Nursing Assessment Essentials and Cultural Competence
40 Questions
0 Views

Choose a study mode

Play Quiz
Study Flashcards
Spaced Repetition
Chat to Lesson

Podcast

Play an AI-generated podcast conversation about this lesson

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 (B)</p> Signup and view all the answers

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

<p>Vagus (B)</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 (C)</p> Signup and view all the answers

What is the function of the Glossopharyngeal nerve?

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

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

<p>Evaluating ability to identify sensation (A)</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) (A)</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 (C)</p> Signup and view all the answers

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

<p>Medications (C)</p> Signup and view all the answers

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

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

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

<p>Palpation (B), Auscultation (D)</p> Signup and view all the answers

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

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

What does the precordium assessment primarily identify?

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

Which type of joint is classified as synovial?

<p>Saddle joint (A), Ball-and-socket joint (C)</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. (C)</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. (B)</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. (B)</p> Signup and view all the answers

What defines a comprehensive nursing assessment?

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

In which situation would a focused nursing assessment typically occur?

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

What is one major benefit of proper documentation in nursing?

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

Which format is used to facilitate structured communication in nursing?

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

Which characteristic is NOT considered effective in therapeutic communication?

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

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

<p>Palpation (A)</p> Signup and view all the answers

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

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

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

<p>Providing reassurance (A)</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 (C)</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 (D)</p> Signup and view all the answers

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

<p>Tympanic (A)</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 (D)</p> Signup and view all the answers

Which descriptor is NOT used during auscultation?

<p>Color (B)</p> Signup and view all the answers

What does HIPAA require regarding patient information?

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

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

<p>Elasticity (C)</p> Signup and view all the answers

What does visual acuity assess?

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

What is the role of a medical record in healthcare?

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

Which part of the ear connects to the eustachian tube?

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

Flashcards

SOAP

A documentation format used in nursing, standing for Subjective, Objective, Assessment, Plan.

SBAR

A communication tool used in healthcare, standing for Situation, Background, Assessment, Recommendation.

Effective Therapeutic Communication

Communication that builds trust and rapport with the patient, involves active listening and empathy, and promotes understanding.

Nonverbal Communication

Communication that uses body language, expressions, and tone of voice, which can convey emotions and meaning without words.

Signup and view all the flashcards

Nontherapeutic Responses

Communication patterns that are unhelpful and can hinder effective communication with the patient.

Signup and view all the flashcards

Inspection in Health Assessment

Using visual observation to assess the patient's appearance, behavior, and physical characteristics.

Signup and view all the flashcards

Characteristics to observe during inspection

Physical characteristics, behavior, odor, age, gender, alertness, body size, skin color, hygiene, posture, and level of comfort.

Signup and view all the flashcards

Percussion Sounds

Sounds produced by tapping on different parts of the body, providing information about the underlying tissues.

Signup and view all the flashcards

Emergency Assessment

A rapid assessment focused on life-threatening or unstable situations. It primarily uses the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure).

Signup and view all the flashcards

Comprehensive Assessment

A thorough and complete evaluation of a patient's health history and physical well-being. It's usually conducted annually for outpatients or upon hospital/long-term care admission.

Signup and view all the flashcards

Focused Assessment

A targeted assessment concentrating on specific health concerns or symptoms. It's performed in various settings and uses in-depth exploration of the identified issue.

Signup and view all the flashcards

Cultural Competence in Healthcare

The ability of healthcare providers to understand and respect the diverse cultural backgrounds of their patients, tailoring care to address their unique beliefs, practices, and values.

Signup and view all the flashcards

Why is Cultural Diversity Knowledge Important?

Understanding cultural diversity allows healthcare providers to recognize and respect individual beliefs, practices, and values, ensuring culturally sensitive and effective care.

Signup and view all the flashcards

Subjective Cues in Assessment

Information directly provided by the patient, including their verbal and nonverbal communication, feelings, and personal experiences.

Signup and view all the flashcards

Objective Cues in Assessment

Measurable and observable information gathered through examination, such as vital signs, results of physical examinations, and visual observations.

