HOLISTIC HEALTH II - MIDTERM REVIEW 100% VERIFIED ANSWERS 2024/2025 CORRECT, Exams of Nursing

Download HOLISTIC HEALTH II - MIDTERM REVIEW 100% VERIFIED ANSWERS 2024/2025 CORRECT and more Exams Nursing in PDF only on Docsity! HOLISTIC HEALTH II - MIDTERM REVIEW 100% VERIFIED ANSWERS 2024/2025 CORRECT The Nursing Process Involves (ADPIE)... Assessment Diagnosis Planning Implementation Evaluation What are the 3 Steps in Tanner's Clinical Judgement Model? Notice Interpret Respond (Reflect) Inspection for the MSK Assessment Includes (SEADS)... Symmetry Erythema Atrophy Deformity Swelling What are the Components of Neurovascular Assessment? Color and temperature Pulse strength Capillary refill Sensory (sensation, paresthesia, decreased sensation, loss of sensation) Motor function (loss of strength or movement) Pain What does RICE stand for? Rest Ice Compression Elevation What Should the Nurse Assess for during a Tracheostomy Assessment? Soiled or loose ties or dressing Nonstable tube Excessive secretions, skin assessment Assess for signs and symptoms of upper and lower airway obstruction Assess signs and symptoms associated with hypoxia and hypercapnia Objective: O2, resp. rate & effort, lung sounds What is nutritional status and what might be some factors affecting one's nutritional status? - balance between intake and requirements - affected by genetic predisposition, determinants of health What range is considered to be a healthy BMI with the least risk for developing health problems? 18.5-24.9 What are the waist circumference values associated with increased health risks? Men: greater than 102 cm (40 inch.) Women: greater than 88 cm (35 inch.) What is the recommended weight gain for healthy pregnant women? 25-35lbs Which supplement is recommended in pregnancy to reduce neural tube defects? Any complications during pregnancy/delivery? What are the changes that occur with menopause? uterus shrinks ovaries atrophy ovulation may occur sporadically sacral ligaments relax/pelvic musculature weakens uterus droops- may protrude or prolapse- into vagina cervix shrinks-paler Vagina-shorter, narrower, less elastic vaginal epithelium - thinner, drier, and itchy, decreased lubrication What are some symptoms of menopause? hair loss hot flashes breast pain loss of libido joint pain/osteoarthritis frequent urination and urinary pain brittle nails fatigue / dizziness / irritability / headaches What are some MODIFIABLE risk factors for breast cancer? increased estrogen alcohol intake obesity high socioeconomic status (later children/fewer) What are the NON-MODIFIABLE risk factors for breast cancer? - sex (female) - age: 50-69 - personal history - family history - dense breast - early menarche / late menopause What are some health recommendations for breast cancer screening? 50-74 years - every 2 years with mammogram 30-69 years for high risk - annual mammogram & MRI Which of the following subjects is most appropriate for the start of the health history? A) Menstrual history B) Self-care behaviours C) Sexual activity D) Obstetrical history A) Menstrual history What would be the most appropriate way to start asking about sexual activity? A) Asking open-ended questions B) Asking straightforward questions to elicit basic fact C) Asking whether the patient feels comfortable talking about sex D) Asking the patient whether she is currently in a sexual relationship A) Asking open-ended questions The parent of a 10-year-old female asks the nurse if her daughter can receive the HPV vaccine. The nurse's best response is: A) "Your daughter can start the HPV series after her first menstrual cycle." B) "Your daughter can start the HPV series now." C) "Your daughter will need to wait until she is sexually active to start the HPV series." D) "The HPV vaccine is not appropriate for females." B) "Your daughter can start the HPV series now." A 65-year-old postmenopausal women states that she thinks she might be menstruating again. Which of the following would be the correct response from the nurse? A) "Don't be silly! You went through menopause years ago." B) "How long have you noticed the bleeding? I would like to explore this further." C) "Many women experience this type of bleeding." D) "I think we have to get some specimens from you for lab work." B) "How long have you noticed the bleeding? I would like to explore this further." Which of the following would NOT be a consideration when examining a woman's breasts? A) In the Western culture, a woman's breasts are crucial to her self-concept. B) Typically, a woman with a breast lump assumes the worst outcome. C) Asking questions about a woman's breasts can trigger deep emotional responses. D) Most women respond to questions and the examination in much the same way. D) Most women respond to questions and the examination in much the same way. The nurse is teaching a woman how to perform BSE. Which statement by the patient would indicate a need for further teaching? A) "The best time to check my breasts is a week before my cycle." B) "I will check my breasts in the shower 1 week after my cycle." C) "I will examine my breast in a clocklike sequence so that I don't miss any surface area." D) "I will be sure to check my armpits." A) "The best time to check my breasts is a week before my cycle." A pregnant woman who has inverted nipples asks the nurse if she can still breastfeed. What is the nurse's best response? A) "You