Ch. 2 Critical Thinking in Health Assessment

Example of Subjective Data

Mrs. G is a 54 year old hairdresser who reports pressure over her left chest "like an elephant sitting there" which radiates to her left neck and arm

Example of Objective Data

Mrs. G is an older, overweight white female, who is pleasant and cooperative. Height 5'4, weight 150 lb, BMI 26, BP 160/80 right arm, sitting, HR 96 and regular, respiratory rate 24 and regular, temp. 97.5 F

A patient who is 2 days postoperative reports pain and requests pain medication. After assessing the patient's pain level, the nurse decides to give the patient oral Percocet instead of intravenous morphine. This nurse is doing which step of the nursing process? a) implementation b) assessment c) diagnosis d) evaluation

a

A new RN tells her preceptor that she has always had trouble remembering all the steps of the nursing process. The preceptor told the new grad that an easy way is to think about the anagram: a) ADPIE b) OLD CART c) REEDA d) PERRLA

a

A client presents to the ER following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states he cannot feel his leg. The nurse notes that the client is lethargic and mildly confused. What subjective data should the nurse document on this client? a) bleeding profusely from the wound b) presence of lethargy c) mild confusion d) unable to feel his leg

d

One characteristic of a nurse who is a critical thinker is the ability to: a) be right most of the time b) form an opinion quickly c) offer advice to clients d) validate information and judgements

d

The nurse gathers the following data: complaint of a headache and sore throat, redness noted on pharynx with white exudates on the tonsils, minimal cough, temperature 100.6 degree F orally. It was noted that the patient had another sore throat 2 weeks ago; the most appropriate nursing diagnosis for this data would be: a) stress related to illness b) infection related to elevated temperature c) ineffective health maintenance related to repeated sore throat d) impaired comfort related to headache and sore throat pain

d

The nurse is grouping subjective and objective data. Which data would the nurse list as subjective? a) IV site without redness b) 50% of meals eaten c) rales on auscultation d) headaches began 3 days ago

d

Which statement would demonstrate the correct method for writing an evaluation of patient progress after implementing the nursing process? a) patient was unable to complete ambulation goal during the shift b) patient needs to ambulate at least 1 more time during an 8-hour shift c) patient ambulated once every 8 hours d) patient ambulated 3/3 times during a planned 8-hour period

d

A hospital nurse is in the process of analyzing physical assessment data the nurse has collected on a patient. Which characteristics of critical thinking should the nurse employ in the analysis? select all that apply. a) use past clinical experience to build knowledge b) avoid considering the client's cultural background when analyzing data c) hypothesize one diagnosis before diagnosing the client d) use rationale to support opinions and decisions e) reflect on thoughts before reaching a conclusion

d, e

Subjective Data

-what the patient tells you -it is the history from the patient, the chief complaints through review of systems -the symptoms reported

Objective Data

-what you detect during the exam -all the physical examination findings and lab tests -the signs -primary factual and descriptive

OLDCART and Headache

O: when did the headache begin? L: where exactly is the headache? can you point to it> D: does the headache come and go? is it continuous? what time of day is it most severe? C: how does the headache feel? is it throbbing? sharp? stabbing? rate it on a scale of 1-10, with 10 being the worst pain you have felt in your life. A: does anything else happen to you when you get the headaches? blurred vision? vomiting? nausea? seizures? R: what have you tried to make your headache subside? cool compresses? rest in a dark room? did it work? T: has the patient seen a health care provider? tried any remedies: medications, acupuncture to make the headache go away?

Considering the acronym OLDCART, the nurse is asking a newly admitted patient questions during the assessment process. The patient is a 35 year old man who presents with pain in the upper arm since lifting weights 3 days ago. What question would be appropriate to ask that would give information for the "D" in the acronym? a) "does the pain come and go or is it constant?" b) "has anything helped relieve the pain?" c) "can you point to where the pain is located?" d) "is there anything that makes the pain worse?"

a

The nurse observes no urine output in a client's indwelling urinary catheter drainage bag. What is the nurse's first action? a) verify positioning of the catheter b) perform a bladder scan c) collect a urinalysis d) apply suprapubic pressure

a

Nursing Diagnosis

a clinical judgement concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, group, or community

Evaluation

a continuing process to determine if the goals have been attained

Treatments

any interventions the patient has previous tried

Relieving Factors

anything the patient has tried to relieve the sign or symptom

The nurse recognizes the following to be a necessary component of performing an accurate assessment. Select all that apply a) incomplete data b) documentation of data c) validation of data d) collection and organization of data e) inaccurate data

b, c, d

Diagnosis

based on a real or potential health problems or human responses to health problems; nurse uses clinical reasoning to formulate diagnoses based on the assessment data and the patient's problem list; it sets the stage for the remainder of the care plan

A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data? a) worried about appearance b) itching sensation all over body c) anxious appearance d) reports of hair loss

c

After collecting subjective and objective data for the admission database, what is the nurse's next action? a) set nurse-driven goals for the client b) evaluate effectiveness of nursing actions c) validate the client's identified problems d) discuss the action plan with the client

c

The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to: a) set goals for the patient b) get physician orders to implement the plan c) discuss the plan with the patient d) document the plan on the cardex for all to utilize

c

The nurse is developing goals after completing the assessment of a newly admitted medical patient. The nurse would document the goals under which part of the nursing process? a) diagnosis b) evaluation c) planning d) implementation

c

The nurse recognize that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step? a) the nurse must be an expert in her field in order to interpret data accurately b) final opinions or judgements must be made rapidly c) diagnostic reasoning skills are required to interpret data accurately d) opinions and comments are not relevant in making accurate interpretations of data

c

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is which of the following? a) nursing intervention b) data organization c) nursing diagnosis d) nursing rationale

c

Planning

devising the best course of action to address the patient's diagnoses; during this stage the nurse and patient select goals for each diagnosis in order to alleviate, decrease, or prevent the problems addressed in the nursing diagnosis

Duration

how long the sign or symptom has been going on

Implementation

interventions that can be completed by the patient, family, or members of the health care team; the interventions should clearly relate to the nursing diagnosis and planned goals

Nursing Process

the broad systematic framework that provides a methodical base for the practice of nursing; it is a problem solving approach to address human responses and needs of each patient, family, and community

What is the goal of health assessment?

the development of an individualized plan of care for each patient

Assessment

the subjective and objective data gathered during the initial health history and physical exam and collected on each patient encounter

T or F: Subjective and objective data are both important parts of an assessment. Subjective data are things the patient or his or her family tells the nurse

true

T or F: When clustering data, age can be a factor in determining the number of nursing diagnoses. The younger child typically has one diagnosis because he or she is more likely to have a single disease

true

Associated Manifestations

what else is going on when the patient experiences the sign(s) or symptom(s)

Characteristic Symptoms

what the symptom feels like, how it is described, and the severity

Onset

when the sign or symptom began

Location

where the sign or symptoms is located; does it radiate?