NR 304 Final Exam

purpose of health history

collect subjective dataprovides a complete picture of the persons past and present health

Health History Sequence

1. Biographic data2. Reason for seeking care3. Present health or history of present illness4. Past history5. Medication reconciliation6. Family history7. Review of systems8. Functional assessment or activities of daily living (ADLs)

subjective data

things a person tells you about that you cannot observe through your senses; symptoms

objective data

information that is seen, heard, felt, or smelled by an observer; signs

open-ended questions

builds and enhances rapport; used when narrative information is needed

Therapeutic Communication Techniques

1) ACTIVE LISTENING - Shows clients that they have your undivided attention2) OPEN-ENDED QUESTIONS - Used initially to encourage clients to tell their story in their own way. Ask questions in a language that a client can understand3) CLARIFYING - Questioning clients about specific details in greater depth or directing them toward relevant parts of the history.4) SUMMARIZING - Validates the accuracy of the story.

Traps of interviewing

1. Providing false assurance or reassurance2. Giving unwanted advice3. Using authority4. Using avoidance language5. Engaging in distancing6. Using professional jargon7. Using leading or biased questions8. Talking too much9. Interrupting10. Using "why" questions

Lethargic

not fully alert; drifts off to sleep when not stimulated can be aroused to name when called in normal voice but looks drowsy, responds appropriately to questions or commands but thinking seems slow and fuzzy

alert

wake or readily aroused, orientated, fully aware of external and internal stimuli and responds appropriately, conducts meaningful interpersonal interactions

stuporous

spontaneously unconscious responds only to vigorous and persistent stimulation, withdraws from pain, appropriate reflexes

comatose

completely unconscious no response to pain or any external or interbal stimuli

medical emergency

any sudden change of LOC is considered __________

orientation

assessed from person, place, time and event; indicates cognition

LOC

indicates alertness of surroundings

4 components of general survey

physical appearance, body structure, mobility, behavior

physical appearance

appearance of hair, clothing, body type, and other physical features

body structure

stature, nutrition, symmetry, posture, position, body build, contour

mobility components

-gait: normally base is as wide as shoulder width, foot placement is accurate; the walk is smooth and even and well balanced-ROM: note full mobility for each joint and that mvmt is deliberate, accurate, smooth and coordinated; no involuntary movement

behavior component

the action that a person takes in regard to the person, object, or situation

height and weight

most common anthropometric measurements used to evaluate growth in children and nutrition status in adults

underweight BMI

less than 18.5

normal BMI

18.5-24.9

Overwight BMI

25-29.9

Obese BMI

over 30

Morbidly Obese BMI

greater than 40

temperature range

98.6-100.4

apical hr

60-100; regular

respiratory rate

12-20; regular

pulse ox

95-100%

normal pulse force

2+

posterior tibial pulse

behind medial malleolus- compare bilaterally

Bounding pulse

A pulse with an increased volume that feels very strong and full

reposition the fingers and assess again

during assessment of the lower extremities of a male client the nurse is unable to palpate the dorsalis pedis pulse. What action should the nurse take first?

notify the HCP immediately

a client is complaining of new-onset call & foot pain. The nurse notes that the leg below the knee is cool & pale. The dorsalis pedis & posterior tibial pulses are assessed as "0" w/ palpation and "0" following validation with a doppler. What is the priority nursing action?

petechiae

tiny punctate hemorrhages, 1 - 3 mm, round and discrete, dark red, purple, or brown

ecchymosis

a large patch of capillary bleeding into tissues

nodule

solid, elevated, hard or soft lesion larger than 1 cm

keloid

a hypertrophic scar

pustule

elevated cavity containing purulent fluid up to 1 cm

Lentigines

variations of hyperpigmentation

sternal area

best area to assess skin turgor

skin turgor

assesses hydration; decreased skin turgor= tenting, dry mucous membranes, dark urine

ABCDEF mole assessment

AsymmetryBorderColorDiameterElevation or evolutionFunny looking

PERRLA

pupils equal, round, reactive to light and accommodation

tympanic membrane

gray pearly, translucent

otitis media

inflammation of the middle ear; most common in little kids

COPD immediate actions

orthopneachest tightness

crepitus

a crackling or grating sound usually of bones

vesicular

refers to soft, low-pitched, normal breath sounds heard over peripheral lung fields

stridor

strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx

Rhonchi

Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways.

