NUR 216 Exam 1 Study Guide

Questions and Answers

What should be prioritized to ensure patient safety during assessment?

Family history of illness

Doctor's previous experience

Review of systems

Patient's reported symptoms (correct)

Which of the following is a significant risk factor for cardiovascular disease?

Age above 60

Multiple family members with history of cardiovascular disease (correct)

Personal history of diabetes

Having a single family member with heart issues

During a general survey, which component is NOT typically observed?

Overall appearance

Body posture

Patient hygiene and grooming

Patient's medical history (correct)

What does a double vision symptom indicate in a patient?

Potential neurological impairment Signup and view all the answers

What is indicated by new sensory impairments like hearing loss?

Serious safety issue Signup and view all the answers

When should history taking and physical assessment occur?

While the patient is alert and able to provide information Signup and view all the answers

Which of the following is important to observe regarding body structure during assessment?

Build and weight of the patient Signup and view all the answers

Which situation would require immediate assessment without delay?

Car accident victim Signup and view all the answers

What does being 'alert and oriented x 4' signify in a patient's mental status assessment?

Patient knows the time, place, person, and situation. Signup and view all the answers

What is the best method to assess a patient's pain?

Patient's self-report of pain level. Signup and view all the answers

Which nonverbal cues may indicate a patient is in pain?

Elevated heart rate and grimacing. Signup and view all the answers

If a patient denies feeling pain but shows signs of discomfort, what should be done next?

Ask open-ended questions to further assess discomfort. Signup and view all the answers

Which pain level is considered a priority concern for patient care?

Severe pain (7 or higher out of 10). Signup and view all the answers

What is the appropriate time frame to reassess pain after administering pharmacological interventions?

Within 30-60 minutes. Signup and view all the answers

Which of the following is NOT a method for reassessing pain?

Documenting an arbitrary level of pain. Signup and view all the answers

What should be the expected effect of nonpharmacological pain interventions within 15 minutes?

Some improvement in pain levels. Signup and view all the answers

What type of data includes information reported by the patient or family?

Subjective data Signup and view all the answers

Which type of question is best used to encourage a patient to share information?

Open-ended questions Signup and view all the answers

What strategy can enhance therapeutic communication?

Making observations about the patient Signup and view all the answers

What should be avoided when communicating with a patient?

Providing false reassurance Signup and view all the answers

What is the acronym OLDCARTS used for in patient assessment?

To create a detailed assessment of the chief complaint Signup and view all the answers

What is not a recommended practice during a patient interview?

Asking about sexual activity as the first question Signup and view all the answers

Which of the following is a key principle of inclusive care?

Ask patients their preferred name and pronoun Signup and view all the answers

When should a patient be asked to change into a gown during an assessment?

Only when necessary for physical assessment Signup and view all the answers

What is the purpose of sitting at eye level with the patient during communication?

To make the patient feel comfortable Signup and view all the answers

What is one of the first actions to take before engaging with a patient?

Wash your hands Signup and view all the answers

Which of the following is considered objective data?

Lab test results Signup and view all the answers

What does the 'S' in OLDCARTS stand for?

Severity Signup and view all the answers

What is the normal blood pressure range for an adult?

SBP < 120 & DBP < 80 Signup and view all the answers

When should you use closed-ended questions during an interview?

To clarify specific details Signup and view all the answers

Which of the following conditions results from a heart rate greater than 100?

Tachycardia Signup and view all the answers

What is considered bradycardia in terms of heart rate?

< 60 beats per minute Signup and view all the answers

For a rectal temperature reading on an adult, how deep should the probe be inserted?

No more than 1-2 inches Signup and view all the answers

What is a common risk factor for undernutrition?

Chronic illnesses Signup and view all the answers

What defines orthostatic hypotension?

Both A and B Signup and view all the answers

Which pulse oximetry reading is considered normal?

<blockquote> 94% </blockquote> Signup and view all the answers

Which body mass index (BMI) category indicates obesity?

30.0-39.9 Signup and view all the answers

What should be assessed to ensure safe swallowing during meal times?

