Health Assessment Exam 1 Study Guide

Health assessment is divided into four steps:

- collecting subjective data - collecting objective data - validation of data - documentation of data

What are some things that need to be validated ?

- discrepancies or gaps between subjective & objective data ex: client says that he's happy, despite learning that he has terminal cancer - discrepancies or gaps between what the patient says @ one time vs another time - findings that are highly abnormal or inconsistent with other findings

What are the 4 types of nursing assessment?

- initial comprehensive - ongoing or partial - focused or problem oriented - emergency

What are the 3 steps in validating data

1. Deciding whether the data requires validation 2. Determine ways to validate the data 3. Identify areas for which data are missing

It is the nurse's job to identify areas in which data are missing... provide an example

98 lbs adult patient ... nurse needs to know if the patient has always been that size, or is he depressed, or being abused etc.

Sensations or symptoms that can be verified only by the client (e.g., pain) A. Subjective data B. Objective data

A. Subjective data

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to A. arrive at conclusions about the client's health B. document any physical symptoms the client may have C. contribute to the medical diagnoses D. validate the data collected

A. arrive at conclusions about the client's health

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is A. continuous B. completed on admission C. linear D. performed only by nurses

A. continuous

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's _______________. A. physiologic status B. holistic wellness status C. developmental history D. level of functioning

A. physiologic status

In an emergency, such as cardiac arrest, what is being evaluated?

Airway Breathing Circulation The ABCs of nursing **the evaluation of the client's airway, breathing, & circulation when cardiac arrest is suspected.**

What parts of the nursing process overlaps?

Assessment & evaluation **assessment & evaluation are ongoing processes. . when the outcomes are not as anticipated, the nurse needs to revisit (reassess) all steps, collect new data, & formulate

Not validating data interferes with which part of the nursing process? A. Assessment B. Diagnosis C. Planning D. Assessment E. Evaluation

B. Diagnosis **failure to validate data causes the nurse's judgments to be made on unreliable data

Assessing whether outcome criteria have been met and revising the plan of care if necessary A. Nursing assessment B. Evaluation C. Nursing diagnostic phase D. Implementation

B. Evaluation

Analysis of subjective & objective data to make a professional nursing judgment A. Implementation B. Nursing diagnostic phase C. Evaluation

B. Nursing diagnostic phase

Developing a plan of nursing care and outcome criteria A. Nursing assessment B. Planning C. Nursing diagnostic phase D. Collaborative problem

B. Planning

Problem that requires the attention or assistance of other health care professionals A. Collaborative problem B. Referral problem

B. Referral problem

An assessment of a client who already has a complete recorded database in the system and return to the health care agency with a specific health concern is referred to as a(n) A. ongoing or partial assessment B. focused or problem-oriented assessment C. emergency assessment D. initial comprehensive assessment

B. focused or problem-oriented assessment

Carrying out the plan of care A. Planning B. Nursing assessment C. Implementation

C. Implementation

Collection of subjective & objective data A. Planning B. Evaluation C. Nursing assessment D. Nursing diagnosis

C. Nursing assessment

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should A. analyze the data that has already been collected B. review any past collaborative problems C. avoid premature judgments about the client D. consult with the client's family members

C. avoid premature judgments about the client

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first A. discuss the client's symptoms with other team members. B. plan for potential laboratory procedures. C. review the client's health care record. D. determine potential health care resources.

C. review the client's health care record

Physiologic complications that nurses monitor to detect their onset or changes in status

Collaborative problem

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed A. entry B. exploratory C. focused D. comprehensive

D. comprehensive

The result of a nursing assessment is the... A. prescription of treatment B. documentation of the need for a referral C. client's physiologic status D. formulation of nursing diagnosis

D. formulation of nursing diagnosis

HITECH Act

Health Information Technology for Economic and Clinical Health Act .... promotes the adoption and meaningful use of health information technology (HIT)

Clinical judgement about individual, family, or community responses to actual or potential health problems and life processes

Nursing diagnosis (collaborative problem or referral)

What are the two key things that need to be included in every documentation?

Nursing history (subjective) Physical assessment (objective)

Findings directly observed or indirectly observed through measurements (e.g., body temperature)

Objective data

What is the purpose of validating data?

To confirm that the subjective & objective data is accurate & reliable.

The nurse should document only what the client tells, and what the nurse observes, not what the nurse interpret or infer from the data. (T/F)

True

The purpose of a nursing health assessment is to collect holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment. (T/F)

True

The depth and scope of nursing assessment has expanded significantly over the past several decades primarily because of a. the growing elderly population with chronic illness. b. rapid advances in biomedical knowledge and technology. c. an increase in the number of baccalaureate programs in nursing. d. an increases in the number of nurse practitioners.

b. rapid advances in biomedical knowledge and technology.

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next, a. cluster the data collected. b. draw inferences and identify problems. c. document conclusions. d. check for the presence of defining characteristics.

d. check for the presence of defining characteristics.

__________ are designed to ensure that the nurse gathers pertinent information needed to meet standards and guidelines of other institutions, and to develop a plan of care for the client. It involves both comprehensive, health, & medical records.

electronic health records "EHR"

A(n) ___________ assessment is a very rapid assessment performed in life-threatening situations. In such situations, an immediate assessment is needed to provide prompt treatment.

emergency

A(n) _______________ assessment does not replace the comprehensive health assessment, it is performed when a comprehensive database exist for a client who comes to the health care agency with a specific health concern.

focused or problem oriented NOTE: should only focus on he problem & not any other systems.

A(n) _____________ assessment involves collection of subjective data about the client's perception of his or her health of all body parts & systems, past health history, family health history, and lifestyle and health practices as well as objective data gathered during a step-by-step physical examination.

initial comprehensive

A physical examination, which include inspection, palpation, percussion, auscultation & etc. are examples of _________ data.

objective

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is...

ongoing & continuous

A(n) ________________ assessment of the client consists of data collection that occurs after the comprehensive database is established... basically a mini-overview

ongoing or partial ex: a partial assessment of a pt with lung cancer admitted to the hospital requires frequent assessment of resp. rate, oxygen saturation, lung sounds etc.

holistic data

physiological, psychological, sociocultural, developmental, spiritual

Biographical data, present health concerns/symptoms, personal health history, family history, and lifestyle & health practices are examples of _________ data.

subjective

Most data start with __________ data and end with _________ data.

subjective objective

The major & only concern during an emergency assessment is.....

to determine the status of the client's life-sustaining physical functions

It is important to document using descriptive words rather than non-descriptive words. (T/F)

true