Foundations Exam 150 cards

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What is critical thinking?

An active, organized, cognitive process used to carefully examine one's thinking and the thinking of others.


What is the order of the nursing process?

1.Assessment 2.Diagnosis 3.Planning 4.Implementation 5.Evaluation


What is subjective data?

What patient states about himself or herself


What is objective data?

Observed when inspecting, percussing, palpating and auscaltating patient during physical examination


What are the components of a health history?

PQRSTU Provocative or palliative Quality or quantity Region or radiation Severity scale Timing Understand patient perception


What are the main components of a mental status examination (Objective data)?

ABCT Appearance (Posture and body movements, dress and hygiene)Behavior (Level of consciousness, facial expression, speech, mood and affect) Cognition (Orientation, attention span, recent memory, new learning judgment)Thought Processes(content)


What are the abnormal findings of levels of consciousness of a mental status examination?

Alert, lethargic, obtunded, stupor, coma and acute confusional state-delirium, blunt effect, depress, anxiety, fear to a normal extent, irritation,


What is mental status?

Emotional and cognitive functioning-such as optimal function toward simultaneous life satisfaction at work, relationships and self. Strikes a balance between good and bad days in order to function socially and occupationally.


What is the subjective data in substance abuse?

If the patient is usually intoxicated or going through subastance withdrawal the history data is difficult and unreliable. However, when sober a patient is willing to provide reliable data when a private setting is provided and confidential.


What is the safe amount allowed for a pregnant woman to consume alcohol?

No amount of alcohol has been determined safe for pregnant women.


What is the objective data in substance abuse?

Clinical lab findings give objective evidence of problem drinking.


What are the overall impressions of general survey, on first encounter?

Physical Appearance(Age, sex, skin,face and signs of distress) Body Structure(Stature, nutrition status, posture, symmetry) Mobility(body movements, ROM) Behavior(Expression, mood and affect, speech and hygiene)


What is systolic pressure?

The peak of MAXIMUM pressure when ejection occurs. First sound you hear.


What is diastolic pressure?

After the ventricles relax the blood remaning in the arteries exerts a MINIMUM pressure. Last sound you hear.


What are the vital signs? (5)

Temperature Pulse Respiratory BP Pain


Pain assessment (7)

COLDSPA Character: description of pain Onset: when did pain start? Location: where is the pain? Duration: how long does pain last? Severuty: how much does it hurt (Scale 1-10) Pattern: when does it come and go Associated Factors: what makes it


What are indicators of malnutrition?

Lower socioeconomic status lifestyle Poor choices in food Chronic dieting or fat diets Disease Geographic location Limited Mobility


What are the anthopometric measurements used for?

Weight and waist circumference


What is the subjective data expected in pain assessment?

Pain is always subjective and is the most reliable indicator of pain! Initial of pain assessment: COLDSPA


What is the objective data expected in pain assessment?

Physical examination process can help understand hte nature of the pain.


Assessment of pain in infants. What to look for.

Bc infants are preverbal and incapable of self report, pain assess. is based on beahvior and physiological cues.


Assessment of pain in children. what to look for.

Children 2 years of age can report pain and point to its location. They cannot rate the intensity of pain at this level. Its helpful to ask the parent/caregiver what words they use for pain.


Name one type of pain. (1 out of 2)

Acute-short term pain and self-limiting, often followed by a predictable trajectory and dissipate after injury heals.(Surgery, trauma, kidney stones)


Name one type of pain. (2 out of 2)

Chronic- (persistent)long term pain can be divided into malignent (cancer related) and nonmalignent. It can last 5,15,20 years or more.


What is the purpose of ispection?

Its concentrated in watching. It is close, careful scrutiny, first of individual as a whole and then each bosy system. Inspection comes first!


What is the purpose of palpatation?

Applies your sense of touch to assess: texture, temp, moisture, organ location and size, swelling, vibration, tenderness and pain.


What is the purpose of percussion?

Tapping the person's skin withshort, sharp stokes to assessunderlying structures.


What is the purpose of auscultation?

Listening to the sounds produced by the body such as heart, blood vessels, lungs and abdomen.


Define laceration.

The act of tearing or splitting. a wound produced by the tearing and/or splitting of body tissue, usually from blunt impact on bony surface.


Define abrasion.

A wound caused by rubbing the skin or mucous membrane.


Define hematoma.

A localized collection of extravasated blood, usually clotted in organ, space or tissue.


Define contusion.

A bruise.Injury to tissues withut the breaking ofskin.producing pain, swelling and tenderness.


Documentation of injury.

When documenting injury, IPV, child or elderly abuse, it must a include a detailed, nonbiased notes, use of injury maps, photographic documentation in health record, other aspects of abuse history.


When to report abuse.

Report abuse only when suspicion is suspected.


Screening for Intimate Partner Violence (IPV).

Routine, universal screening for IPV means asking every woman at every health care encounter if she has been abused by husband, boyfriend, intimate or ex-partner


What to question when suspect abuse.

"I am concerned about your health conditions, is there a chance that stress at home is contributing to these problems"


What are the functions of the skin?

Protection, prevents penetration, perception, temp regualtion, identification, communication, wound repair, absorption and excretion and production of Vitamin D.


What are the normal changes in infants and children?

Thickness, permeability, temp regulation and hair


What are the normal changes in aging adults?

Thickness, glands, coloration and hair.


What are the characteristics of a physical exam on skin?

ABCDE Assymmetry-irregular not equal Borders-normal or irregular border lines Color Variation Diameter- less that 6mm Elevation or enlargement


What are the risk factors for skin cancer?

Sun exposure, tanning, radiation therapy, family history, atypical moles, pigmentation irregularities, fair skin, age, male gender, chemical exposure,and smoking.


What are the risk reduction for skin cancer?

Sunscreen, long-sleeves and caps, avoid sunburns, frequent examination of the skin and Vitamin B3 diet.


Name the widespread of color change in skin.

Pallor- white Erythema- redness Cyanosis- blue Jaundice-yellow


Describe Stage I in pressure ulcers.

Intact skin appears red but unbroken. Localized redness in lighlty pigmented skin will blanch (turns light with fingertip pressure). Dark skin appears darker but not blanch.


Describe Stage II in pressure ulcers.

Partial thickness skin erosion with loss of epidermis or also the dermis. Suoerficial ulcer look shallow like anabrasionor open blister with a red pink wounded bed.