Podcast
Questions and Answers
What does it mean for a patient to be Alert & oriented x 4?
What does it mean for a patient to be Alert & oriented x 4?
- The patient remembers their name and location.
- The patient is aware of the current date and why they are there.
- The patient can only recognize familiar faces in their surroundings.
- The patient knows their name, location, date, and reason for visit. (correct)
Which statement accurately reflects the gold standard for pain assessment?
Which statement accurately reflects the gold standard for pain assessment?
- Vital signs are the most important part of assessing pain.
- The provider's assessment is the best indicator of pain.
- Patient's self-report of pain determines its severity. (correct)
- Nonverbal indicators are the only way to assess pain.
If a patient is in severe pain but denies it, what should the nurse do?
If a patient is in severe pain but denies it, what should the nurse do?
- Immediately notify the provider for further evaluation.
- Ignore the signs of pain and document the denial.
- Ask open-ended questions to assess the discomfort further. (correct)
- Reassess pain after a certain time without further inquiry.
What constitutes severe pain on a scale of 1 to 10?
What constitutes severe pain on a scale of 1 to 10?
How should pain reassessment be conducted?
How should pain reassessment be conducted?
What to do if nonpharmacological interventions do not help within 15 minutes?
What to do if nonpharmacological interventions do not help within 15 minutes?
What is an example of a subjective indicator of pain?
What is an example of a subjective indicator of pain?
What should be done if a patient's vital signs return closer to normal during pain reassessment?
What should be done if a patient's vital signs return closer to normal during pain reassessment?
What is an important consideration when assessing patient safety regarding sensory impairments?
What is an important consideration when assessing patient safety regarding sensory impairments?
What does a family history of cardiovascular disease indicate?
What does a family history of cardiovascular disease indicate?
Which system is assessed for symptoms like shortness of breath and wheezing?
Which system is assessed for symptoms like shortness of breath and wheezing?
Why might history taking and physical assessment need to occur simultaneously?
Why might history taking and physical assessment need to occur simultaneously?
What is the purpose of a General Survey in physical assessment?
What is the purpose of a General Survey in physical assessment?
Which of these is NOT a component of the General Survey?
Which of these is NOT a component of the General Survey?
What aspect of body structure may indicate obesity?
What aspect of body structure may indicate obesity?
Which of the following behaviors might indicate abnormal activity in a patient?
Which of the following behaviors might indicate abnormal activity in a patient?
What is considered hypotension in blood pressure readings?
What is considered hypotension in blood pressure readings?
What temperature range is considered normal for a patient?
What temperature range is considered normal for a patient?
When assessing for orthostatic hypotension, what indicates a positive finding?
When assessing for orthostatic hypotension, what indicates a positive finding?
What is classified as tachycardia in a heart rate reading?
What is classified as tachycardia in a heart rate reading?
Which method of temperature measurement is considered the most accurate?
Which method of temperature measurement is considered the most accurate?
What BMI value indicates obesity?
What BMI value indicates obesity?
What is a normal respiratory rate for adults?
What is a normal respiratory rate for adults?
Which of the following is a risk factor for undernutrition?
Which of the following is a risk factor for undernutrition?
When should a rectal temperature not be taken?
When should a rectal temperature not be taken?
What constitutes bradycardia in a heart rate reading?
What constitutes bradycardia in a heart rate reading?
What type of data includes information reported by the patient or family?
What type of data includes information reported by the patient or family?
Which type of question is recommended to begin an interview?
Which type of question is recommended to begin an interview?
What should be avoided during therapeutic communication?
What should be avoided during therapeutic communication?
What is the purpose of using the OLDCARTS acronym?
What is the purpose of using the OLDCARTS acronym?
Which of the following is considered objective data?
Which of the following is considered objective data?
When should a healthcare provider explain expectations to a patient?
When should a healthcare provider explain expectations to a patient?
Which of the following best describes 'therapeutic communication'?
Which of the following best describes 'therapeutic communication'?
What is an essential step before interacting with a patient?
What is an essential step before interacting with a patient?
In a health history interview, how should a healthcare provider address a patient?
In a health history interview, how should a healthcare provider address a patient?
What could negatively impact a patient's comfort during an interview?
What could negatively impact a patient's comfort during an interview?
Which of the following factors is important in providing inclusive care?
Which of the following factors is important in providing inclusive care?
Which element is NOT part of the functional assessment?
Which element is NOT part of the functional assessment?
What is a common purpose of closed-ended questions during an interview?
What is a common purpose of closed-ended questions during an interview?
During which stage of an interview should sensitive topics be addressed?