Signup and view all the flashcards

Purpose of Documentation in Nursing

Documentation serves as a legal record of patient care, ensuring continuity of care, communication among healthcare providers, and evaluation of patient progress.

Signup and view all the flashcards

Auscultation Purpose

Listening to sounds produced by the body to assess organ and tissue function.

Signup and view all the flashcards

Auscultation Descriptors

Characteristics used to describe sounds heard during auscultation. These include intensity, pitch, duration, and quality.

Signup and view all the flashcards

Ophthalmoscope Purpose

A tool used to examine the interior structures of the eye.

Signup and view all the flashcards

Medical Record Purpose

A legal document containing essential patient information for care, legal proceedings, and research.

Signup and view all the flashcards

HIPAA

The Health Insurance Portability and Accountability Act, protecting patient health information and ensuring privacy.

Signup and view all the flashcards

ABCDE Skin Assessment

A mnemonic representing key features to assess potential skin lesions: Asymmetry, Border, Color, Diameter, Evolution.

Signup and view all the flashcards

Visual Acuity

The clarity or sharpness of vision, often assessed using a Snellen chart.

Signup and view all the flashcards

Sensory Nerve for Face & Mouth

The Facial Nerve (Cranial Nerve VII) is responsible for sensory function related to the face and mouth.

Signup and view all the flashcards

Common Nose & Sinus Symptoms

Common symptoms include facial pressure, pain, headache, nasal congestion, epistaxis (nosebleeds), and halitosis.

Signup and view all the flashcards

Subjective Thorax & Lung Data

Includes past medical history, lifestyle, occupation, environmental exposures, medications, and family history.

Signup and view all the flashcards

Thorax & Lung Assessment Techniques

Techniques include inspection, palpation, chest expansion assessment, tactile fremitus, percussion, and auscultation.

Signup and view all the flashcards

Anterior Chest Examination Components

Inspection, Palpation, Auscultation.

Signup and view all the flashcards

Posterior Chest Examination Components

Inspection, Palpation, Tactile fremitus, Symmetric Expansion, Percussion, Auscultation.

Signup and view all the flashcards

Joint Types in Musculoskeletal Assessment

Fibrous (synarthrotic), Cartilaginous (amphiarthrotic), Synovial (diarthrotic).

Signup and view all the flashcards

Main Joints Assessed

Temporomandibular joint (TMJ), Shoulder, Elbow, Wrist and hand, Hip, Knee, Ankle, Foot, Spine.

Signup and view all the flashcards

Stroke Risk in African Americans

African Americans have a significantly higher risk of stroke compared to White Americans, with a 2x greater chance of dying from a stroke.

Signup and view all the flashcards

Functional Status Recommendation for Minorities

The Office of Minority Health recommends a functional status that includes activities like walking 10 steps, sitting for 2 hours, reaching overhead, grasping small objects, lifting 10 pounds, and participating in social activities.

Signup and view all the flashcards

Cranial Nerve I: Olfactory

The olfactory nerve is responsible for the sense of smell.

Signup and view all the flashcards

Cranial Nerve II: Optic

The optic nerve transmits visual information from the eyes to the brain.

Signup and view all the flashcards

Cranial Nerve III: Oculomotor

The oculomotor nerve controls eye movements, pupil constriction, and eyelid elevation.

Signup and view all the flashcards

Cranial Nerve V: Trigeminal

The trigeminal nerve controls facial sensation, chewing, and jaw movements.

Signup and view all the flashcards

Priority Neurological Assessments

Urgent assessments for significant changes in neurological status include: acute mental status change, unexplained consciousness changes, seizure activity, pupil size changes, progressing weakness, altered sensation, and vital sign fluctuations.

Signup and view all the flashcards

Advanced Practice Neurological Assessments

Advanced assessments include a more in-depth evaluation of the patient's neurological function, potentially involving specialized tests or consultations.

Signup and view all the flashcards

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).

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Quiz Team

Related Documents

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.

More Like This

Use Quizgecko on...
Browser
Open
Browser
Browser