should not have any problems breast feeding because your nipples do not affect milk production." B) "There are a number of supports available that can help you breastfeed your child. We can ensure we have these in place to help you with breastfeeding." C) "I have seen many women struggle with breastfeeding when they have inverted nipples. I would avoid it." D) "The baby won't likely be able to latch on to your nipples because they're inverted." Risk factors: HPV, multiple sexual partners, smoking Prevention: regular use of condoms or a diaphragm, vaccination against HPV, screening with PAP What is phimosis? inability to retract foreskin What is paraphimosis? foreskin is retracted but can't move back up What are some important considerations/questions for the subjective male health assessment? Patient history: cryptorchidism/fistulas, injuries (trauma), kidney disease/stones, UTIs, cancer, diabetes, HPN, neurological impairment, respiratory or cardiovascular conditions (increased risk for erectile dysfunction) Family history: cancer, infertility, hernia, IBD DADSPIES: Male Health Diet- high fat/low fiber (prostate cancer), red/processed meat/ low fiber (colon cancer) water Alcohol Drugs Smoking Physical exam - Fit screening, testicular exam, prostate Immunizations- Gardasil (HPV) Exercise- inactive/obese (colon/prostate cancer) Stress/sex - safe sex (condoms) Testicular Self-Examination (TSE): Steps - after a warm shower or bath - examine each testicle one at a time - cancerous lumps usually on side but can be on front This virus presents with clusters of small vesicles, surrounding erythema and erupts on the glans or foreskin. It is often painful and the virus remains dormant indefinitely... Herpes (HSV-2) This infection presents with soft, pointed, moist, fleshy, painless papules- single or multiple- cauliflowerlike patch- that occur on the shaft of the penis, behind the corona, or around the anus. It is correlated with early onset of sexual activity, infrequent use of contraception, multiple sexual partners... Genital Warts (HPV) Carcinoma - red, raised warty growth or as an ulcer, with watery discharge - as it grows, it may necrose and slough - usually painless - on glans, inner lip of the foreskin and after chronic inflammation - enlarged lymph nodes What is testicular torsion? - sudden twisting of the spermatic cord - blood supply is cut off leading to ischemia and engorgement - pain is excruciating in testicle - red, swollen scrotum - surgical intervention immediately required What is epididymitis? - acute infection of epididymis - pain is gradual - red, swollen scrotum - elevation of affected testicle usually lessons pain - antibiotic therapy indicated The nurse is reviewing the importance of testicular self-examination (TSE) with a 17-year-old male patient. Which of the following statements by the patient confirms his understanding of TSE? A. "I will check my testicles for lumps when I'm in the shower." B. "I will bear down, and check my groin area while seated." C. "I will check my testicles while lying on my right side." D. "I will have my testicles examined by my health care provider every year." A. "I will check my testicles for lumps when I'm in the shower." Soft, pointed, fleshy papules that occur on the genitalia caused by the human papillomavirus (HPV) are known as: A. chancres. B. genital warts. C. urethritis. D. varicoceles. B. genital warts. _____________ is an emergency requiring surgery. A. A scrotal hernia B. Epididymitis C. Testicular torsion D. Cryptorchidism C. Testicular torsion What's the difference between a direct and an indirect inguinal hernia? indirect: most common, pain with straining, congenital or acquired, more common in infants and young men direct: less common, usually painlesss, acquired weakness This type of hernia may be extremely painful and is more common in women... femoral hernia Assessing for benign prostatic hypertrophy (BPH)... Subjective: Urinary frequency, urgency, hesitancy, straining to urinate, weak stream, intermittent stream, sensation of incomplete emptying, nocturia. - usually not palpable - may be palpable in pregnant women - ask client to swallow Hypo or Hyperthyroidism: dry hair, puffy face, slow heartbeat? Hypothyroidism Hypo or Hyperthyroidism: weight gain, constipation, brittle nails? Hypothyroidism Hypo or Hyperthyroidism: hair loss, weight loss, scant menstrual periods? Hyperthyroidism What are the 4 accessible lymph node examination sites? neck, arms, axillae, inguinal region What subjective questions would you ask to a patient with an eye complaint? - Do you wear glasses/contacts - How often do you change contacts - How long do you wear them - How do you clean your eyes/lashes - How do you remove eye make up - Do you wear eye protection- at work/sunlight/sports/yard work/hobbies Eye Assessment: OPQRSTUA A: associated symptoms: blind spots, floaters, halos, Night vision affected? flashing lights, discharge, redness, or inflammation, excess tearing, dryness, itching, sensitivity to light If there was trauma/injury to the eye ask: - How did it happen? High velocity injury? Blunt force trauma? If there was Vision change ask: - When did it start? Gradual or sudden onset? Double vision/central/peripheral What is retinitis pigmentosa? - genetic abnormalities of rods and cones or RPE of the retina - leads to progressive sight loss - defective light to