Health Assessment in Nursing Chapter 1 Review

Nursing diagnosis

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

Nursing Assessment

Collection of subjective and objective data

The nurse is seeing a new patient for the first time what type of health assessment is the nurse going to complete? a. Comprehensive Assessment b. Ongoing or Partial Assessment c. Focused or Problem-oriented Assessment d. Emergency Assessment

Comprehensive Assessment

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?

Determine any changes from the baseline data

Collaborative problem

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

Is the following statement true or false? Subjective data are sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.

True. Subjective data are sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.

Evaluation

Assessing whether outcome criteria have been met and revising the plan of care if necessary

A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment?

Body systems

What occurs during the assessment phase of the nursing process? A. Collect subjective and objective data B. Determine outcome criteria and develop a plan of care C. Carry out the plan D. Assess whether outcome criteria have been met and revise the plan as necessary

Collect subjective and objective data Assessment is collection of subjective and objective data. Planning is determining outcome criteria and developing a plan. Implementation is carrying out the plan. Evaluation is assessing whether outcome criteria have been met and revising the plan as necessary.

What are the basic types of health assessments? a. Ongoing, Partial, Focused/Problem-Oriented, and Emergency b. Initial, Comprehensive, Ongoing, Focused/Problem-Oriented, and Emergency c. Initial, Comprehensive, Focused/Problem-Oriented, and Emergency d. Comprehensive, Ongoing/Partial, Focused/Problem-Oriented, and Emergency

Comprehensive, Ongoing/Partial, Focused/Problem-Oriented, and Emergency

A 16 year old male arrives to the hospital status post motor vehicle crash with a major head laceration, multiple contusions and abrasions, and a compound fracture of the left femur. His blood pressure is 100/65 and his heart rate is pounding. What type of assessment will this patient receive? a. Initial Comprehensive Assessment because he is a new patient to the emergency room. b. Ongoing or Partial Assessment because he has been seen at the hospital for a past football injury. c. Focused or Problem-oriented Assessment because he has major head laceration and compound fracture. d. Emergency Assessment because he arrived with multiple trauma injuries.

Emergency Assessment because he arrived with multiple trauma injuries.

A 75 year old women is admitted to the hospital with lung cancer that requires frequent assessment of lung sounds, the nurse is focusing on the color and temperature of the extremities to determine level of oxygenation. What type of nursing assessment is being completed? a. Comprehensive Assessment b. Ongoing or Partial Assessment c. Focused or Problem-oriented Assessment d. Emergency Assessment

Ongoing or Partial Assessment

Referral problem

Problem that requires the attention or assistance of other health care professionals

Is the following statement true or false? Physical medical assessment collects holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment.

False Holistic nursing assessment collects holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment. Physical medical assessment focuses primarily on the client's physiologic development status.

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 diagnosis. d. validate the data collected.

arrive at conclusions about the client's health.

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 data that have already been collected. b. review any past collaborative problems. c. avoid premature judgments about the client. d. consult with the client's family members.

avoid premature judgments about the client.

Nursing diagnostic phase

Analysis of subjective and objective data to make a professional nursing judgment

Implementation

Carrying out the plan of care

Planning

Developing a plan of nursing care and outcome criteria

Is the following statement true or false? A partial assessment is done when the client first enters a health care facility.

False. A partial or ongoing assessment of the client consists of data collection that occurs after the comprehensive database is established. This takes place after the client is admitted to the health care facility.

Objective data

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

Your patient John P. tells you that he has bad back pain and you complete your COLDSPA assessment character, onset, location, duration, severity, pattern, and associated factors. What type of nursing assessment is being completed? a. Comprehensive Assessment b. Ongoing or Partial Assessment c. Focused or Problem-oriented Assessment d. Emergency Assessment

Focused or Problem-oriented Assessment

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

Head-to-toe

A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?

Making incorrect nursing judgments or diagnoses

What type of data: Auscultation

Objective Data

What type of data: BP 180/100, apical pulse 80 and irregular

Objective Data

What type of data: Data that is collected by observation and physical examination

Objective Data

What type of data: Inspection of client

Objective Data

What type of data: Respiration 16 per min

Objective Data

What type of data: X-ray film reveals fractured pelvis

Objective Data

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?

Ongoing or partial

Before actually meeting the client and beginning the nursing health assessment, there are several things you should do to prepare. Select all that apply ___ Review Clients Medical Record ___ Call the clients spouse at work ___ Know Clients Age, Sex, Religion, Education Level, and Occupation ___ Review past chronic diseases

Review Clients Medical Record; Know Clients Age, Sex, Religion, Education Level, and Occupation; Review past chronic diseases

Subjective data

Sensations or symptoms that can be verified only by the client (e.g. pain)

What type of data: "I have a headache."

Subjective Data

What type of data: "It frightens me."

Subjective Data

What type of data: 'I am not hungry."

Subjective Data

What type of data: Data elicited and verified by the client

Subjective Data

What type of data: Information collected from client interview

Subjective Data

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.

check for the presence of defining characteristics.

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.

comprehensive.

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.

continuous.

An assessment of a client who already has a complete recorded database in the system and returns 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.

focused or problem-oriented assessment.

The result of a nursing assessment is a. prescription of treatment. b. documentation of the need for a referral. c. client's physiologic status. d. formulation of nursing diagnoses.

formulation of nursing diagnoses.

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.

physiologic status.

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.

rapid advances in biomedical knowledge and technology.

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.

review the client's health care record.