NUR 216 Exam 1 Study Guide

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Questions and Answers

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?

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?

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?

A pain level of 7 or higher. Signup and view all the answers

How should pain reassessment be conducted?

Consider subjective report, nonverbal cues, and vital sign changes. Signup and view all the answers

What to do if nonpharmacological interventions do not help within 15 minutes?

Provide a more appropriate intervention. Signup and view all the answers

What is an example of a subjective indicator of pain?

Patient self-reporting pain level. Signup and view all the answers

What should be done if a patient's vital signs return closer to normal during pain reassessment?

This is a sign of successful pain management. Signup and view all the answers

What is an important consideration when assessing patient safety regarding sensory impairments?

They may affect the patient's ability to understand instructions. Signup and view all the answers

What does a family history of cardiovascular disease indicate?

It is a significant risk factor for the patient. Signup and view all the answers

Which system is assessed for symptoms like shortness of breath and wheezing?

Respiratory system Signup and view all the answers

Why might history taking and physical assessment need to occur simultaneously?

To expedite the assessment process while the patient is alert. Signup and view all the answers

What is the purpose of a General Survey in physical assessment?

To provide an overall first impression of the patient. Signup and view all the answers

Which of these is NOT a component of the General Survey?

Emergency medical history Signup and view all the answers

What aspect of body structure may indicate obesity?

Weight/build Signup and view all the answers

Which of the following behaviors might indicate abnormal activity in a patient?

Restlessness or pacing Signup and view all the answers

What is considered hypotension in blood pressure readings?

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

What temperature range is considered normal for a patient?

Normal ranges can vary among individuals Signup and view all the answers

When assessing for orthostatic hypotension, what indicates a positive finding?

Decrease in blood pressure by > 20 mm Hg Signup and view all the answers

What is classified as tachycardia in a heart rate reading?

HR > 100 Signup and view all the answers

Which method of temperature measurement is considered the most accurate?

Rectal measurement Signup and view all the answers

What BMI value indicates obesity?

30.0 - 39.9 Signup and view all the answers

What is a normal respiratory rate for adults?

12-18 breaths per minute Signup and view all the answers

Which of the following is a risk factor for undernutrition?

Alcohol use Signup and view all the answers

When should a rectal temperature not be taken?

If the patient has diarrhea Signup and view all the answers

What constitutes bradycardia in a heart rate reading?

HR < 60 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 recommended to begin an interview?

Open-ended questions Signup and view all the answers

What should be avoided during therapeutic communication?

Asking 'why' questions Signup and view all the answers

What is the purpose of using the OLDCARTS acronym?

To obtain thorough assessment of a chief complaint Signup and view all the answers

Which of the following is considered objective data?

Vital signs Signup and view all the answers

When should a healthcare provider explain expectations to a patient?

Before any procedures or assessments Signup and view all the answers

Which of the following best describes 'therapeutic communication'?

Communication that encourages patient expression and understanding Signup and view all the answers

What is an essential step before interacting with a patient?

Wash hands and introduce yourself Signup and view all the answers

In a health history interview, how should a healthcare provider address a patient?

Directly address the patient Signup and view all the answers

What could negatively impact a patient's comfort during an interview?

Rushing through the questions Signup and view all the answers

Which of the following factors is important in providing inclusive care?

Asking for preferred names and pronouns Signup and view all the answers

Which element is NOT part of the functional assessment?

Patient's psychiatric history Signup and view all the answers

What is a common purpose of closed-ended questions during an interview?

To clarify specific information Signup and view all the answers

During which stage of an interview should sensitive topics be addressed?

After rapport has been built Signup and view all the answers

What is the primary purpose of using a malnutrition screening tool?

To evaluate possible malnutrition Signup and view all the answers

Which physical assessment technique involves listening to body sounds?

Auscultation Signup and view all the answers

What should be the first step when assessing a patient?

Inspection Signup and view all the answers

What is important to determine regarding weight loss?

If it was intentional or unintentional Signup and view all the answers

Which device is primarily used to measure blood pressure?

Sphygmomanometer Signup and view all the answers

What type of sound is typically assessed with the bell side of a stethoscope?

Low-pitched sounds Signup and view all the answers

What must be done to ensure patient confidentiality during assessments?

Obtain permission if others are present in the room Signup and view all the answers

What is the first consideration when prioritizing patient care?

The most pressing safety concern or intervention Signup and view all the answers

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.