Podcast
Questions and Answers
Which technique is considered a therapeutic communication method?
Which technique is considered a therapeutic communication method?
- Giving false reassurance
- Defending
- Requesting an explanation
- Offering self (correct)
What is the appropriate pulse rate for an adult?
What is the appropriate pulse rate for an adult?
- 40-60 bpm
- 60-100 bpm (correct)
- 120-160 bpm
- 100-120 bpm
Which of the following is a non-therapeutic communication technique?
Which of the following is a non-therapeutic communication technique?
- Making observations
- Belittling feelings expressed (correct)
- Encouraging comparisons
- Restating
What is the normal respiratory rate range for adults?
What is the normal respiratory rate range for adults?
Which technique can help in exploring a patient's feelings during a conversation?
Which technique can help in exploring a patient's feelings during a conversation?
When should a rectal temperature be taken?
When should a rectal temperature be taken?
How does anxiety affect heart rate?
How does anxiety affect heart rate?
Which communication technique is useful for focusing on a topic?
Which communication technique is useful for focusing on a topic?
Which symptom is characteristic of Major Depressive Disorder (MDD)?
Which symptom is characteristic of Major Depressive Disorder (MDD)?
What primary safety concern should be addressed first when dealing with a patient in a manic episode of Bipolar Disorder?
What primary safety concern should be addressed first when dealing with a patient in a manic episode of Bipolar Disorder?
What is the therapeutic lithium level range to avoid toxicity?
What is the therapeutic lithium level range to avoid toxicity?
Which condition is characterized by a chronic and non-reversible decline in cognitive function?
Which condition is characterized by a chronic and non-reversible decline in cognitive function?
What treatment is commonly used for schizophrenia that necessitates regular lab monitoring?
What treatment is commonly used for schizophrenia that necessitates regular lab monitoring?
Which of the following is an example of subjective data?
Which of the following is an example of subjective data?
Which disorder involves intrusive thoughts and repetitive actions to manage anxiety?
Which disorder involves intrusive thoughts and repetitive actions to manage anxiety?
What is the primary purpose of conducting a cultural assessment?
What is the primary purpose of conducting a cultural assessment?
Which of the following statements best describes objective data?
Which of the following statements best describes objective data?
Which of the following is a common symptom of body dysmorphic disorder?
Which of the following is a common symptom of body dysmorphic disorder?
Which symptom is NOT associated with shock?
Which symptom is NOT associated with shock?
What is an essential strategy for managing Generalized Anxiety Disorder (GAD)?
What is an essential strategy for managing Generalized Anxiety Disorder (GAD)?
Identifying social determinants of health (SDOH) is important because it helps to:
Identifying social determinants of health (SDOH) is important because it helps to:
What type of warning signs might indicate a potential deterioration in a patient’s condition?
What type of warning signs might indicate a potential deterioration in a patient’s condition?
Which set of symptoms indicates Fluid Volume Deficit (FVD) in adults?
Which set of symptoms indicates Fluid Volume Deficit (FVD) in adults?
What is the normal capillary refill time considered to be?
What is the normal capillary refill time considered to be?
What is a sign of increased intracranial pressure (ICP)?
What is a sign of increased intracranial pressure (ICP)?
The functional assessment focuses on which aspect of a patient's health?
The functional assessment focuses on which aspect of a patient's health?
Which of the following heart sounds is abnormal and may indicate heart failure?
Which of the following heart sounds is abnormal and may indicate heart failure?
Which percussion sound would be expected over an air-filled structure like the stomach?
Which percussion sound would be expected over an air-filled structure like the stomach?
Which component is NOT typically included in a comprehensive health history?
Which component is NOT typically included in a comprehensive health history?
In the context of mental health, what does maladaptation refer to?
In the context of mental health, what does maladaptation refer to?
A high heart rate during exercise is an example of:
A high heart rate during exercise is an example of:
During a lung assessment, which of the following abnormal sounds is associated with airway constriction?
