Health Assessment, Nursing Today, The Healthcare Delivery System
What are the three major components of a comprehensive health assessment?
Health history
physical examination
documentation/clinical analysis of findings.
What do the letters ADPIE stand for?
Assessment, Diagnosis, Planning, Implementation, and Evaluation.
What is considered a normal adult respiratory rate?
12-20 breaths per minute.
Which mental health disorder is characterized by episodes of depression alternating with episodes of mania?
Bipolar disorder
What does PERRLA stand for?
Pupils Equal, Round, Reactive to Light, and Accommodation.
According to Benner's model, what stage describes a nurse who relies heavily on rules and guidelines for decision-making?
Novice Nurse
Which step of the nursing process involves collecting and validating patient data?
Assessment
What is included in general inspection of the patient?
Appearance
level of consciousnessmobility
hygiene
posture
behavior
What are the 3 major macronutrients required by the body?
carbohydrates
fats
proteins
What is the normal appearance of a healthy tympanic membrane?
Pearly gray, shiny, and intact with a visible cone of light.
What is the primary goal of obtaining a health history before performing a physical examination?
To collect subjective data and identify patient concerns, risks, and health needs.
What is the difference between a medical diagnosis and a nursing diagnosis?
A medical diagnosis identifies a disease or condition; a nursing diagnosis identifies human responses to actual or potential health problems.
What is cultural competence?
The ability to provide effective, respectful care that meets the social, cultural, and linguistic needs of patients.
A patient has a BMI of 17.0. What does this finding indicate?
Underweight status and possible malnutrition risk.
What condition should a nurse suspect when a patient reports eye pain, halos around lights, and sudden vision changes?
Glaucoma
Which level of health care focuses on health promotion and disease prevention services such as immunizations and wellness visits?
Primary care
A patient has oxygen saturation of 88%, shortness of breath, and tachypnea. Which nursing diagnosis would be the priority?
O2 Saturation of 88%
age
stress
activity level
medication
pain
weight
smoking
What assessment finding defines a Stage I pressure injury?
Intact skin with non-blanchable redness over a bony prominence.
What assessment tool is used when assessing a patient for a headache?
OLDCARTS
Why should discharge planning begin when a patient is admitted?
continuity of care
identification of patient needs at home
facilitate safe transition after hospitalization
During evaluation, a nurse discovers that a patient's outcomes were not met. What should the nurse do next?
reassess the patient
revise the plan of care
When a patient refuses treatment due to religious belief, what is the nurse's most culturally competent response?
respect the patient's beliefs
explore the concern
educate
collaborate an acceptable plan
Clubbing of the fingernails is often associated with which system disorder?
respiratory system disorders (cardiovascular could also work)
A patient presents with hoarseness, dysphagia, a neck mass, and cervical lymphadenopathy. What serious condition should be suspected?
Head and Neck cancer or Thyroid malignancy