resonant percusson

normal percussion tone over lung lobes;

tympany

The percussion note one should hear over the abdomen

between scalpula

where will the nurse palpate tactile fremitus most intensely?

crackles

what adventitious lung sound would be a high-pitched popping sound heard over the lower lung lobes?- cannot clear with cough

incentive spirometry

helps prevent atelectasis and lung expansion

pneumonia

why is a client recovering from abdominal surgery who is "splinting" and "guarding" their abdomen at risk for resp problems?

5 listening points of the heart

aortic, pulmonic, erb's point, tricuspid, mitral

Chronic Arterial Insufficiency

during an exam, the nurse notes that a client's legs turn white when they are raised above the client's head. The nurse should suspect....

venous stasis ulcer

on inspection of a client's leg, the nurse notes an ulcer on the lateral ankle with drainage. The nurse suspects....

arterial insufficiency

- skin is pale and shiny- hair loss distribution- distal, dry ulcer- absent or weak pulse- cool temperature- no edema

venous insufficiency

- swollen leg- darkened hyperpigmentation at ankle- ulcers on leg and ankle- moderate to severe pitting edema- palpable pulse- hard skin, normal temp

DVT

unilateral swelling; pain; redness; warmth

Abdominal Aortic Aneurysm

expected to hear a bruit upon auscultation

Cholecystitis

Murphy's sign; GI symptoms and vomiting and fever all indicate

appendicitis

Blumberg's sign; iliopsoas sign; GI symptoms, vomiting and fever; rebound tenderness on McBurney's point

abduct

the nurse is caring for a client after a hip arthroplasty. The client has a pillow between the legs. What movement would be used on the hip

Expected older adult changes

decreased height; progressive decrease in reaction time; decreased muscle strength; slight flexion of hips and knees; decreased ROM and flexibility; kyphosis- breast tissue atrophies

Phalen's test

hold both hands back to back; while flexing at the wrist 90 degrees for 60 seconds

tinel's sign

"pins and needles" sensation felt when an injured nerve site is tapped

assess neurovascular function (6 P's)

a client recovering from an open reduction of the humerus states, "I haven't been able to extend the fingers on my hand since this morning" What action should the RN take next?

6 P's

PainPulsePallorParesthesiaParalysisPressure

Dysarthria

slurred speech

Dysphonia

can speak but can't make voice phonate

Broca

part of frontal lobe where expressive aphasia is an issue

Wernicke

part of temporal lobe associated with language comprehensive and receptive aphasia is an issue

heel to shin test

low extremity movements smooth and steady

finger to finger test

rapid alternating movements of upper extremities smooth and steady

romberg test

client maintains balance with feet together and eyes closed for 20-30 seconds without support

tandem walking

client able to ambulate smoothly with minimal swaying

Glasgow Coma Scale

assessed LOChighest score is 15

decorticate

mid brain injury flexion of arms, wrist, fingers; adduction of arms tightly against thorax; plantar flexion in lower extremities; all move to core

decerebrate

indicates brain stem injury; feet in plantar flexion; teeth clenched

CN XI

-spinal accessory-assess the shoulders for strength

CN VII

facial nerve- raise eyebrows, smile, frown

CN V

trigeminal nerve- sensory and motor of face

CN IX

-glossopharyngeal-assess mouth for taste-assess mouth for movement of soft palate and the gag reflex-assess swallowing and speech

monthly

how often should a male client peform a TSE

palpate all 4 quadrants

the healthcare provider is performing a client breast exam on a female client. Which actions will the provider include?

Herpes

lesion that looks like a small painful blister

papule

what kind of lesion is syphilis

HPV

also known as genital warts

BP 86/58

a client in the ICU develops pre-renal failure following surgery. Which cue could be linked to this type of renal failure?

anuria

no urine

dysuria

painful urination

oliguria

Decreased urine output

polyuria

excessive urination

hematuria

blood in the urine

nocturia

excessive urination at night

Average urine output

30 mL/hour