During a lung assessment, which of the following abnormal sounds is associated with airway constriction?
Which ego defense mechanism involves justifying behavior with logical reasons?
Which ego defense mechanism involves justifying behavior with logical reasons?
In assessing for chronic venous insufficiency, which symptom would you most likely observe?
In assessing for chronic venous insufficiency, which symptom would you most likely observe?
Which symptom is indicative of fluid volume overload in adults?
Which symptom is indicative of fluid volume overload in adults?
Which of the following is not one of the Six Ps of Acute Arterial Occlusion?
Which of the following is not one of the Six Ps of Acute Arterial Occlusion?
What should be avoided to maintain rapport in therapeutic communication?
What should be avoided to maintain rapport in therapeutic communication?
Which of the following is an early indicator of shock?
Which of the following is an early indicator of shock?
What is the appropriate auscultation order for cardiac assessment?
What is the appropriate auscultation order for cardiac assessment?
Which assessment should be performed first in a focused assessment of a patient presenting with chest pain?
Which assessment should be performed first in a focused assessment of a patient presenting with chest pain?
What period is the fetus most susceptible to teratogens?
What period is the fetus most susceptible to teratogens?
Which of the following illnesses is NOT considered a teratogen?
Which of the following illnesses is NOT considered a teratogen?
What is included in the GTPAL system for pregnancy outcomes?
What is included in the GTPAL system for pregnancy outcomes?
What is the normal range for fetal heart rate (FHR)?
What is the normal range for fetal heart rate (FHR)?
Which fetal circulation shunt allows blood to bypass the lungs?
Which fetal circulation shunt allows blood to bypass the lungs?
How is Naegel’s Rule utilized to estimate the date of delivery?
How is Naegel’s Rule utilized to estimate the date of delivery?
In fetal heart rate monitoring, what does sustained tachycardia indicate?
In fetal heart rate monitoring, what does sustained tachycardia indicate?
What does IUGR stand for, and what does it indicate?
What does IUGR stand for, and what does it indicate?
Flashcards
Subjective Data (Symptoms)
Subjective Data (Symptoms)
Information gathered directly from the patient about how they are feeling, such as pain, fatigue, or dizziness. It cannot be measured directly and depends on the patient's communication.
Objective Data (Signs)
Objective Data (Signs)
Observable or measurable data about a patient's health, such as a high temperature, swelling, or abnormal heart rhythm. It can be gathered through assessments or diagnostic tools.
Health History - Components and Purpose
Health History - Components and Purpose
A detailed record of a patient's health history including current problems, past medical conditions, family history, social habits (e.g., smoking), and a review of systems. It helps guide care by understanding the patient's baseline health and risk factors.
Functional Assessment - Components and Purpose
Functional Assessment - Components and Purpose
An assessment of how a patient's health affects their ability to perform everyday activities, such as walking, cooking, bathing, and dressing. It helps understand the impact of illness on daily life.
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Cultural Assessment - Purpose
Cultural Assessment - Purpose
Respecting and incorporating a patient's cultural beliefs and practices into their care. This includes understanding dietary preferences, spiritual beliefs, and the patient's views on medical treatments. This builds trust and helps ensure patients adhere to care plans.
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Social Determinants of Health (SDOH) / Barriers to Care
Social Determinants of Health (SDOH) / Barriers to Care
Factors outside of healthcare that impact a person's health, including socioeconomic status, housing, education, access to transportation, and exposure to violence. Identifying these barriers helps address inequalities in care and improve patient outcomes.
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Recognizing Sets of Cues (Normal vs. Abnormal)
Recognizing Sets of Cues (Normal vs. Abnormal)
Recognizing patterns in patient data to determine if findings are normal for the situation or indicate potential problems. For example, a high heart rate during exercise may be normal, but a high heart rate during rest could signify a medical issue.
