Nursing Assessment Findings Quiz

Common Assessment Findings

• Abdominal pain correlates with discomfort and pain levels.
• Low oxygen supply leads to impaired gas exchange resulting in oxygen deprivation.
• Amnesia and hallucinations indicate altered thought processes.
• Loneliness leads to social isolation, affecting emotional well-being.
• Anemia manifests as activity intolerance due to reduced oxygen-carrying capacity.
• Anxiety disorders are prevalent, with associated feelings of anxiety.
• Acute Respiratory Distress Syndrome (ARDS) results in impaired gas exchange.
• Arthritis contributes to discomfort and alters daily activities.
• Physical abuse cases include battered partners and child abuse, leading to violence concerns.
• Bedridden patients face diversional activity deficits, impacting quality of life.
• Burns may lead to fluid volume excess, requiring careful monitoring.
• Constipation signifies altered bowel elimination patterns.
• Ineffective airway clearance can result from cough, cyanosis, and pulmonary edema.
• Hypoxia indicates impaired gas exchange with significant risks.
• Psychological issues can lead to hopelessness, fear of rejection, and negative self-esteem.

Nursing Theorists

• Florence Nightingale: Environmental Theory focuses on using the environment to promote health.
• Hildegard Peplau: Psychodynamic Theory emphasizes nurse-patient relationships in four phases.
• Virginia Henderson: 14 Nursing Need Theory outlines basic human needs.
• Dorothea Orem: Self-Care Theory centers around patients taking responsibility for their own care.
• Callista Roy: Adaptation Model helps in understanding how individuals adapt to health changes.
• Jean Watson: Philosophy and Caring Theory highlights the importance of caring in nursing.

Common Laws of Nursing Practice

• PN RA 9137 emphasizes providing comprehensive nursing care.
• RA 2808 defines the true essence of nursing practice.
• RA 6425 regulates narcotics under the Dangerous Drug Act.
• RA 7305 is the Magna Carta for Public Health Workers, ensuring fair treatment and rights.
• RA 7610 pertains to the anti-child abuse laws, safeguarding minors.

Nursing Ethics

• Nursing ethics provide a guideline for the professional conduct of nurses.
• The Code of Ethics outlines essential characteristics of nursing as a profession.
• The Principle of Double Effect allows actions that may benefit while causing potential harm, focusing on intention and outcomes.

Principles of Professional Communication

• Effective communication involves sharing necessary information openly and honestly.
• Trust is fundamental in establishing rapport with patients.
• Collaboration and information sharing among healthcare teams enhance patient care.

Nursing Process

• Developed by Lydia Hall in 1955 as a systematic approach to nursing care.
• Consists of Goal-oriented, Organized, Systematic, and Humanistic elements.
• Assessment involves continuous data collection, both subjective and objective.

Assessment Components

• Nursing health history includes thorough interviews covering biographic data, chief complaints, health history, and family background.
• Gordon's functional health patterns help focus assessment on key health areas.

Vital Signs and Measurements

• Body temperature varies between surface (subcutaneous) and core (deep tissue), typically ranging from 36.7 to 37.0°C.
• Normal pulse rates are 60-100 bpm, with specific sites for measurement.
• Adult normal respiration rates are between 16 and 20 breaths per minute.
• Blood pressure norms are typically 120/80 mmHg, with variations indicating health status.

Directional Terms

• Superior: upper; Inferior: lower; Anterior: front; Dorsal: back.
• Medial refers to the middle, while lateral indicates the side or distance from the midline.
• Proximal means nearer to the attachment, and distal means further from it in limb descriptions.

General Survey and Physical Examination

• General surveys focus on overall appearance, behavior, hygiene, and signs of distress.
• Physical exams should follow a cephalocaudal approach, assessing body systems thoroughly.