dark/dark to light adaptation or night blindness is possible What is macular degeneration? - common eye disorder among older adults - blurred or reduced central vision d/t thinning of macula What is the Hirschberg corneal reflex test? - done to determine if strabismus (squint) is present - doctor shines penlight on eye from about 50cm away and observes position of light that reflects off cornea Horner's syndrome, ptosis & anhidrosis Horner's syndrome- miosis Ptosis- drooping of upper eyelid Anhidrosis- absence of sweating of the face What is hyphema? blood in the anterior chamber of the eye What is cataract? A condition in which the lens of the eye becomes opaque or cloudy and making vision difficult. What is exophthalmos? bulging eyes What is blepharitis? inflammation of the eyelid; scaly, greasy flakes, and crusted eyelid margins What is a hordeolum? stye What is the difference between acute (narrow-angle) and open-angle glaucoma? Narrow-angle: sudden increase in intraocular pressure, aqueous fluid blockage, sudden vision changes, severe eye pain, nausea/vomiting, tearing, emergent Open-angle: gradual vision loss, patchy blind spots, gradual damage to optic nerve Subjective Assessment: Ears history of ear infections, discharge, hearing loss, tinnitus, vertigo, cancer of ear, trauma, sinusitis, smoking, physical exam Objective Assessment: Tympanic Membrane - pull pinna up and back before inserting speculum - membrane translucent, pearly grey - cone of light is visible What is otitis media? - middle ear infection - absence of light reflection What is the difference between conductive and sensorineural hearing loss? conductive- sound wave transmission through external or middle ear is obstructed, can be caused by blockage of external auditory canal sensorineural (perceptive)- results from problems beyond the middle ear, cochlear nerve damage, damage to CN VIII What does the whisper test evaluate? loss of high frequency sounds Developmental Ear Considerations: Older Adults The umbilicus is at the level of... T10 The groin is in the region of... L1 The knee is at the level of... L4 Neurological Developmental Considerations: Older Adults - general atrophy with a steady loss of neurons in the brain and spinal cord - loss of muscle bulk and tone in the face, in the neck, and around the spine - loss of vibratory sense at the ankle - decreased muscle strength - decreased or absent Achilles reflex - impaired fine coordination and agility - loss of position sense at the big toe - irregular pupil shape - decreased pupillary reflexes Ischemic vs Hemorrhagic Stroke Ischemic: blockage of blood flow Hemorrhagic: rupture of blood vessel What does the stroke acronym FAST stand for? Face drooping, arm weakness, speech difficulty, time to phone 9-1-1 What are some risk factors for stroke? - History of cardiovascular disease - Hypertension - Cigarette smoking or exposure to second- hand smoke - Diabetes - Diet and nutrition - Physical inactivity - Obesity and fat distribution - History of TIA - Other cardiac conditions - Dyslipidemia - Asymptomatic carotid stenosis - Postmenopausal hormone therapy Strokes are more common in _______________, but have a have a higher mortality rate in ______________ men; women Complete Neurological Exam performed on an individual who has neurological concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of neurological dysfunction Screening Neurological Exam performed on seemingly well individuals with no significant subjective findings from the health history Neurological Recheck appropriate for those who are demonstrating neurological deficits Glasgow Coma Scale - used to define a person's LOC - normal total: 15 points What are the components of a neurological physical examination? 1) Vital signs 2) General survey 3) Gross assessment of strength (grade arms and legs, compare bilaterally) 4) Cranial Nerves 5) Cerebellar Function 6) Sensory function 7) Motor function Test Cranial Nerves: Cranial Nerve I: Olfactory Nerve (sensory) - test the sense of smell in patients who report loss of smell - head trauma, abnormal mental status, presence of an intracranial lesion is suspected - with the patient's eyes closed, occlude one nostril and present an aromatic substance Test Cranial Nerves: Cranial Nerve II: Optic Nerve (sensory) - test visual acuity - test visual fields by confrontation Test Cranial Nerves: Cranial Nerves III, IV, and VI: Oculomotor, Trochlear, and Abducens Nerves - PERRLA - increasing intracranial pressure causes sudden, unilateral dilation and nonreactivity of a pupil - assess extraocular movements with Diagnostic Positions Test Test Cranial Nerves: Cranial Nerve V: Trigeminal Nerve motor- assess the muscles of mastication by palpating the temporal and masseter muscles as the patient clenches the teeth sensory- test light touch sensation on designated areas of the patient's face: forehead, cheeks, and chin. This tests all three divisions of the nerve: (a) ophthalmic, (b) maxillary, and (c) mandibular 2) Corneal Reflex Test Cranial Nerves: Cranial Nerve VII: Facial Nerve motor: note mobility and facial symmetry as the patient: smile, lift eyebrows, show teeth, and puff cheeks. Then, press the patient's puffed cheeks in, and note whether the air escapes equally from both sides sensory: ask patient to identify a taste Test Cranial Nerve: Cranial Nerve VIII: Acoustic (Vestibulocochlear) Nerve (Sensory)