Nursing Assessment Essentials and Cultural Competence
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Questions and Answers

Which demographic group has the highest likelihood of dying from a stroke?

  • White Americans
  • African Americans (correct)
  • Hispanics
  • Asian Americans

    • What is one recommended functional status by the Office of Minority Health?

  • Lift or carry something about 10 kg (22 lb)
  • Walk up to 10 steps without resting (correct)
  • Walk up to 25 steps without resting
  • Sit for about 4 hours

    • Which cranial nerve is responsible for the sense of smell?

  • Optic
  • Olfactory (correct)
  • Trigeminal
  • Oculomotor

    • What is an urgent assessment for significant changes in neurological status?

    <p>Pupil size changes</p> Signup and view all the answers

    Which cranial nerve is tested when asking a patient to say 'ah'?

    <p>Vagus</p> Signup and view all the answers

    Which of the following is NOT a sign of significant changes in neurological status?

    <p>Increased energy levels</p> Signup and view all the answers

    What is the function of the Glossopharyngeal nerve?

    <p>Provide sensory function to the throat</p> Signup and view all the answers

    Which assessment is a priority for a patient with unilateral weakness?

    <p>Evaluating ability to identify sensation</p> Signup and view all the answers

    What is the primary cranial nerve responsible for sensory function related to the face and mouth?

    <p>Facial Nerve (Cranial Nerve VII)</p> Signup and view all the answers

    Which of the following is NOT a common symptom associated with nose and sinus assessment?

    <p>Chronic cough</p> Signup and view all the answers

    Which component is included in the subjective data collection for thorax and lung assessment?

    <p>Medications</p> Signup and view all the answers

    Which technique is NOT utilized in the assessment of the thorax and lungs?

    <p>Neck flexibility assessment</p> Signup and view all the answers

    Which of the following components is part of the anterior chest examination?

    <p>Palpation</p> Signup and view all the answers

    What is typically NOT included in the components of a comprehensive physical assessment?

    <p>Sleep apnea</p> Signup and view all the answers

    What does the precordium assessment primarily identify?

    <p>Rate and rhythm of heart sounds</p> Signup and view all the answers

    Which type of joint is classified as synovial?

    <p>Saddle joint</p> Signup and view all the answers

    What is the primary purpose of an emergency nursing assessment?

    <p>To address life-threatening or unstable situations.</p> Signup and view all the answers

    Which of the following best describes objective cues in a health assessment?

    <p>Measurable information obtained through observations.</p> Signup and view all the answers

    Why is cultural competence important in nursing practice?

    <p>It allows recognition and respect of diverse beliefs and practices.</p> Signup and view all the answers

    What defines a comprehensive nursing assessment?

    <p>Encompasses complete health history and physical assessment.</p> Signup and view all the answers

    Which of the following statements about subjective cues is accurate?

    <p>They include feelings, personal experiences, and communication.</p> Signup and view all the answers

    What is a key component of cultural competence in healthcare?

    <p>Awareness of one's own cultural biases.</p> Signup and view all the answers

    In which situation would a focused nursing assessment typically occur?

    <p>When addressing a specific health concern.</p> Signup and view all the answers

    What is one major benefit of proper documentation in nursing?

    <p>It ensures compliance with regulatory requirements.</p> Signup and view all the answers

    What is the primary purpose of documentation in nursing?

    <p>To establish a baseline and meet legal requirements</p> Signup and view all the answers

    Which format is used to facilitate structured communication in nursing?

    <p>SOAP (Subjective, Objective, Assessment, Plan)</p> Signup and view all the answers

    Which characteristic is NOT considered effective in therapeutic communication?

    <p>Unwanted advice</p> Signup and view all the answers

    During which technique of health assessment are you likely to use touch?

    <p>Palpation</p> Signup and view all the answers

    Which of the following is a characteristic to observe during an inspection?

    <p>Skin color</p> Signup and view all the answers

    Which of the following is considered a nontherapeutic response in patient communication?

    <p>Providing reassurance</p> Signup and view all the answers

    What is the main focus of the inspection technique in health assessment?

    <p>To gain an overall impression of the patient</p> Signup and view all the answers

    Which of the following is an example of a characteristic to observe during an inspection?

    <p>Level of alertness</p> Signup and view all the answers

    Which percussion tone is characterized by a clear, hollow sound?

    <p>Tympanic</p> Signup and view all the answers

    What is the primary purpose of auscultation in nursing assessments?

    <p>To listen to sounds from organs and tissues</p> Signup and view all the answers

    Which descriptor is NOT used during auscultation?

    <p>Color</p> Signup and view all the answers

    What does HIPAA require regarding patient information?

    <p>Protection of specific health information</p> Signup and view all the answers

    Which of the following is NOT part of the ABCDE skin assessment model?

    <p>Elasticity</p> Signup and view all the answers

    What does visual acuity assess?

    <p>Clarity or sharpness of vision</p> Signup and view all the answers

    What is the role of a medical record in healthcare?

