Assessment Exam 1 Flashcards


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1

_____________ communication includes appearance, demeanor, facial expression, attitude, silence, listening

Nonverbal

2

_______________is the most important skill to learn and develop fully in order to collect complete and valid data from your client

Listening

3

Listing- SOLER

Square up to person you are listening to

Open posture

Lean in

Eye contact

Relax and respond

4

Avoid ________________________, and avoid being more then 2-3 feet away from patient

Excessive or insufficient eye contact

5

______________ communication includes open ended questions, close ended questions, laundry list, rephrasing, well- placed phrases, inferring, provide information

verbal

6

Providing a list of words to choose from in describing symptoms, conditions, or feelings to help you obtain specific answers is an example of a _____________________.

Laundry list

7

Reviewing the medical records regarding past visits, previous test results, medications, lab results, allergies, previous procedures, etc. before meeting with the client so that you have some background information before going into the room, is part of what phase of the interview process?

Pre-introductory

8

Nursing goals during_______________: establish an agenda for the interview and establish a trusting relationship and rapport with the client

introductory phase

9

___________________ phase includes:

Introduce yourself, Explain purpose of interview, Discuss the type of questions that will be asked, Explain why we are taking notes “I am paying attention, just want to make sure I get everything.”; Assure client that confidential information will remain confidential

      1. Unless patient is at risk to themselves or somebody else
      2. Understanding HIPAA is important to ensure patient confidentiality
    1. Make sure that the patient is comfortable
      1. Sit with them at eye level which shows equality and respect, arms not folded
      2. Need to establish a nurse-client rapport to ensure that you are receiving complete and accurate data

Introductory

10

During the ______________ phase: Nurse draws out the client’s comments about major bio data, reasons for seeking care, history of present health concern (COLDSPA), past health history, family history, review of body systems (ROS) for current problems, lifestyle and health practices, and developmental level; Interpret and validate information received from the client by listening, observing cues, and using critical thinking; Collaborate with client to identify problems and goals

working

11

During the _________________ phase:

Nurse summarizes info obtained during working phase , Validates problems and goals with client, Discuss possible plans to resolve the problem w/ client; ask the client if they have any questions or concerns

Summary

12

When interviewing older clients, must first assess __________________.

hearing acuity

13

What does COLDSPA stand for?

Character

Onset

Location

Duration

Severity

Pattern

Associated factors

14

“What does the pain feel like?” is part of ___________________.

Character

15

"When did the pain start?" is part of ______________.

onset

16

“Where does it hurt the most? Does it radiate or go to any other part of your body?”, is part of a ________________ question.

location

17

“How long does it last?” is part of a ______________ question.

duration

18

“What other symptoms occur with it? How does it affect you?” is a part of ______________________ question.

associated factors

19

If you have dry, flaky skin, you are deficient in:

Vitamin A

Vitamin B

Linoleic Acid

20

If you have Dry skin with poor turgor, you are _________________________

Dehydrated

21

Rough scaly skin with bumps is a sign of?

Vitamin A deficiency

22

Thinning, dry hair is a sign of?

Protein deficiency

23

Sores that won't heal?

Protein, vitamin c, or zinc deficiencies

24

______________ is a voice volume disorder, caused by an issue within the larynx or impairment of cranial nerve X

Dysphonia

25

______________is a defect in the muscles that control speech.

Dysarthria

26

Working Phase:

biographical data

reasons for seeking care

history of present health concern

past health history

family history

review of body systems (ROS) for current health problems

lifestyle and health practices

developmental level.

27

The health history has eight sections:

  • Biographical data
  • Reasons for seeking health care
  • History of present health concern
  • Personal health history
  • Family health history
  • ROS for current health problems
  • Lifestyle and health practices profile
  • Developmental level
28

___________________ is used to view the red reflex and to examine the retina of the eye

Ophthalmoscope

29

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?

Palpation

30

____________ (heard over part air and part solid) Loud, low, hollow sound of a normal lung

Resonance

31

_______________________ (heard over mostly air) Very loud, low, booming sound heard from a Lung with emphysema

Hyperresonance

32

___________ (heard over air) loud, high, drumlike sound heard over stomach

Tympany

33

_______________ (heard over more solid tissue) is a medium pitched, thud like sound hear over Diaphragm, pleural effusion, liver

Dullness

34

________________(heard over very dense tissue) soft, high pitched heard over Muscle, bone, sternum, thigh

Flatness