Health Assessment - Weeks 1 and 2 Practice Flashcards

Comprehensive flashcards covering health assessment concepts, mental status examination, substance use assessment, family violence, trauma-informed care, evidence-based practice, communication frameworks, general survey, vital signs, and pain assessment based on Weeks 1 and 2 lecture materials.

How is mental status defined in health assessment?

Mental status is defined as a person's emotional and cognitive functioning.

Which behaviors are assessed to infer an individual's mental health functioning?

Consciousness, language, mood, affect, orientation, attention, memory, abstract reasoning, thought process, thought content, and perceptions.

What are the four main headings of the mental status assessment represented by the acronym A-B-C-T?

Appearance, Behavior, Cognition, and Thought processes.

What are the key clinical characteristics of the Alert, Lethargic, Obtunded, Stupor, and Comatose levels of consciousness?

Alert: awake and easily arousable. Lethargic (somnolent): easily arousable, difficult to keep awake, drowsy, slow but appropriate speech, responds to verbal/tactile stimuli. Obtunded: difficult to arouse, sleeps most of the time. Stupor (semi-comatose): responds to noxious or painful stimuli, moans, nonverbal. Comatose: completely unconscious, no response to pain or stimuli.

How is delirium defined during a mental status assessment?

Delirium is a transient state of being awake but extremely confused due to a change in environment, illness, infection, age, or medications.

Which mental health screening tools are designated for infants/children, school-age children, and adolescents/adults?

Infants and Children: Denver II screening Test. School Age children: Behavior Checklist. Adolescents and Adults: A-B-C-T / Mini Mental Exam.

How are Intoxication, Abuse, Dependence, Tolerance, and Withdrawal defined in substance use assessment?

Intoxication: maladaptive behavioral changes due to effects on CNS from a substance. Abuse: daily or recurrent use such that impairment and decreased functioning has occurred leading to ongoing problems. Dependence: physiological reliance. Tolerance: requires more to get the desired effect. Withdrawal: cessation of substance leads to physiological effects.

What are the heavy drinking screening thresholds for men and women during health assessment?

Asking how many times in the past year the individual had $5$ or more drinks a day (for men) or $4$ or more drinks a day (for women).

What are the seven categories of recreational illicit drug use listed in substance assessment?

Marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, methamphetamines, and non-medical use psychotherapeutics (Rx pain relievers, tranquilizers, and sedatives).

What are the purpose and structure of the Clinical Institute Withdrawal Assessment Scale (CIWA) and Clinical Opioid Withdrawal Scale (COWS)?

CIWA: most sensitive scale for objective measurement of alcohol withdrawal, containing $10$ measured criteria (including vital signs and O2 sat), with subscales having $7$ criteria except Orientation which has $4$. COWS: an $11$-item clinician-administered scale rating common signs and symptoms of opiate withdrawal over time.

What does each letter in the TWEAK screening tool stand for when evaluating alcohol use in women?

T = Tolerance (how many drinks can you hold / feel high?); W = Worry (have close friends or relatives complained?); E = Eye-opener (drink in morning when getting up?); A = Amnesia (told about things said but cannot remember?); K = Kut down (sometimes feel need to cut down?).

What are the four main categories of Intimate Partner Violence (IPV)?

Physical violence, Sexual violence, Stalking, and Psychological aggression (emotional abuse of an aggressive nature). IPV also includes teen dating violence.

How are child neglect, physical abuse, sexual abuse, and emotional abuse defined?

Neglect: failure to provide for children's basic needs. Physical abuse: nonaccidental injury that leads to harm to a child. Sexual abuse: fondling, sexual acts, exploitation, and trafficking. Emotional abuse: a pattern of behavior that harms a child's sense of self-worth or development.

What are the six core principles of Trauma-Informed Care (TIC)?

1. Safety; 2. Trustworthiness and Transparency; 3. Collaboration and Mutuality; 4. Empowerment, Voice, and Choice; 5. Cultural, Historical, and Gender Awareness; 6. Humility.

What three main categories of potential traumatic events are identified in trauma-informed care?

1. Abuse (Emotional, Sexual, Physical, Domestic violence, Witnessing violence, Bullying, Cyberbullying, Institutional); 2. Loss (Death, Abandonment, Neglect, Separation, Natural disaster, Accidents, Terrorism, War); 3. Chronic Stressors (Poverty, Racism, Invasive medical procedure, Community trauma, Historical trauma, Family member with substance use disorder).

What components form the database in Evidence-Based Practice?

Subjective data + objective data + patient's record, and laboratory studies.

How do the 6 functions of clinical judgment align with the 5 steps of the Nursing Process?

6 functions of clinical judgment: 1. Recognize cues (What matters most?), 2. Analyze cues (What does it mean?), 3. Prioritize hypotheses (Where do I start?), 4. Generate solutions (What can I do?), 5. Take action (What will I do?), 6. Evaluate outcomes (Did it help?). Nursing Process steps: 1. Assessment, 2. Analysis, 3. Planning, 4. Implementation, 5. Evaluation.

How are First-level, Second-level, and Third-level priority care defined?