Volume of food consumed Signup and view all the answers

Which of the following is not a common factor contributing to malnutrition?

High calorie diet Signup and view all the answers

What should be assessed to determine the seriousness of unintentional weight loss?

Whether the weight loss was intentional or unintentional Signup and view all the answers

What is the first step in the physical assessment sequence?

Inspection Signup and view all the answers

What tool should be used if there are concerns about a patient's potential malnutrition?

Malnutrition screening tool Signup and view all the answers

Which technique involves tapping on the patient's body to assess density?

Percussion Signup and view all the answers

In auscultation, which device is commonly used to amplify body sounds?

Stethoscope Signup and view all the answers

Which side of the stethoscope is used for high-pitched sounds?

The diaphragm Signup and view all the answers

What is an important patient right regarding their health information?

Confidentiality and HIPAA adherence Signup and view all the answers

What is crucial to prioritize when managing patient assessments?

Determining which patient requires the most immediate attention Signup and view all the answers

Study Notes

General, Communication, & Health History

Subjective Data: Information reported by the patient or family, crucial for health history.
Objective Data: Observable/measurable information such as physical assessment findings and vital signs.
Open-ended Questions: Broad questions encouraging patients to elaborate, useful at the start of an interview.
Closed-ended Questions: Direct questions, generally for clarification; should be used sparingly.

Therapeutic Communication

Strategies for Effective Communication: Making observations, summarizing, and showing empathy enhances patient interaction.
Encouragement: Use open-ended questions to foster patient expression.
Avoidances: Steer clear of "why" questions, assumptions, false reassurances, and accusations during conversations.

Comfort & Therapeutic Considerations

Start with handwashing, self-introduction, and ensuring privacy.
Explain procedures clearly before proceeding.
Maintain eye contact, avoid rushing, and sit at eye level with the patient.
Patients can have a support person during consultations; address the patient directly.

Inclusive Care

Provide culturally competent care by recognizing diverse backgrounds.
Always ask for preferred names and pronouns, and avoid biases to create a safe environment.

Patient Interview & Health History

Chief Complaint: Brief description of the reason for the patient's visit.
History of Present Illness (HPI): Detailed narrative linked to the chief complaint; use OLDCARTS for thorough assessment.
Past Medical History: Include mental, surgical, and family medical history.
Functional Assessment: Assess the patient’s ability to perform activities of daily living (ADLs).

General Survey, Pain, & Vitals

General Survey: First impression assessment encompassing hygiene, behavior, mental status, and more.
Pain Assessment: Trust the patient's self-report for pain; advocate for adequate management and reassess regularly.
Vital Signs: Repeat abnormal readings promptly; know normal ranges for blood pressure, temperature, pulse, respiratory rate, and oxygen saturation.

Nutrition & Anthropometric Measurements

Body Mass Index (BMI): Classifications include normal (18.5-24.9), overweight (25-29.9), obese (30.0-39.9), and morbidly obese (> 40).
Malnutrition Risks: Consider factors like age, chronic illnesses, and cultural impacts during assessment for undernutrition.

Physical Assessment Techniques

Follow the sequence: Inspection, Palpation, Percussion, Auscultation for effective assessment.
Inspection: Visual and olfactory observations are key.
Palpation: Check for abnormalities in texture and moisture using finger pads.
Percussion & Auscultation: Assess density and listen for body sounds, using direct or indirect methods.

Equipment and Patient Rights

Stethoscope Use: Differentiate between diaphragm (high-pitched sounds) and bell (low-pitched sounds).
Patient Confidentiality: Ensure HIPAA compliance and obtain patient permission regarding room presence.
Transparency: Share assessment findings with the patient post-evaluation.

Miscellaneous Tips

Prioritization: Determine the most critical intervention or concern if limited to one immediate action.
Assess impact levels of findings on patient functioning to guide care decisions.

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Description

Prepare for the NUR 216 Exam 1 with this comprehensive study guide. This guide highlights key concepts in understanding subjective and objective data, essential for effective communication and health history assessment. Ideal for nursing students looking to excel in their exams.