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Identify Warning Signs of Problems and Changes in Patient Condition
Identify Warning Signs of Problems and Changes in Patient Condition
Identifying warning signs that suggest a patient's condition is worsening, such as changes in mental status, vital signs, or appearance of new symptoms. This prompts immediate action to address potential deterioration.
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Therapeutic Communication
Therapeutic Communication
A type of communication used in healthcare to build trust, gather information, and create a safe space for patients.
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Therapeutic Techniques
Therapeutic Techniques
A communication technique that uses silence, acceptance, and other methods to understand and support patients.
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Axillary Temperature
Axillary Temperature
Taking a patient's temperature with a thermometer placed under the armpit, often used for children.
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Rectal Temperature
Rectal Temperature
Taking a patient's temperature with a thermometer inserted into the rectum, used sparingly due to potential risks and discomfort.
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Pulse
Pulse
The number of times a person's heart beats per minute, a vital sign reflecting heart health.
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Respirations
Respirations
The number of breaths a person takes per minute, another vital sign reflecting respiratory function.
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Non-therapeutic Communication
Non-therapeutic Communication
A communication technique that can hinder rapport and understanding, such as giving false reassurance or making judgments.
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Vital Signs
Vital Signs
A set of vital signs, including temperature, pulse, respirations, and blood pressure, used to assess a patient's overall health.
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Cardiac Assessment
Cardiac Assessment
Auscultating heart sounds (S1, S2, S3, S4) and identifying murmurs.
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APeTM
APeTM
Aortic, pulmonic, Erb's point, tricuspid, mitral.
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Apical Pulse
Apical Pulse
Palpating and listening to the heart at the 5th intercostal space, left of the sternum, for 1 minute to determine rate and regularity.
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Crackles
Crackles
A crackling sound heard on auscultation of the chest, often due to fluid or mucus in the airways.
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Wheezes
Wheezes
A low-pitched, rumbling sound heard on auscultation of the chest, often due to airway constriction.
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Percussion Sounds (Abdomen)
Percussion Sounds (Abdomen)
Percussing the abdomen to distinguish between bone (flat), solid organs (dull), and air-filled structures (tympany).
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CSMP (Extremities)
CSMP (Extremities)
Assessing the color, sensation, mobility, and perfusion of the extremities, focusing on areas distal to any injury.
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Skin Assessment
Skin Assessment
Assessing the skin for changes like pallor, cyanosis, jaundice, or rubor, indicating systemic issues.
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Hypovolemic Shock
Hypovolemic Shock
A state where the body's tissues and organs aren't getting enough blood flow due to low blood volume.
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Increased Intracranial Pressure (ICP)
Increased Intracranial Pressure (ICP)
A collection of signs indicating increased pressure within the skull, potentially caused by brain swelling or bleeding.
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Denial
Denial
A defense mechanism where someone avoids accepting reality or acknowledging uncomfortable feelings.
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Displacement
Displacement
A defense mechanism where someone redirects negative emotions to a less threatening person or object.
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Rationalization
Rationalization
A defense mechanism where someone creates logical explanations for their actions to avoid facing uncomfortable feelings.
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Suppression
Suppression
A defense mechanism where someone consciously pushes away unpleasant thoughts or memories.
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Repression
Repression
A defense mechanism where someone unconsciously pushes away unpleasant thoughts or memories.
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Schizophrenia
Schizophrenia
A serious disorder that involves disturbances in thought processes like delusions and hallucinations. Individuals experiencing schizophrenia often have difficulty connecting with reality.
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Major Depressive Disorder (MDD)
Major Depressive Disorder (MDD)
A type of depression characterized by frequent episodes of intense, low mood. These episodes are often severe and disruptive to daily life.
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Dysthymia
Dysthymia
A chronic form of depression, characterized by persistent low mood and other symptoms. Typically, symptoms are less severe than MDD but are present for a longer period.
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Bipolar Disorder (BPD)
Bipolar Disorder (BPD)
A mental health condition characterized by alternating episodes of mania and depression. During manic episodes, individuals experience high energy, impulsivity, and impaired judgment.