First-level priority: emergent, life-threatening, and immediate ABC (airway, breathing, circulation). Second-level priority: urgent, requiring attention to avoid further deterioration. Third-level priority: important to patient's health but can be addressed after more urgent problems are addressed.

How do the Holistic Model and Social Determinants of Health approach patient care?

Holistic model: interdependent functioning of mind, body, and spirit to maintain optimal health. Social Determinants of Health: external factors influencing well-being, such as environment, access to healthcare, community, education, and economic stability.

How do patient-centered and clinician-centered interview styles differ?

Patient-centered interviewing follows the patient's needs. Clinician-centered interviewing is clinician-led where the clinician 'takes charge' of the encounter. Skilled encounters merge both approaches.

What is the distinction between explicit bias and implicit bias in healthcare?

Explicit bias: conscious or deliberate decisions or preferences founded on beliefs, stereotypes, or associations based on a perceived group identity. Implicit bias: a set of unconscious beliefs or associations that lead to a negative evaluation of a person based on their perceived group identity.

What techniques improve patient health literacy during clinical interactions?

Oral teaching (simple, easy instructions using conversational structure without medical jargon), Written materials (large print, plain language avoiding jargon), and Teach back (asking the patient to restate information to verify understanding).

What are the characteristics of Complete, Focused, Follow-up, and Emergency databases?

Complete total health database: describes current and past health state and forms a baseline. Focused or problem-centered database: collects a 'mini' database with a smaller, focused scope. Follow-up database: evaluates the status of identified problems at regular intervals. Emergency database: rapid collection of data compiled concurrently with lifesaving measures.

What does each component of the SBAR standardized communication tool stand for?

Situation: brief description of pertinent patient variables, demographics, diagnosis, location. Background: pertinent history directly related to current health status. Assessment: pertinent assessment findings obtained with data interpretation. Recommendation or Request: what you need or want for the patient regarding medical treatment or assistance.

What does each letter stand for in the I-PASS verbal handoff tool?

I = Illness Severity (Stable, 'watcher', unstable); P = Patient Summary (Summary statement, events leading to admission, hospital course, ongoing assessment, plan); A = Action List (To do list, timeline and ownership); S = Situation Awareness & Contingency Planning (Know what's going on, plan for what might happen); S = Synthesis by Receiver (Receiver summarizes what was heard, asks questions, restates key action items).

What four main domains are observed during the general survey?

Physical Appearance, Body Structure, Mobility, and Behavior.

What are the six components of a complete health history?

Chief Complaint, Present Illness, Past Medical/Surgical History, Family History, Personal and Social History, and Review of Systems.

What is the standard order of physical assessment techniques, and how does it change for abdominal tenderness?

Standard order: 1st Inspection, 2nd Palpation, 3rd Percussion, 4th Auscultation. In case of abdominal tenderness: 1st Inspect, 2nd Auscultate, 3rd Percuss, 4th Palpate.

What are the adult normal values and abnormal thresholds for pulse, temperature, respirations, and blood pressure?

Pulse: normal adult $60\text{--}100\,\text{bpm}$ (Bradycardia < $60\,\text{bpm}$, Tachycardia > $100\,\text{bpm}$). Temperature: normal $98.6^\circ\text{F}$ (Hypothermia < $98.6^\circ\text{F}$, Hyperthermia > $100^\circ\text{F}$). Respirations: normal adult $12\text{--}20\,\text{bpm}$ (Bradypnea < $12\,\text{bpm}$, Tachypnea > $20\,\text{bpm}$). Blood Pressure: normal adult $120/80\,\text{mmHg}$ (Systolic during contraction, Diastolic during relaxation).

How are Visceral, Deep Somatic, Cutaneous, and Referred pain categorized by origin?

Visceral pain: originates from larger interior organs (stretching, ischemia, tumor); accompanied by vomiting, nausea, pallor, diaphoresis, and elevated BP. Deep somatic pain: comes from blood vessels, joints, tendons, muscles, and bones; described as aching or throbbing. Cutaneous pain: derived from skin surface and subcutaneous tissues; sharp, burning sensation. Referred pain: felt at a particular site but originates from another location innervated by the same spinal nerve.

How do Acute, Chronic, and Breakthrough pain differ in duration and clinical presentation?

Acute pain: short-term (< $6\,\text{months}$), self-limiting, predictable event, dissipates after healing; includes incident pain. Chronic pain: persistent (> $6\,\text{months}$), categorized as malignant (cancer-related) or nonmalignant (musculoskeletal), does not stop when injury heals. Breakthrough pain: transient spike in pain level of moderate to severe intensity in an otherwise controlled pain syndrome.

What nonverbal behaviors distinguish acute pain from chronic pain?

Acute pain behaviors: guarding, grimacing, vocalizations (moaning), agitation, restlessness, stillness, diaphoresis, and changes in vital signs. Chronic pain behaviors: bracing, rubbing, diminished activity, sighing, and changes in appetite.

What does each letter stand for in the PQRST pain assessment method?

P = Provocation (what triggers pain or makes it better?); Q = Quality (what does pain feel like, e.g., sharp, dull, throbbing?); R = Region (where is pain located? does it spread?); S = Severity (intensity rated on a $0\text{--}10$ scale); T = Timing (when does pain occur, and how long does it last?).