Quiz.txt

Here is a detailed study guide based on the questions provided: 1. Objective data is factual, measurable information that can be observed and verified, such as vital signs or lab results. Subjective data is information provided by the patient, such as their symptoms or feelings. 2. E...

Here is a detailed study guide based on the questions provided: 1. Objective data is factual, measurable information that can be observed and verified, such as vital signs or lab results. Subjective data is information provided by the patient, such as their symptoms or feelings. 2. Evidence-based practice refers to making clinical decisions based on the best available research evidence, in combination with clinical expertise and patient preferences. 3. The nursing process is a systematic approach to patient care that includes the following steps: - Assessment: Gather data about the patient's health status. Example nursing action: Obtain a health history. - Diagnosis: Identify the patient's nursing diagnoses. Example nursing action: Analyze assessment data to identify a risk for falls. - Planning: Develop a care plan with patient-centered goals. Example nursing action: Collaborate with the patient to set a goal to ambulate 50 feet with assistance. - Implementation: Carry out the interventions in the care plan. Example nursing action: Provide fall prevention education to the patient. - Evaluation: Monitor the patient's progress and adjust the plan as needed. Example nursing action: Evaluate the patient's progress towards their goal of ambulating 50 feet. 4. Objective data in a physical exam should be written in a factual, descriptive manner, such as "Skin is warm, dry, and intact" or "Pupils are equal, round, and reactive to light." 5. A complete history gathers comprehensive information about the patient's past and present health status, while a focused/problem-centered history focuses on the specific issue or concern that prompted the visit. 6. Cultural competence is the ability of healthcare providers to deliver care that is respectful of and responsive to the patient's cultural beliefs, practices, and needs. Nurses can demonstrate cultural competence by being aware of their own biases, actively learning about different cultures, and adapting their communication and care approaches accordingly. 7. Spirituality refers to an individual's sense of meaning, purpose, and connection to something greater than themselves, which may or may not be associated with religious beliefs or practices. 8. A cultural assessment should include information about the patient's health beliefs, practices, and values; language and communication preferences; social support systems; and any cultural or religious traditions that may impact their healthcare. 9. When taking notes during a patient interview, the nurse should be mindful not to let the note-taking process interfere with the flow of the conversation or their ability to actively listen to the patient. 10. The phases of the interview process are: - Opening: Establish rapport and set the stage for the interview. - Body: Gather information through questioning and active listening. - Closing: Summarize key points and plan next steps. - Summary: Document the interview findings. 11. Open-ended questions encourage the patient to provide more detailed information, while closed-ended questions elicit yes/no or short answer responses. 12. Verbal interview strategies: - Empathy: Demonstrate understanding and compassion for the patient's experience. - Reflection: Restate or paraphrase the patient's statements to ensure understanding. - Facilitation: Use prompts or silence to encourage the patient to continue sharing. - Interpretation: Offer insights or perspectives on the patient's statements. - Confrontation: Gently challenge the patient's beliefs or behaviors in a non-judgmental way. 13. Verbal communication refers to the words and tone used, while nonverbal communication includes body language, facial expressions, and gestures. If there is a discrepancy between the two, the nurse should explore the discrepancy with the patient to understand the underlying meaning. 14. When using an interpreter, the nurse should speak directly to the patient, maintain eye contact, and ensure the interpreter accurately conveys the information in the patient's preferred language. 15. The purpose of a health history is to gather information about the patient's past and current health status, including medical history, family history, and lifestyle factors. 16. When a patient reports pain, follow-up questions should explore the characteristics of the pain, such as location, intensity, duration, quality, and any relieving or aggravating factors. 17. Family health history questions should cover major illnesses, such as cancer, heart disease, diabetes, and mental health conditions, that may have a genetic component. 18. To assess for self-promotion, the nurse should ask about the patient's participation in screening and self-care activities, such as breast self-exams, testicular self-exams, and skin checks. 19. A genogram is a visual representation of a family's health history that can provide insights into patterns of illness, relationships, and other factors that may influence the patient's health. 20. Functional ability assessment questions should explore the patient's ability to perform activities of daily living, such as bathing, dressing, and ambulating, as well as any assistive devices or adaptations they use. 21. The four techniques used in a physical assessment, in general order, are: 22. Inspection: Visually examine the body part or area. 23. Auscultation: Use a stethoscope to listen to body sounds. 24. Percussion: Tap the body to assess for changes in sound and vibration. 25. Palpation: Use the hands to feel for changes in texture, temperature, and swelling. 26. Palpation is the technique used to assess texture, temperature, moisture, and swelling. 27. The five senses of the body are sight, hearing, touch, smell, and taste. 28. When performing an abdominal assessment, the nurse should start with light palpation to assess for tenderness, followed by deeper palpation to assess for organ size and abnormalities. 29. A dull sound on percussion indicates the presence of a solid structure, such as an organ, while a resonant, high-pitched sound indicates the presence of air. 30. The parts of a stethoscope are the diaphragm and the bell. The diaphragm is used to hear high-pitched sounds, such as heart murmurs, while the bell is used to hear low-pitched sounds, such as bowel sounds. 31. Crepitus is the crackling or grating sensation felt during palpation, swelling is the accumulation of fluid in the tissues, and pulsation is the rhythmic expansion and contraction of an artery. These characteristics would be assessed through palpation. 32. The four vital signs are temperature, blood pressure, pulse, and respirations. 33. Pulse and respirations should be assessed for a full minute to obtain an accurate measurement. 34. The normal ranges for vital signs are: - Adult: Temperature 97.6-99.6°F, BP 120/80 mmHg, Pulse 60-100 bpm, Respirations 12-20 breaths per minute - Child: Temperature 97.6-99.6°F, BP 90/60 to 120/80 mmHg, Pulse 80-120 bpm, Respirations 12-20 breaths per minute - Infant: Temperature 97.6-99.6°F, BP 70/40 to 100/60 mmHg, Pulse 100-160 bpm, Respirations 30-60 breaths per minute 31. When taking vital signs on an obese patient, a larger blood pressure cuff should be used to ensure an accurate reading. 32. The blood pressure cuff should be inflated 30 mmHg above the point where the palpated pulse disappears. 33. Orthostatic hypotension is a drop in blood pressure when a patient moves from a seated or lying position to a standing position, often indicated by a decrease of 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure. 34. To assess respirations in an infant, the nurse should observe the rise and fall of the chest and abdomen, and count the number of breaths per minute. 35. In addition to the patient's self-report, nurses can assess pain through observation of nonverbal cues, such as facial expressions, body language, and changes in vital signs. 36. Rectal temperature measurement is typically appropriate for infants, young children, or patients who are unable to hold a thermometer under the tongue. 37. The advantages of open-ended questions are that they encourage the patient to provide more detailed information and allow the nurse to better understand the patient's perspective. 38. The PQRST mnemonic can be used to guide pain assessment questions: - Provocation/Palliation: What makes the pain better or worse? - Quality: How would you describe the pain (e.g., sharp, dull, burning)? - Region/Radiation: Where is the pain located, and does it radiate anywhere? - Severity: On a scale of 0-10, how would you rate the pain? - Timing: When did the pain start, and how long does it last? 39. Factors that can affect the accuracy of a blood pressure reading include the patient's position, the cuff size, and whether the patient's legs are crossed. 40. Acute pain is sudden in onset, severe, and time-limited, while chronic pain is persistent, often lasting for months or years. 41. When assessing pain in a patient with dementia, the nurse should observe for nonverbal cues, such as facial expressions, body language, and changes in behavior, and consult with the patient's family or caregivers to better understand the patient's pain experience.