases.
2. Peripheral Vascular Resistance – the opposition to blood through the arteries. When the diameter of the vessels becomes smaller (when they constrict) the pressure needed to push the blood becomes greater.
3. Volume of circulating blood – how tightly the blood is packed into the arteries. Increases the blood in the vessels increases the pressure.
4. Viscosity – The “thickness” of the blood is determined by its formed elements, the blood cells. When the contents are thicker, the pressure increases.
5. Elasticity of vessel walls – When the vessel walls are stiff and rigid, the pressure needed to push the contents increases.

Front 26

The average BP in a young adult is 120/80 mm hg. This varies with many factors, such as:

Back 26

1. age – Normally, a gradual rise occurs through childhood and into adult years.
2. Gender – Before puberty, no difference exists between males & females. After puberty, females usually have lower BP than males. After menopause, BP in females is higher than in males.
3. Race – In U.S., a black adult’s BP is usually higher than a white person of the same age. Hypertension occurs twice as much in blacks than in whites. This appears to be related to genetics and environmental factors.
4. Diurnal Rhythm – A daily cycle of a peak and a trough occurs. The BP climbs to a high in the late afternoon and early evening and then declines to an early morning low.
5. Weight – BP is higher in obese than in people with normal weight the same age.
6. Exercise – Increasing activity will increase BP. Within 5 minutes of stopping exercise , the BP should return to baseline.
7. Emotions – BP momentarily increases with fear, anger, and pain as a result of stimulation of the sympathetic nervous system.
8. Stress – The BP is elevated in people feeling continual tension because of lifestyle, occupational stress, or life problems.

Front 27

Define how pulse pressure is determined

Back 27

Pulse Pressure is the difference between the systolic and the diastolic and reflects the stroke volume. Stroke volume is the amount of blood pumped out of a ventricle with each beat. Pulse Pressure increases when stroke volume increases or vascular compliance decreases. Vascular compliance is a measure of the change in the volume of blood in the vessels produced by a change in pressure. Pulse pressure can be used to take the pulse.

Front 28

What type of blood pressure measurement error is most likely to occur if the examiner does not check for the presence of an auscultatory gap?

Back 28

If the auscultatory gap is undetected, the result would be a falsely low systolic or a falsely high diastolic reading.
Note: inflate the cuff until the artery pulsation is obliterated and then 20 to 30 mm hg beyond.This will avoid missing an auscultatory gap, which is a period when Korotkoff’s sounds disappear during auscultation.

Front 29

pressure forcing blood into the tissues, averaged over the cardiac cycle. It is not an average of systolic and diastolic pressures, but is a value closer to diastolic pressure plus one third pulse pressure.

Back 29

mean arterial pressure

Front 30

The nurse is assessing a pt’s pain. The nurse knows that which of the following is considered the most reliable indicator of pain?

Back 30

The most reliable indicator of pain is considered to be the subjective report--whatever the experiencing person says it is!

Front 31

When assessing the quality of a pt’s pain, the nurse should ask which question?

Back 31

When assessing the quality of a patient's pain, the nurse should ask the questions of the initial pain assessment (page 184), which include:

Where is your pain?
When did your pain start?
What does your pain feel like?
How much pain do you have now?
What makes your pain better or worse?
Hoe does pain limit your function or activities?
How do you usually behave when you are in pain?/How would others know you are in pain?
What does this pain mean to you?/Why do you think you are having pain?

Front 32

Nociception is the term used to describe how noxious stimuli are typically perceived as pain. During which phase of nociception does the conscious awareness of a painful sensation occur?

Back 32

There are 4 phases of nociception (how noxious stimuli are perceived as pain). The phases are transduction (when the noxious stimulation takes place), transmission (when the pain impulse moves from the level of the spinal cord to the brain), perception (when the conscious awareness of the painful sensation occurs), and modulation (when the pain message is inhibited). When a person has pain, it is not perceived or felt until the perception phase.

Front 33

A type of pain that implies an abnormal processing of the pain message and is difficult to assess and treat

Back 33

Neuropathic pain

Front 34

The conscious of a painful sensation

Back 34

perception

Front 35

Pain that is diagnosed when the pain continues for 6 months or longer

Back 35

Chronic

Front 36

Pain derived from skin surface and subcutaneous tissues

Back 36

Cutaneous

Front 37

The term to describe how noxious stimuli are typically perceived as pain

Back 37

Nociception

Front 38

Pain that comes from sources such as the blood vessels, joints, tendons, muscles, and bones is known as deep_____ pain

Back 38

Somatic

Front 39

According to Mccaffery, this is "whatever the experiencing person says it is, existing whenever he says it does"

Back 39

Pain

Front 40

Pain that is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals

Back 40

Acute pain

Front 41

Pain that is felt at a particular site but originates from another location

Back 41

Referred pain