NURS 308 Final Exam

culturally sensitive

has basic knowledge of and constructive attitudes of another culture

culturally appropriate

applies underlying background knowledge to provide best possible care of another culture

culturally competent

understands and attends to the whole person including: immigration status, stress factors, social factors, cultural differences

FICA

spiritual assessment tool Faith, Importance, Community, Action

RCOPE

tool for religious coping with loss assessment

what are the four types of databases?

complete, focused, follow up, emergency

the interview purposes

-gathering complete and accurate data
-establish a rapport and trust
-teach the person about health state
-begin teaching health promotion and disease prevention

what are the 4 parts of the interview process?

verbal, nonverbal, internal factors, external factors

internal factors of the interview process

liking others, empathy, ability to listen, self-awareness, biases

external factors of the interview process

privacy, interruptions, set-up of physical environment, note-taking, dress, equal sitting, room temperature, lighting, distance, comfort of patient

traps of interviewing (10)

providing false assurance/reassurance, giving unwanted advice, using authority, avoidance language, engaging in distancing, using professional jargon, leading or biased questions, talking too much, interrupting, using "why" questions

responses

facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary

HEEADSSS

Home, Education + employment, Eating, Activities, Drugs, Sexuality, Suicide/depression, Safety

health history consists of these things

biographical data, source of history, reasons for seeking care, present health or history of present illness, past history, family history, review of systems, functional assessment

when someone complains of a symptom, ask about these things (subjective data)

location, character of quality, quantity or severity, timing (onset, frequency, duration), aggravating or relieving factors, associated factors, client's perceptions

purpose of the review of systems (every single body part)

-evaluate past and present health state of each body system
-another opportunity to obtain significant data about patient's health
-evaluate health promotion practices

what are the nursing process steps?

1. Assessment

2. Diagnosis

3. Outcome Identification

4. Planning

5. Implementation

6. Evaluation

evidence based practice

clinical decision making that integrates the best available research with clinical expertise and patient characteristics and preferences and physical exam and assessment

ABCT

acronym used for a MSE, appearance, behavior, cognition, thought process

things that require a full mental exam (6)

• initial screening suggests an anxiety disorder or depression

• brain lesions (trauma, tumor, stroke, cerebrovascular accident)

• behavior changes (memory loss, inappropriate social interaction)

• aphasia (caused by brain damage)

• symptoms of psychiatric mental illness

• concentration problems, trouble with simple activities, inappropriate judgement, linguistic difficulty

what things should you look for when assessing client appearance? (collecting objective data)

posture, body movements, dress, grooming and hygiene, pupils

what things should you look for when assessing client behavior? (collecting objective data)

level of consciousness, facial expression, speech, mood and affect

levels of consciousness

alert, lethargic, obtunded, stupor, coma

alert

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

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; inattentive; loses train of thought; spontaneous movements are decreased

obtunded

Sleeps most of time, difficult to arouse—needs loud shout or vigorous shake, acts confused when is aroused, converses in monosyllables, speech may be mumbled and incoherent, requires constant stimulation for even marginal cooperation.

stupor

spontaneously unconscious; responds only to persistent and vigorous shake or pain; has appropriate motor response (withdraws hand to avoid pain); otherwise can only groan, mumble, or move restlessly; reflex activity persists

coma

completely unconscious, no response to pain or to any external or internal stimuli (when suctioned, does not try to push the catheter away); light coma has some reflex activity but no purposeful movement; deep coma has no motor response

what are the five things you can do to assess cognitive function?

orientation, attention span, recent memory, remote memory, new learning (4 unrelated words)

what is the tool for screening for anxiety?

GAD-7

what is the tool for screening for depression?

PHQ-2

what do you look for when assessing thought process and perceptions?

does this person make sense? perceptions, screening for anxiety, depression and suicidal thoughts

what are the four main parts of the general survey?

physical appearance, body structure, mobility, behavior

serial weights

weight taken at the same time of day and same type of clothing (record this for a proper measurement)

what part of the brain regulates temperature?

hypothalamus

what is a normal oral temperature?

37°C / 98.6°F

what is a normal core temperature?

37.2°C / 99°F

how much does rectal temperature differ from oral temperature?

0.7 to 1 °F higher

how long does a mercury oral thermometer take to get an accurate reading?

3-4 minutes, up to 8 with fever

how does axillary temperature differ from oral temperature?

1°F lower than oral

how does temporal temperature differ from oral temperature?

0.5 °F lower than oral

what is the normal pulse range for an adult?

50-95

what is a normal adult rate of respirations?

10-20 / minute

tachypnea

greater than 24 breaths/minute

prehypertension

Systolic: 120-139 Diastolic: 80-89 not a disease, but it can be an indication

what are the five factors that affect blood pressure?

cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, elasticity of vessel walls

what are some other factors to consider for blood pressure? (not the 5 main factors)

diurnal rhythm, exercise, emotions, weight, age, sex, race, stress

what are the four sources of pain?

visceral, deep somatic, cutaneous, referred

what should we ask for a brief pain inventory?

