Ch 3 Knowledge Check Questions

State four guidelines that will help you to obtain complete and accurate data when conducting an interview (this content is in Volume 2).

Answer: (Refer to Clinical Insights in Volume 2, Chapter 3, as needed.) Any of the following are correct: Individualize your approach based on the client's age, developmental level, and cultural background. Begin with neutral topics. Ask more personal or threatening questions after you and the client are more comfortable with each other. Use active listening. Don't get caught up in note taking. Pay attention to nonverbal communication. Use open-ended questions as much as possible to encourage the client to talk. Don't ask too many questions. Avoid asking, "Why?" Avoid jargon and "talking down" to the client. Confirm that the client understands terminology he uses. Refocus the client when the "story" becomes scattered or does not produce useful information. Curb your curiosity. Stick with collection of relevant patient data. Don't give advice or voice approval/disapproval.

List several things you could do to be sure the client is comfortable before the interview (this content is in Volume 2).

Answer: (Refer to Clinical Insights in Volume 2, Chapter 3, as needed.) These are a few examples—there may be many more: Introduce yourself, and call the client by name. Provide privacy. Sit down so the patient won't feel he is being rushed. Check the client's anxiety level. If he is anxious or frightened, you should try to relieve his anxiety before proceeding with the interview. Ask whether he is thirsty or needs to use the bathroom. Provide a bedpan, if necessary. Ask whether he is in pain; administer analgesic if necessary.

How is it different?

Answer: A nursing assessment is holistic and focuses on client responses to disease, pathology, and other stressors. A medical assessment focuses on disease and pathology.

Knowledge Check 3-1 What are the four features common to all definitions of assessment?

Answer: Assessment involves data collection, use of a systematic and ongoing process, categorizing of data, and recording of data

Knowledge Check 3-4 What are the 10 components of a nursing history and why are they important?

Answer: Biographical data. Provide basic information about the client. The person's responses to these questions reflect his mental status and ability to communicate. Chief complaint/reason for seeking healthcare. This is the client's perception or reason for seeking medical or nursing advice. From this, you will be able to target your assessment to gather the most relevant and important data. History of present illness. This provides details about the client's current health problem. Client's perception of health status and expectations for care. This will give you insight into the client's view of his health problem and what he expects to be done for him. Past health history. The past health (medical) history will help guide your assessment and help you to understand some of the data you obtain. Family health history. This includes data on first-degree blood relatives such as mother, father, siblings, and maternal and paternal grandparents. It includes data about diseases that relatives have had, their current state of health, whether they are alive, and cause if death if they are not. Risk factors for various illnesses and disorders (e.g., hypertension, allergies) are often tied to multigenerational problems. Social history. This includes information about family and other relationships, economic status, occupations, exposure to toxic materials, home and neighborhood conditions, and ethnicity. It also includes data about tobacco, alcohol, and drug use as well as exercise habits. Medication (nutritional supplements, herbs) history and medical device use. Current and past medication usage may uncover some medical history the client has forgotten to disclose. Current medications are of utmost importance because (1) they may interact with newly prescribed medications and (2) some may affect certain body symptoms, causing abnormalities in your assessment findings (e.g., skin color, laboratory values). Also inquire about vitamin and nutritional supplements and the use of alternative therapies, as they may interact with the allopathic treatment plan. A thorough health history includes use of medical devices, such as bracing, inhalers, home CPAP. Complementary/alternative modalities. These therapies can support or interfere with conventional therapies. Review of body systems and associated functional abilities. This includes subjective data regarding body systems, as well as functional abilities. This review provides information on the client's concerns and the effect of illness on the client's life.

How is a nursing assessment similar to a medical assessment?

Answer: Both collect data that you use to identify problems and plan care. Both collect data about physical problems and disease symptoms

What are two things you should do to prepare yourself before an interview?

Answer: Numerous answers are possible, including the following: Be sure you know the purpose of the interview and how the data will be used. Read the client's health record. Form some goals and think of some opening questions for the interview. Schedule enough uninterrupted time. Gather the necessary assessment forms and equipment. Take a deep breath and compose yourself before entering the room.

Smell (e.g., fecal odor)

Answer: Numerous answers are possible, including the following: body odor; breath odor; and odor from wound secretions, drains, urine, or vaginal secretions.

Hearing (e.g., bowel sounds)

Answer: Numerous answers are possible, including the following: breath sounds, coughing, heart sounds, blood pressure, spoken words.

Knowledge Check 3-3 Give at least two more examples of data you might obtain with each of the following senses. One example is provided for each. Touch (e.g., bladder distention)

Answer: Numerous answers are possible, including the following: firmness or mobility of lesions (e.g., masses, nodules), firmness of uterine fundus after childbirth, edema, skin temperature, pulse rate and rhythm, crepitus in joints, liver enlargement.

Vision (e.g., facial expression of pain)

Answer: Numerous answers are possible, including the following: general appearance (e.g., height, weight, posture, grooming), skin color, condition of equipment, readings from monitors and pumps, gait.

You check the result of the Pap smear on the computer and see that it is normal.

Answer: Objective data (Observed by someone other than the patient) Secondary data (You did not get the information directly from the patient. Pap smear cytology would be primary data for the pathologist.)

The nurse practitioner tells you that Sami is anemic.

Answer: Objective data (Observed by someone other than the patient; not told to you by the patient. It isn't the verbal reporting of data that makes them "subjective"; it is the verbal reporting by the patient.) Secondary data for you (You did not get the data from Sami.) Actually, anemia is a diagnostic conclusion made by the nurse practitioner, not data. But when you receive the information, it is, for you, data.

Knowledge Check 3-2 During Sami's appointment at the women's clinic, she has a Pap smear, breast exam, and blood work. She also informs the nurse that her menstrual flow is heavy and that she experiences severe abdominal cramping. These data are added to the database as references for future visits. Sami's Pap smear results and breast exam are normal, but she is moderately anemic. When the lab results indicate a low hemoglobin level, the nurse practitioner suspects that Sami's heavy flow may be causing her anemia. According to clinic protocol, she prescribes birth control pills for Sami to control her menstrual symptoms and provide contraception. Ongoing assessment will include visits every 6 months to manage her birth control pills and monitor the anemia. State whether the following data are primary or secondary, subjective or objective: You see in Sami's health record that her breast exam was normal.

Answer: Objective data (Someone other than Sami made the observation; it was not from Sami's perspective.)

Sami tells the nurse practitioner that she experiences cramping with her menstrual cycle. For the nurse practitioner, would this be primary or secondary, subjective or objective data?

Answer: Primary data (The nurse practitioner obtained the information from Sami.) Subjective data (Sami's perspective, told directly to the nurse practitioner by Sami)