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level: Level 1

Questions and Answers List

level questions: Level 1

QuestionAnswer
What is the key element of nursing care?assessment
objective datanurse sees, hears, measures, and feels; more than one person can verify with observation and measurements
signsrashes, altered vital signs, abnormal lung or heart sounds, and visible drainage or exudate
drainagerefers to the passive or active removal of fluids from a body cavity, wound, or other source of discharge by one or more methods
exudaterefers to fluid, cells, or other substances the are slowly exuded, or discharged from cells or blood vessels through small pores or breaks in the cell membrane, usually as a result of inflammation or injury
perspiration, pus & serumidentified as exudates
symptomssubjective indications of illness that the patient perceives
Examples of symptomspain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety
subjective datathe interviewer encourages a full description by the patient of the onset, the course, and the character of the problem and any factors that aggravate or alleviate it
pruritusthe symptoms of itching
diseasea pathologic condition of the body, is any disturbance of a structure or function of the body
What characterizes a given disease?recognized set of signs and symptoms
What allows the health care provider to make a medical diagnosis?the sign & symptoms that are clustered or grouped
Disease conditionshereditary, congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, environmental
etiologystudy of all factors that may be involved in the development of a disease; the cause of disease
hereditary diseasestransmitted genetically from parents to children; examples are cystic fibrosis, sickle cell anemia, color blindness, & hemophilia
congenital diseasesappear at birth or shortly thereafter but are not caused by genetic abnormalities
inflammatory diseasesthose in which the body reacts with an inflammatory response to some causative agent
degenerative diseaseimplies degeneration, often progressive, of some part of the body; osteoarthritis
infectious diseasesresult from the invasion of microorganisms into the body; AIDS, tuberculosis, pneumonia
deficiency diseasesresult from the lack of a specific nutrient; iron deficiency anemia
metabolic diseasecaused by a dysfunction that results in a loss of metabolic control of homeostasis in the body; diabetes mellitus, hypothyroidism
neoplastic diseasedisease is described as an abnormal growth of new tissues; sometimes benign & malignant (cancerous)
malignant neoplasmsa serious threat to health because of the rapid growth of the cells and their ability to invade and metastasize
traumatic conditionsresult from physical and emotional trauma
environmental diseasesare a group of conditions that develop from exposure to a harmful substance in the environment; carbon monoxide, asbestos
asbestosanother substance in the environment that potentially leads to lung problems and various cancers
autoimmune responsesthe body develops immunoglobulins (antibodies) against its own tissues or body substances; rheumatoid arthritis, ulcerative colitis
risk factorany situation, habit, environmental condition, genetic predisposition, physiologic condition, or other variable that increases the vulnerability of an individual or group to illness or accident
What are the 4 major category risk factors for diseasesgenetic and physiologic, age, environment & lifestyle
How are diseases described?in terms of duration
chronic diseasedevelops slowly and persists over a long period, often for a person's lifetime; diabetes mellitus
diabetes mellitusinability of the body to use glucose
What is chronic disease frequently described as?early, late, or terminal; another possibility that it is in remission
remissionmeans a partial or complete disappearance of clinical and subjective characteristics of the disease has occurred
acute diseasebegins abruptly with marked intensity of severe signs and symptoms and then often subsides after a period of treatment; appendicitis
organic diseaseresults in a structural change in an organ that interferes with its functioning; stroke
functional diseaseoften appear to be those of organic disease, but careful examination fails to evidence of structural or physiologic abnormalities; nervous and mental diseases
infectionis caused by an invasion of microorganisms, such as bacteria, viruses, fungi, or parasites, that produce tissue damage
inflammationa protective response of body tissues to irritation, injury, or invasion by disease-producing organisms
Cardinal signs of inflammationerythema (redness), edema (swelling), heat, pain, purulent drainage (pus), and loss of function
inflammatory responsethe body's defense against some causative agent
increased blood flow to the areaerythema and heat
purulent exudatethe accumulation of neutrophils, dead cells, bacteria, and other debris from the infectious process
assessmentis an evaluation or appraisal of the patient's condition
What does assessment involve?the orderly collection of information concerning the patient's health status
Data collected establishes what?a baseline
What does baseline allow?health care providers or the nurse to identify problems and plan care
astheniacondition of debility, loss of strength and energy, and depleted vitality
diaphoresissecretion of sweat, especially the profuse secretion associated with an elevated body temperature, physical exertion, exposure to heat, and mental or emotional stress
ecchymosisdiscoloration of an area of the skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls (also called a bruise)
fetidpertaining to something that has a foul, putrid, or offensive odor. Also called malodorous
jaundiceyellow tinge to the skin; often indicates obstruction in the flow of bile from the liver