0-10 in last 24 hours, impact on mood, walking ability, and sleep

what are four pain rating scales? (ways we can determine a client's pain)

numeric, faces, verbal descriptor, visual analogue

bulb matrix

at the root, expanded area where new hair cells are produced at a high rate

vellus hair

fine hair that covers whole body (except soles and palms)

terminal hair

Darker, thicker hair that grows on the scalp and eyebrows and, after puberty, on the axillae, the pubic area, and the face and chest in the male.

objective data

-is integrated throughout the complete physical examination
-start with outer surface and then focus on underlying structure

erythema

redness of the skin (fever, blushing)

where can you check a dark-colored person for skin color changes?

sclera, mucosa, sublingual cavity

diaphoresis

profuse sweating

what texture of the skin do you want?

smooth, soft and hard

nail contour should be how many degrees?

160 or less

what should you evaluate and note about lesions? (6 things)

color, elevation, shape, size, location, exudate

if the 6 danger signs are fulfilled, what can that be a sign of?

malignant melanoma

annular or circular

lesion shape that begins in center and spreads to periphery

gyrate

lesions that are coiled spirals or twisted, snake-like

macule

Solely a color change, flat and circumscribed, of less than 1 cm. Examples: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever.

patch

Macules that are larger than 1 cm. Examples: mongolian spot, vitiligo, café au lait spot, chloasma, measles rash.

papule

Something you can feel (i.e., solid, elevated, circumscribed, less than 1 cm diameter) caused by superficial thickening in epidermis. Examples: elevated nevus (mole), lichen planus, molluscum, wart (verruca).

plaque

papules coalesce to form surface elevation wider than 1 cm. A plateau like, disk-shaped lesion. Examples: psoriasis, lichen planus

nodule

Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule. Examples: xanthoma, fibroma, intradermal nevi

tumor

larger than a few centimeters in diameter, firm or soft, deeper into dermis; may be benign or malignant, although it implies "cancer" to most people. Examples: lipoma, hemangioma

vesicle

elevated cavity containing free fluid up to 1cm in diameter; a "blister" Clear serum flows if wall is ruptured. Examples: herpes simplex, early varicella (chicken pox), herpes zoster (shingles), contact dermatitis

bulla

Larger than 1 cm diameter; usually single chambered (unilocular); superficial in epidermis; thin walled and ruptures easily. Examples: friction blister, pemphigus, burns, contact dermatitis.

cyst

encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin. Examples: sebaceous cyst, wen

pustule

turbid fluid (pus) in the cavity. Circumscribed and elevated. Examples: impetigo, acne

scale

compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells. Examples: after scarlet fever or drug reaction, psoriasis, seborrheic dermatitis, eczema, ichthyosis, dry skin

atrophic scar

the resulting skin level is depressed with loss of tissue; a thinning of the epidermis. Examples: striae (stretch marks)

purpuric lesions

Caused by blood flowing out of breaks in the vessels. Red blood cells and blood pigments are deposited in the tissues (extravascular). Difficult to see in dark-skinned people.

petechiae

tiny punctate hemorrhages, 1 to 3 mm, round and discrete; dark red, purple, or brown in color

erythema migrans

In Lyme Disease, First stage has the distinctive bull's eye, red macular or papular rash in 50 % of cases. The rash radiates from the site of the tick bite, with some central clearing, and is usually located in axillae, midriff, inguina, or behind knees, with regal lymphadenopathy. Rash fades in 4 weeks; untreated individual then may have disseminated diseasse with fatigue, anorexia, fever, chills, joint or muscle aches. Antibiotic treatment shortens symptoms and decreases risk for sequelae.

basal cell carcinoma

usually starts as a small, pink or red papule with a pearly translucent top and overlying telangiectasia. Then develops rounded, pearly borders with central red ulcer or looks like large open pore with central yellowing. Most common form of skin cancer; slow but inexorable growth. Basal cell cancers occur on sun-exposed areas of face, ears, scalp, shoulders

squamous cell carcinoma

cancer that arises from actinic keratoses or denovo. Erythematous scaly patch with sharp margins, 1 cm or more. Develops central ulcer and surrounding erythema. usually on hands or head, areas exposed to UV radiation; at right, on habitual sun-exposed scalp. Less common than basal cell carcinoma but grows rapidly

malignant melanoma

Most serious form of skin cancer; often characterized by black or dark brown patches on the skin that may appear uneven in texture, jagged, or raised.

furuncle

red, swollen, hard, tender, pus-filled lesion caused by acute, localized bacterial infection usually on the back of the neck, buttocks, occasionally on wrists or ankles

onycholysis

fungal infection of the nails; green, thick, crumbly nails

acrocyanosis

Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming.

erythema toxicum

pink rash that appears suddenly anywhere on the body of a term newborn during the first 3 weeks.

actinic keratosis

cancerous, red/scaly/raised rough spots

palpebral fissure

opening between eyelids

canthus

angle where the upper and lower eyelids meet

caruncle

small, fleshy mass containing sebaceous glands

presbyopia

impaired vision as a result of aging

miosis

constricted and fixed pupils

mydriasis

dilated and fixed pupils

Murphy sign

tenderness in the right subcostal area on inspiration, associated with acute cholecystitis (inflammation of the gall bladder)

Blumberg sign

rebound tenderness; possible appendicitis

Bulge sign

(for swelling in suprapatellar pouch) confirms presence of small amounts of fluid as you try to move the fluid from one side of the joint to the other

McMurray test

Evaluates meniscus for tear

Allis' sign

1 knee significantly lower than the other knee

talipes equinovarus

clubfoot; inversion

Osgood-Schlatter disease

swelling of the tibial tubercle below the knee; stress on the patellar tendon; occurs during puberty; self-limiting (will go away on its own)

corticospinal/pyramidal tract fibers

voluntary movements that require skill