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Body Dysmorphic Disorder
Body Dysmorphic Disorder
A mental health condition where individuals are preoccupied with perceived flaws or defects in their appearance. This preoccupation often leads to avoidance of social situations and repetitive behaviors like mirror checking.
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Delirium
Delirium
A state of acute confusion with a sudden onset. This can be caused by various factors, such as medication side effects, infections, or injuries.
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Dementia
Dementia
A chronic and progressive condition that causes a decline in cognitive abilities, such as memory, language, and judgment. It is not reversible and typically worsens over time.
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Generalized Anxiety Disorder (GAD)
Generalized Anxiety Disorder (GAD)
An anxiety disorder that involves chronic and excessive worry. Individuals with GAD often struggle to control their worries, which can interfere with daily life.
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Organogenesis
Organogenesis
The period of fetal development (2-8 weeks) when organs are forming and the fetus is most vulnerable to teratogens. This is a crucial time as exposure to harmful substances (like alcohol or certain medications) can lead to birth defects.
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Teratogens
Teratogens
Substances that can cause birth defects in a developing fetus. They can be drugs, alcohol, infections, or environmental factors.
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Fetal Circulation/Shunts
Fetal Circulation/Shunts
Fetal circulation involves blood flow bypassing the lungs. The three shunts involved are the ductus arteriosus (connects the aorta and pulmonary artery), ductus venosus (connects the umbilical vein to the inferior vena cava), and foramen ovale (opening between the atria).
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Naegel's Rule
Naegel's Rule
A method of calculating the expected due date using the first day of the woman's last menstrual period (LMP). It involves subtracting 3 months, adding 7 days, and adjusting the year if needed.
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GTPAL
GTPAL
A system used to document a woman's obstetrical history. It includes: Gravida (total pregnancies), Term births (babies born at 37 weeks or more), Preterm births (babies born between 20-36 weeks), Abortions (pregnancies ending before 20 weeks), and Living children.
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Fetal Heart Rate (FHR) Monitoring
Fetal Heart Rate (FHR) Monitoring
Fetal heart rate monitoring is used to assess the baby's wellbeing during pregnancy. A normal fetal heart rate is between 110-160 beats per minute.
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Non-Stress Test (NST)
Non-Stress Test (NST)
A test used to assess fetal wellbeing by monitoring the baby's heart rate in response to its own movements.
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Contraction Stress Test (CST)
Contraction Stress Test (CST)
A test used to assess fetal wellbeing during labor by giving the mother a contraction to see how the baby's heart rate responds.
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History Taking and Physical Examination
- Recognizing Cues (Normal vs. Abnormal): Nurses assess patient data to determine if findings are typical or indicate potential problems. A high heart rate during activity might be normal, but a sudden change is concerning.
- Identifying Warning Signs: Abnormal mental status, vital sign changes, or new symptoms signal potential deterioration and require immediate action.
- Subjective Data (Symptoms): This includes patient-reported experiences like pain, fatigue, or nausea. It is not directly measurable but relies on communication. Example: patient reports nausea and dizziness for three days.
- Objective Data (Signs): Observable and measurable data, such as high temperature, swelling, or abnormal heart rhythms, obtained through assessments and diagnostic tools.
- Health History Components and Purpose: Comprehensive health history includes current complaints, past medical history, family history, social history, and review of systems. This helps understand baseline health and risk factors.
- Functional Assessment Components and Purpose: Evaluating how health impacts daily activities (walking, cooking, bathing, etc.) Understanding this helps tailor care.
- Cultural Assessment Purpose: Care respects patients' cultural beliefs and practices, improving trust and adherence to treatment plans, including dietary preferences, spiritual practices, and views on medical treatments
- Identify Social Determinants of Health (SDOH) / Barriers to Care: Identifying barriers like housing, employment, education, transportation, and access to care helps address inequalities and improve outcomes.