orthopneaan abnormal condition in which a person has to sit or stand to breathe deeply or comfortably. Occurs in many disorders of the respiratory and cardiac systems
sallowpertaining to an unhealthy, yellow color; usually said of a complexion or skin
scleral icterusthe color of the sclera is yellow; this jaundice is the result of coloring of thsclera with bilirubin that infiltrates all tissues of the body
Frequently noted signs & symptoms of disease conditionsanorexia, asthenia, bradycardia, constipation, coughing, cyanosis, diaphoresis, diarrhea, dyspnea, ecchymosis, edema, erythema, fetid, fever, inflammation, jaundice, lethargy, nausea, orthopnea, pain, pallor, pruritus, purulent drainage, sallow, sclera icertus, tachypnea, & vomit
nursing assessmentcomprises the gathering, verifying, & communicating data about the patient
purpose of the assessmentis to establish a baseline database about the patient's level of wellness, health practices, past illnesses, related experiences, & health care goals
data collected during nursing assessmenthealth history, physical examination findings, results of laboratory & diagnostic tests, & information from health care team members & the patient's family or significant others
physical assessment techniquesuse inspection, palpation, auscultation, & percussion
postions for examinationsitting, supine, dorsal recumbent, lithely, sims, prone, lateral recumbent, knee-chest
sitting positionto assess vital signs head & neck lungs breasts etc; provides full expansion of lungs and provides better visualization of symmetry of upper body parts
supineto assess head, neck, lungs, heart, abdomen, extremities, & pulses; most normally relaxed position & provides easy access to pulse sites
dorsal recumbentto assess head/neck, lungs, breast, heart, abdomen; positioned for abdominal assessment because it promotes relaxation of abdominal muscles
lithotomyto assess female genitalia and genital tract; position provides maximal exposure of genitalia & facilitates insertion of vaginal speculum
simsto assess rectum & vagina; flexion of the hip and knee improves exposure of rectal area
prone positionto assess musculoskeletal system; this position is used only to assess extension of hip joint
lateral recumbentto assess heart; this position aids in detecting murmurs
knee-chest positionto assess rectum; this position provides maximum exposure of rectal area
What is the nurse first task before proceeding to the nurse health history?to establish an effective nurse-patient relationship
First step in initiating the nurse-patient relationshipto introduce oneself, including name, position, & the purpose of the interview
why is it important to state the estimate length of time for an assessment?it helps ensure cooperation
next step in initiating nurse-patient relationshipto communicate the nurse's trustworthiness & discretion to patients
How is the nurse-patient relationship enhanced?by the professionalism & competence conveyed
nursing health historythe initial step in the assessment process
Data collected provide the nurse with what information?patient's level of wellness, changes in life patterns, sociocultural role & mental and emotional reactions to illness
inspectionthe technique the nurse uses most frequently; begins with the nurse's first contact with the patient & continues throughout the gathering of the nursing history
palpationthe nurse uses the hands and sense of touch to gather data
what are the 3 palpation techniques?light, moderate, & deep
auscultationthe process of listening to sounds produced by the body
3 systems where you auscultatecardiovascular, respiratory, & gastrointestinal systems
percussionuse of the fingertips to tap the body's surface to produce vibration & sound; technique the nurse uses least frequently
tympanyhigh-pitched drumlike sound that a hollow organ such as the stomach produces while using percussion
dullnessa low-pitched thud like sound percussion over a dense organ such as the liver produces
flatnessa soft high-pitched flat sound percussion over a muscle produces
common laboratory & diagnosis testsblood analysis, urine analysis, diagnostic imaging examinations, stool analysis, & sputum analysis
chief complaintpatient's subjective reason for seeking healthcare
OPQRSTUV methodquestions asked when getting the history of present illness; onset-timing, precipitating-palliative, quality-quanity, region-radiation, severity scale, treatments, understanding, & values
health historyessential in planning nursing interventions & to identify habits & lifestyle patterns
family historyto determine whether the patient is at risk for illnesses of a genetic or familial nature and to identify areas of health promotion and illness prevention; provides information about family structure, interaction & function that are often useful in planning care
environmental historyprovides data about the patient's home & work environments; identifies areas of concern such as exposure to pollutants that can affect health
psychosocial & cultural historyincludes data about the patient's primary language, cultural group, educational background, attention span, & developmental stage; provides information about the patient's coping skills & support systems
if nursing's goal is to promote health while respecting individual value system & lifestylesculture-based behavior must be understood
Review of systems (ROS)a systematic method for collecting data on all body systems; the nurse asks the patient about normal functioning of each system & any changes the patient has noted, usually subjective data
the correct way to record such informationa clear, concise record
ROS guidecan be used to guaranteed a complete interview
level of consciousness (LOC)level of orientation; patient oriented to person, place, time, & purpose
nursing physical assessmentphysical examination performed
