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Nursing 251 Health Assessment Cumulative Final Questions and Correct Answers

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  • NURS 251
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  • NURS 251

Initial comprehensive Assessment occurs when client first presents themselves, and gives and overall picture of "health" Ongoing/Partial Assessment Occurs after comprehensive data base is established; is a reevaluation of problem or baseline looking for Improvement/deterioration Focused/ Problem ...

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  • 4 de agosto de 2024
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  • NURS 251
  • NURS 251
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Nursing 251 Health Assessment
Cumulative Final Questions and Correct
Answers
Initial comprehensive Assessment ✅occurs when client first presents themselves, and
gives and overall picture of "health"

Ongoing/Partial Assessment ✅Occurs after comprehensive data base is established;
is a reevaluation of problem or baseline looking for Improvement/deterioration

Focused/ Problem Assessment ✅Occurs in relation to a specific health concern but
doesn't replace comprehensive assessment

Emergency Assessment ✅Occurs rapidly when life-saving action needs to be taken;
immediate diagnosis needed to begin treatment

Primary Vs. Secondary source ✅Primary is Patient; secondary is family, medical
records, nurse, doctor

Methods for Validation ✅-Recheck (repeat)
-clarify (asking client)
-verify (as another physician to listen)
-compare (differences in stories and body language)

Euro-American ✅-Very time conscious
-Arm's length distance while communicating
-Speaks directly and maintains eye contact
-Productive, prefer action over inaction
-Measure accomplishments by external standards

African-American ✅-Time orientation is not strict
-Present oriented instead of future
-Avoids eye contact
-May use jargon or slang
-Self-Care and Folk Medicine very prevalent
-Attempts home remedies first

Latin-American (hispanic) ✅-Very modest
-Time orientation not strict
-Don't like to be questioned
-Politeness is a sign of respect

,-Tends to express emotions openly
-Tends to have a fatalistic outlook on life
-Illness is an imbalance between Hot and Cold

Asian-American ✅-Privacy, No expression of emotions
-Unlikely to complain about problems
-Physical contact not acceptable
-Do not react well to painful diagnostic work-up
-Goal of therapy is to restore balance of Yin and Yang

Native American ✅-Respect of the body
-Present oriented
-Respect for the elderly
-All disorders believed to have aspects of the supernatural
-Theology and medicine strongly interwoven
-Fear of witchcraft

Stereotype ✅A simplified, generally inflexible conception of the members of a group or
subgroup

Ethnocentrism ✅A tendency to view people unconsciously by using your own group
and your own customs as standards for all judgments

Four Primary Physical examination techniques ✅1. inspection
2. palpation
3. percussion
4. Auscultation

Light palpatation ✅Little to no depression- less than 1 cm; Uses: pulse, skin texture,
temperature, moisture

Moderation palpatation ✅Depression 1-2 cm using dominant hand in circular motion;
uses: Body organs and masses

Deep palpatation ✅Depression 2.5-5cm with Two hand technique placing non-
dominant hand over dominant hand; Uses: deep organs

Bimanual ✅Capture organ between both hands; Uses: breast tissue, spleen, uterus,
ovaries, and masses

Resonance ✅Air filled lung

Hyperresonance ✅excess air (emphysematous lung)

Tympanic ✅Air in gastric region

, Dull ✅Thud-like, solid organ

Flat ✅Extreme dullness, bone

What are the 5 vital signs? ✅1. Temperature
2. Pulse
3. Respirations
4. Blood Pressure
5. Pain

Ways to find temperature ✅oral
tympanic
axillary
rectal
forehead

Normal Body Temperature ranges:
C ✅36.5- 37.7 *C

Normal Body Temperature ranges:
F ✅96.9- 99.9* F

Older Adults range ✅95.0*- 97.5*F

Normal variations in temperature: ✅lowest in morning (4-6 AM)
highest in evening (8 PM-midnight)
exercise, stress, ovulation = highest

Oral temp technique ✅non-mercury glass: hold for 5 minutes
digital: until beeps

Tympanic temperature variation ✅higher than oral - 0.8 C or 1.4 F

Axillary: use on? technique ✅babies
10 minutes (glass non-mercury thermometer)
as needed for digital

Axillary temp variation ✅normally lower than oral - 0.5 C or 1 F

When do you use rectal temperatures ✅comatose patients, uncooperative, infants

Rectal (red) ✅insert 1 inch
non-mercury glass thermometer - 3 minutes

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