During which stage of an interview should sensitive topics be addressed?
What is the primary purpose of using a malnutrition screening tool?
What is the primary purpose of using a malnutrition screening tool?
Which physical assessment technique involves listening to body sounds?
Which physical assessment technique involves listening to body sounds?
What should be the first step when assessing a patient?
What should be the first step when assessing a patient?
What is important to determine regarding weight loss?
What is important to determine regarding weight loss?
Which device is primarily used to measure blood pressure?
Which device is primarily used to measure blood pressure?
What type of sound is typically assessed with the bell side of a stethoscope?
What type of sound is typically assessed with the bell side of a stethoscope?
What must be done to ensure patient confidentiality during assessments?
What must be done to ensure patient confidentiality during assessments?
What is the first consideration when prioritizing patient care?
What is the first consideration when prioritizing patient care?
Study Notes
General Communication & Health History
- Subjective Data: Information reported by the patient or family, integral to health history.
- Objective Data: Information that can be observed or measured, including physical assessments and vital signs.
- Open-ended Questions: Encourage patient dialogue; useful at interview onset (e.g., "Tell me about...").
- Closed-ended Questions: Direct queries requiring brief responses, used to clarify details after initial rapport is established.
Therapeutic Communication
- Strategies: Make observations, restate or summarize patient statements, and convey empathy.
- Best Practice: Encourage expression through open-ended questions.
- What to Avoid: Asking "why," making assumptions, giving false reassurance, or accusing the patient.
Comfort & Therapeutic Considerations
- Initial Steps: Wash hands, introduce yourself, provide privacy.
- Patient Preparation: Explain what is to be done; avoid sensitive topics until rapport is established.
- Body Language: Maintain eye contact, ensure patient comfort, and sit at eye level.
- Inclusivity: Ask for preferred names and pronouns, provide culturally competent care.
Patient Interview & Health History Components
- Chief Complaint: Brief indication of why the patient is seeking healthcare.
- History of Present Illness (HPI): Detailed assessment using OLDCARTS (Onset, Location, Duration, Characteristics, Aggravating/Alleviating factors, Related symptoms, Treatments, Severity) for thorough inquiry.
- Medical History: Include past medical, surgical, and mental health histories along with medication use.
- Functional Assessment: Evaluate the patient's ability to perform ADLs (activities of daily living).
- Family History: Important in identifying risk for diseases, particularly cardiovascular issues.
- Review of Systems: Systematic collection of information across different bodily systems.
General Survey & Vital Signs
- General Survey: Initial observation of patient’s hygiene, affect, appearance, and mental status as part of physical assessment.
- Pain Management: Advocate for pain control and assess pain subjectively according to the patient’s reporting.
- Vital Signs:
- Blood Pressure: Normal < 120/80 mmHg; adjust cuff size, watch positioning, and prepare the patient appropriately.
- Temperature: Varies; core temperatures are most accurate. Consider baseline for each patient.
- Pulse:
- Normal: 60-100 bpm; lower in athletes (40-60 bpm).
- Bradycardia and tachycardia indicate conditions requiring further attention.
- Respiratory Rate: Norm is 12-18 breaths/minute; deviations such as bradypnea or tachypnea require assessment.
- Pulse Oximetry: Normal reading > 94%.
Nutrition & Anthropometric Measurements
- Body Mass Index (BMI): Range classifications - Normal (18.5-24.9), Underweight (< 18.5), Overweight (25-29.9), Obese (30-39.9), Morbidly Obese (> 40).
- Malnutrition Risks: Includes alcoholism, chronic illness, and socioeconomic status; use screening tools.
- Weight Loss Assessment: Differentiate between intentional and unintentional weight loss due to its implications for health.
Physical Assessment Techniques
- Assessment Sequence: Inspection, palpation, percussion, and auscultation.
- Inspection: Visual and olfactory observations.
- Palpation: Assess texture, temperature, and abnormalities through touch.
- Percussion: Evaluate underlying structure density via sound; observe characteristics of the sound produced.
- Auscultation: Listening to bodily sounds directly or with amplification devices like a stethoscope.
Patient Rights and Prioritization Tips
- Confidentiality: Adhere to HIPAA guidelines before starting assessments.
- Transparency: Discuss findings with the patient after completion of the assessment.
- Prioritization: Identify critical interventions and focus on urgent patient needs based on abnormal findings.
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Description
Prepare for the NUR 216 Exam 1 with this study guide focusing on the distinctions between subjective and objective data, as well as the types of questions used in health history assessments. Understand how to gather and interpret data effectively for improved patient care.