usually the first to detect changes in the patient's conditionnurses
the critical step in forming the nurse care planthe nursing assessment
Best time to assess the patientas soon after admission as possible
who performs the initial baseline assessment?RN
Who's responsibility is it to perform the ongoing assessment?RN or LVN
When can portions of the assessment be performed?when observation of changes in the patient's condition are noted
focused assessmentattention is concentrated or focused on a particular part of the body, where signs and symptoms are localized or most active, to determine their significance
if the patient expresses special concerns, or observation of changes in a patient's status is notedit is necessary to analyze the system presented by performing a focused assessment
if a complete physical assessment is necessaryany painful areas are best assessed last; ensures better cooperation from patient
For accuracy when should you measure the patient's height & weight?on admission then compare the results with the patient's staled height & weight
Physical assessment guideneurologic(LOC), integumentary(skin condition), cardiovascular(apical pulse/pitting edema), respiratory(lungs), gastrointestinal(abdomen), urinary(urine), mobility(activity level)
pain assessment scalemost commonly used numeric scale 0-10
mild painratings of 3-5
moderate painratings of 5-7
severe painratings greater than 7
turgorrefers to the elasticity of the skin caused by the outward pressure of the cells & interstitial fluid
dehydration results indecreased skin turgor
marked edema results inincreased skin turgor
normal carotid pulseregular & palpable without a thrill
thrilla vibrating sensation the nurse perceives during palpation along the artery
bruitsabnormal "swishing" sounds heard over organs, glands, & arteries; results from a narrow or partially occluded artery, such as occurs in atherosclerosis
cracklesadventitious breath sounds produced by fluid in the bronchioles and the alveoli, are short, discrete, interrupted, crackling, or bubbling sounds; defined as fine, medium, or coarse
wheezessounds produced by the movement of air through narrowed passages in the tracheobronchial tree; classified as sibilant or sonorous
sibilant wheezeshave a high-pitched squeaking and musical quality and are produced by airflow through narrowed airways
sonorous wheezeshave a lower-pitched, coarser, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and the large airways; most likely to clear at least somewhat with a cough
stridora high-pitched, inspiratory, crowing sound, louder in the neck than over the chest wall
pleural friction rubsare produced by inflammation of the pleural sac; the nurse hears a rubbing, grating, or squeaky sound on auscultation
"lub-dub" sound of the heartcaused by the closure of the atrioventricular and the semilunar valves
first normal heart soundoccurs with closure of the atrioventricular valves; auscultated most clear at the apex
second normal heart soundoccurs with closure of the semilunar valves and signals the end of systole; auscultated most clear at the base
3rd & 4th heard soundsextra heart sounds; auscultated best at the apex
third sound of the heartsometimes normal in children, abnormal in adults; dull soft sound & sometimes a early sign of heart failure
fourth sound of the heartheard immediately before sound 1, soft with a low pitch; sometimes normal & sometimes pathologic, it is heard in patients with coronary artery disease after myocardial infarction or cardiomyopathy
peripheral vascular systemarteries provide oxygen & nutrients to the tissues
ischemiaresults if there is a decreased supply of oxygenated blood to the tissues; often this is caused by a narrowing of an artery
fine crackleshigh-pitched, discrete; not cleared by a cough
medium crackleslower more moist sound heard during the mid stage of inspiration; not cleared by a cough
coarse cracklesloud, bubbly noise; not cleared by a cough
rhonchi (sonorous wheeze)loud, low coarse sounds like a snore; most likely cleared by a cough
wheeze(sibilant wheeze)musical noise sounding like a squeak; usually louder during expiration
anorexiaany reports of nausea, vomiting, or altered or deceased appetite
peristalsiswavelike movements of the intestine
How often do bowel sounds occur?15-60 seconds
what are bowel signs classified as?active, hyperactive, hypoactive, or absent
normal rate for bowel sounds4 to 32 per minute
How long do you listen to bowel sounds for?1 minute for all four quadrants
2 significant alterations in bowel soundsdecreased & increased
borborygmiiincreased sounds with a characteristically high-pitched, loud, rushing sound
decreased bowel soundsdiminished or absent bowel sounds accompany inhibition of bowel motility; occurs with inflammation
increased bowel soundsloud,gurgling borborygmi often accompanies increased motility of the bowel, such as diarrhea
edemaan excessive accumulation of fluid in the interstitial spaces caused by leakage of fluid from veins and capillary beds
pitting edema scaleTrace(1+), Mild(2+), Moderate(3+), severe(4+)
trace edemaa barely perceptible pit (2mm)
mild edemaa deeper pit (4mm), with fairly normal contours, that rebounds in 10 to 15 seconds
severe edemaan even deeper pit(8mm), edema that possibly lasts as long as 2 to 5 minutes before rebounding
unilateral edemalikely the result of occlusion of a major vein
how does the health care provider perceive signsby using senses of sight touch smell & hearing
universal signs of infectionerythema, edema, pain, heat, loss of function, and purulent, malodorous drainage
what does interviewing a patient initially help with?identify signs, symptoms, and areas of patient concern that examination seeks to clarify
what does the nurse's role require?the nurse to be familiar with normal assessments and thus able to identify abnormalities