- **Use of Therapeutic Communication:**Effective communication, using techniques like active listening and open-ended questions, builds rapport and gathers accurate information, especially important during patient interactions and professional communications with coworkers.
Therapeutic Communication Techniques
- Using silence
- Accepting
- Giving recognition
- Offering self
- Giving broad openings
- Offering general leads
- Placing the event in time or sequence
- Making observations
- Encouraging description of perceptions
- Encouraging comparison
- Restating
- Reflecting
- Focusing
- Exploring
- Seeking clarification and validation
- Presenting reality
- Voicing doubt
- Verbalizing the implied
- Attempting to translate words into feelings
- Formulating a plan of action
- Giving false reassurance
- Rejecting
- Approving or disapproving
- Agreeing or disagreeing
- Giving advice
- Probing
- Defending
- Requesting an explanation
- Indicating the existence of an external source of power
- Belittling feelings expressed
- Making stereotypical comments
- Using denial
- Interpreting
- Introducing an unrelated topic
Vital Signs
- Temperature: Body temperature reflects physiological function. Axillary measurements are common in children.
- Pulse: Measured in beats per minute (bpm). Increased in fever, pain, anxiety, and stimulants.
- Respiration: Measured in breaths per minute (bpm). Rates below 12 or above 20 are significant.
- Blood Pressure (BP): Affected by stress, pain, and fluid balance.
- Oxygen Saturation (O2 sat): Normal is 95-100%. Below 90% indicates hypoxemia.
- Pain (6th Vital Sign): Uses OPQRST mnemonic for assessment (Onset, Provocation/Palliative, Quality, Region/Radiation, Severity, Timing).
Physical Assessment
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Purpose: Assess baseline, identify abnormalities, and evaluate changes over time; enables tailored care plans
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Techniques:
-
Inspection: Observing patient's appearance.
-
Palpation: Using hands to feel texture, temperature, and tenderness.
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Percussion: Tapping body parts to evaluate underlying structures.
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Auscultation: Listening for sounds using a stethoscope (cardiac, lung, and bowel sounds).
Additional Topics
- Abdomen Techniques: Auscultate bowel sounds before palpating.
- HEENOT: Includes assessing head, eyes, ears, nose, oral cavity, and throat.
- Thorax/Chest: Assessing the heart, including apical pulse and characteristic heart sounds. Also, assess lung sounds.
- Abdomen - Percussion Sounds: Differentiate between bone, solid organs, and air-filled structures. Percussion evaluates these structures.
- Extremities: Assess distal circulation (pulses and capillary refill). In extremity assessment, color, sensation, mobility, and perfusion are also important.
- Mental Health as a Continuum: Mental health exists on a spectrum, from healthy coping to maladaptive behaviors. Illness occurs when stressors overwhelm the ability to adapt.
- Ego Defense Mechanisms: These unconscious processes help manage stress but can distort reality. Examples include denial, displacement, and rationalization.
- Therapeutic Communication (as listed above)
- Substance Use: Substances like alcohol and benzodiazepines slow down the CNS, leading to decreased heart rate and breathing. Withdrawal can cause increased activity and stimulation.
- Maternal-Newborn Nursing: Includes antepartal, intrapartal, and postpartum periods, ethical dilemmas, and potential complications.
- Specific Disorders/Conditions covered include various categories of disorders such as personality disorders, eating disorders, anxiety disorders, and others, along with assessments and treatments.
- Focused Assessments: Target specific complaints or injuries (e.g., chest pain, trauma) to prioritize information collection and address patient needs efficiently.
- Fluid volume balance: Determining if a patient has fluid volume deficit or excess is key for accurate care.
- Pain: This is considered a vital sign and should be assessed and treated accordingly.
- Safety: Ensuring patient safety is a priority in all assessments; noting risk factors (suicide, self-harm) during mental health screening is crucial.
- Other specific assessments: A variety of specific physical assessment techniques used in different contexts, particularly for pregnancies, newborn conditions, and other specific medical problems.
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