Introduction

Question 1

Nurses relied on their natural senses; the client’s face and body would be observed for “changes in color, tem- perature, muscle strength, use of limbs, body output, and degrees of nutrition, and hydration” (Nightingale, 1992).

Answer 1

LATE 1800s–EARLY 1900s

Question 2

The American Journal of Public Health documents routine client and home inspection by public health nurses in the 1930s.

Answer 2

1930–1949

Question 3

Nurses were hired to conduct pre-employment health stories and physical examinations for major companies, such as New York Telephone, from 1953 through 1960

Grad nurse (3 years)
BSN (5 years)

Answer 3

1950–1969

Question 4

The early ____ prompted nurses to develop an active role in the provision of primary health services and expanded the professional nurse role in conducting health histories and physical and psychological assessments (Holzemer, Barkauskas, & Ohlson, 1980; Lysaught, 1970).

Answer 4

1970–1989

Question 5

Standard 2

Answer 5

“The registered nurse analyzes the assessment data to determine the diagnoses or issues.”

Question 6

DOCTORS ORDERS

Answer 6

Subjective data, objective data, assess, plan (SOAP)

Question 7

NANDA

Answer 7

North American Nursing Diagnosis Assessment

Question 8

4 types of health assessment

Answer 8

IOFE
1. Initial comprehensive assessment
2. Ongoing or partial assessment
3. Focused or problem-oriented assessment
4. Emergency assessment

Question 9

Collection of subjective data about patient’s perception o his or health of all body parts or systems

Answer 9

Initial Comprehensive Assessment

Question 10

Collection of objective data gathered during step-by-step physical examination

Answer 10

Initial comprehensive assessment

Question 11

Data collection that appears after the
comprehensive database is established

Mini-overview of the patient’s condition as a follow-up on health status

Answer 11

Ongoing / partial assessment

Question 12

To provide prompt treatment
Evaluation of patient’s ABC / CAB
o Airway
o Breathing
o Circulation

Answer 12

Emergency Assessment

Question 13

These are the sensations, symptoms,
perceptions, desires, preferences, beliefs,
feelings, ideas, and values of the patient

• Anything that can be elicited and verified
only by the patient

• Biographical information
• History of present health concern
• Past health history
• Family history
• Health and lifestyle practices

Answer 13

Collection of subjective data

Question 14

4 Steps of health assessment

Answer 14

1. Collection of subjective data
2. Collection of objective data
3. Validation of data
4. Documentation of data

Question 15

The crucial step of assessment
• Done to prevent inaccuracy of data

Answer 15

Validation of data

Question 16

Forms the database of the entire nursing
process
• Needed to ensure valid conclusion
• Narrative technique
o Write patient’s condition
o Contractions
-What’s attached to the patient
o Standing orders
No erasures
SOAPIE

Answer 16

Documentation of data

Question 17

Obtained by general observation and
performing the four (4) physical techniques (IPPA)
• Assessment of:
o Physical characteristics
o Body functions
o Vital sign measurements
o Behavior

Answer 17

Collection of Objective data

Question 18

Technique in Documentation of Data

Answer 18

SOAPIE Technique, subjective, objective, assessment, planning, intervention, evaluation

Question 19

Establishing rapport and trusting
relationship with the patient to elicit
accurate information

Gather information on patient’s
developmental, psychological,
physiologic, sociocultural, and spiritual
statuses to identify deviations that can
be treated with nursing and
collaborative interventions

Answer 19

Interviewing

Question 20

4 phases of interview

Answer 20

1. Pre introductory phase
2. Introductory phase
3. Working phase
4. Summary / closing phase

Question 21

The nurse reviews the medical record before
meeting with the client
• Nurse knows the patient’s biographical
information

Answer 21

Pre introductory phase

Question 22

The meeting phase of the patient and client
• The nurse:
o Introduces self to the patient
o Explains the purpose of interview
o Discusses the questions
o Explains reason for taking notes
o Assures patient’s confidentiality

Answer 22

Introductory phase

Question 23

The nurse:
o Elicits patient’s comments about
biographic data
o Reasons for seeking care
- History of present health concern
- Past health history
- Family history
- Review of body systems for current health problems
- Lifestyle and health practices
- Developmental level of patient

Answer 23

Working phase

Question 24

COLDSPA

Answer 24

Character, onset, location, duration, severity, pattern, associated factors

Question 25

Identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client’s birth date, Social Security number, medical record number, or similar identifying data

Answer 25

Biographic Data

Question 26

• A process of data collection used to verify if the information is legitimate or correct
• One way to pre-empt medications (to prepare beforehand medical interventions)

Answer 26

Data triangulation

Question 27

To become proficient, the nurse must have basic knowledge in these three areas:
- Types and operation of equipment
needed for the particular examination
- Preparation of the setting, oneself,
and the client for the physical assessment
- Performance of the four (4)
assessment techniques (IPPA)
▪ Inspection
▪ Palpation
▪ Percussion
▪ Auscultation

Answer 27

Physical Examination

Question 28

Physical assessment techniques

Answer 28

IPPA
1. Inspection
2. Palpation
3. Percussion
4. Auscultation

Question 29

4 types of palpation

Answer 29

Light palpation, moderate palpation, deep palpation, bimanual palpation

Question 30

Different assessment of percussion

Answer 30

Eliciting pain
Determining location, size, and shape
Determining density
Detecting abnormal masses
Eliciting reflexes

Question 31

aims to achieve relevant nursing education, humane working conditions, better career prospects, and a dignified existence for the Filipino nurses.

Answer 31

RA 7164 – 1991

Question 32

seeks to better protect and improve the nursing profession, but still upholding the same revered state policies and aspirations.

Answer 32

RA 9173 – 2002

Question 33

Paralysis on one side of the body

Answer 33

Hemipaglia

Question 34

Indicates progression or worsening of
situation

Answer 34

Weakness (continuous)

Question 35

Symptoms can include yellowish
pigment

Answer 35

Hepatitis / cirrhosis

Question 36

Unable to pass stool
o Results to severe constipation
o Black stool
- Upper GI tract involvement
-May include feeling nausea
o Note that the character of the stool is
important

Answer 36

Fecal impaction

Question 37

The one that must be prioritized according to
Maslow’s hierarchy of needs and ABCs of life

Was used by the physician Alexander The
Great

Answer 37

Triage

Question 38

Mental and bodily processes

Answer 38

Psychophysiologic

Question 39

From head to foot assessment

Including hair strands

Answer 39

Cephalocaudal technique

Question 40

Actual
o Now / on the spot

Anticipated
o Risk / potential

Answer 40

Familial tendencies / Hereditary predisposition

Question 41

Functional nurse

Answer 41

CMB, charge nurse, medication nurse, bedside nurse

Question 42

Case management

Answer 42

CCU cardiac care unit and GI (colonoscopy nurse)

Question 43

The movement of healthcare from the
acute care setting to the community

• Advanced practice nurses have been increasingly used in the hospital as clinical nurse specialists and
  in the community as nurse practitioners

Answer 43

1990-present

Question 44

Nursing process ADPIRE

Answer 44

Assessment, nursing diagnosis, planning, implementation, rationale, evaluation