    <p>It functions as a legal document</p> Signup and view all the answers

    Which part of the ear connects to the eustachian tube?

    <p>Middle ear</p> Signup and view all the answers

    Study Notes

    Nursing Assessment Essentials

    • Types of Nursing Assessments:
      • Emergency: life-threatening or unstable situations (e.g., based on A, B, C, D, E).
      • Comprehensive: annual health history and physical assessment for outpatients or upon hospital/long-term care admissions.
      • Focused: smaller scope, deeper investigation for specific issues.

    Cultural Competence in Healthcare

    • Definition: Cultural competence is a complex combination of knowledge, attitudes, and skills healthcare providers use for culturally sensitive care. This includes understanding the patient's overall situation.

    Importance of Cultural Diversity

    • Rationale: Knowledge of cultural diversity is essential to recognize and respect the diverse beliefs, practices, and values of patients from various backgrounds.

    Subjective Cues

    • Definition: Subjective cues are the patient's verbal and nonverbal communications, feelings, and personal experiences.

    Objective Cues

    • Definition: Objective cues are measurable observations such as vital signs, auscultation, and visual appearance.

    Documentation in Nursing

    • Purpose: Essential for setting a baseline, adhering to HIPAA regulations, meeting legal requirements, and facilitating communication between healthcare providers.
    • Common Formats:
      • SOAP (Subjective, Objective, Assessment, Plan)
      • SBAR (Situation, Background, Assessment, Recommendation).

    Effective Therapeutic Communication

    • Characteristics: Caring, empathy, establishing a complex, ongoing, and interactive nurse-patient relationship.

    Nonverbal Communication Skills

    • Important Skills: Physical appearance, facial expressions, posture/positioning, gestures/eye contact, voice tone, use of touch.

    Nontherapeutic Responses

    • Avoid: False reassurance, sympathy, unwanted advice, biased questions, changing the subject, irrelevant/distracting conversations, technical/overwhelming language, interrupting.

    Health Assessment Techniques

    • Inspection: Observing the patient to gather overall impression and assess severity.
    • Palpation: Feeling.
    • Percussion: Tapping to assess sounds.
    • Auscultation: Listening with a stethoscope.

    Health Assessment Purposes

    • Inspection (Purpose): Obtaining an overall impression of the patient and assessing the severity of the situation by consciously observing and collecting data.

    Thorax and Lung Assessment

    • Subjective Data: Past medical history, lifestyle and personal habits, occupational history, environmental exposures, medications, family history.
    • Assessment Techniques: Inspection, palpation, chest expansion assessment, tactile fremitus, percussion of the chest, and auscultation.
    • Components (Anterior): Inspection, palpation, auscultation.
    • Components (Posterior): Inspection, palpation, tactile fremitus, symmetric expansion, percussion, auscultation.

    Musculoskeletal Assessment

    • Joint Types: Fibrous (synarthrotic), cartilaginous (amphiarthrotic), synovial (diarthrotic).
    • Main Joints: Temporomandibular joint (TMJ), shoulder, elbow, wrist and hand, hip, knee, ankle, foot, spine.

    Documentation of Muscular Strength

    • Method: Observing client pushing against resistance from the examiner.
    • Ethnic Differences: African Americans have double the stroke risk compared to White Americans; Hispanics and Native Americans also have increased risk, while Asian Americans have less risk.

    Functional Status Guidelines

    • Office of Minority Health Suggestions: Walking 10 steps without rest, sitting 2 hrs, overhead reaching, grasping small objects, and lifting/carrying 4 kg (10 lb) weights. Participating in social activities.

    Cranial Nerve Functions

    • Details about each nerve's function are provided.

    Neurological Priority Assessments

    • Urgent assessments for significant neurological changes include: acute change in mental status, unexplained changes in consciousness, seizure activity, altered pupil responses, progressive weakness, changing sensory perception, and considerable changes in vital signs.

    Advanced Practice Assessments

    • Includes: Deep Tendon Reflexes, Weber and Rinne tests using tuning forks, and the Phalen test.

    Stroke Level of Consciousness Assessment

    • Assessment Method: Glasgow Coma Scale (ranging from 3 to 15).

    FAST Stroke Recognition

    • Acronym: F- Face drooping, A- Arm weakness, S- Speech difficulty, T- Time to call 911.

    Eyelid Drooping (Ptosis)

    • A drooping eyelid.

    Difficulty Swallowing (Dysphagia)

    • Difficulty swallowing.

    Stroke Risk Factors

    • High-Risk Groups: Individuals age 55 or older, men, African Americans, with hypertension, smoking, excessive alcohol consumption, and obstructive sleep apnea (OSA).

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    Nursing Assessment Essentials PDF

    Description

    Explore the essential components of nursing assessments, including emergency and comprehensive evaluations. Learn the importance of cultural competence and how understanding diverse patient backgrounds can enhance healthcare delivery. Assess your knowledge of subjective and objective cues in patient care.

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