2M

Question 1

• reportedly by the client
• may include S/S described by client but not noticeable to others.
• may include demographic information, patient and family information, past & current medical conditions, etc.

Answer 1

SUBJECTIVE DATA

Question 2

• information that the health care professional gathers during a physical examination
• consist of information that can be seen, felt, smelled or heard by the HCP.

Answer 2

OBJECTIVE DATA

Question 3

sensations or symptoms (e.g. – pain, hunger), feelings (e.g. – happiness, sadness), perceptions, desires, preference, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.

Answer 3

SUBJECTIVE DATA

Question 4

Observations and measurements made by the data collector based on an acceptable standard. data directly and indirectly observed through measurements

Answer 4

OBJECTIVE DATA

Question 5

skills need to collect objective data

Answer 5

o Inspection
o Palpation
o Percussion
o Auscultation

Question 6

PHASES OF THE INTERVIEW

Answer 6

PRE-INTRODUCTORY PHASE
INTRODUCTORY PHASE
WORKING PHASE
SUMMARY AND CLOSING PHASE

Question 7

nurse introduces herself and reviews the medical records before meeting the client.

Answer 7

PRE-INTRODUCTORY PHASE

Question 8

nurse explains the purpose of the interview, discusses the types of the questions that will be asked. Explains the reason for taking notes and assures the client that information will remain confidential.

Answer 8

INTRODUCTORY PHASE

Question 9

the nurse elicits the client with comments about major biographical data, reasons for seeking care, history of patient’s present health concern, past health history, family history, review of body systems for current health problems, lifestyle & health practice, and lastly developmental level

Answer 9

WORKING PHASE

Question 10

nurse summarizes information obtained during the working phase, validates problems & goals with the client

Answer 10

SUMMARY AND CLOSING PHASE

Question 11

NON-VERBAL COMMUNICATION

Answer 11

APPEARANCE
DEMEANOR
FACIAL EXPRESSION
ATTITUDE
SILENCE
LISTENING

Question 12

appearance should be professional

Answer 12

APPEARANCE

Question 13

an overload aspect of communication

Answer 13

FACIAL EXPRESSION

Question 14

one of the most important nonverbal skills to
develop as a health professional is a non-judgmental attitude

Answer 14

ATTITUDE

Question 15

allows the nurse and the client to reflect and organize thoughts which facilitate more accurate reporting and data
collection

Answer 15

SILENCE

Question 16

most important skill to learn and develop fully in
order to collect complete and valid data

Answer 16

LISTENING

Question 17

VERBAL COMMUNICATION

Answer 17

OPEN-ENDED QUESTIONS
CLOSE-ENDED QUESTIONS
LAUNDRY LIST
REPHRASING
WELL-PLACED PHRASES

Question 18

are used to elicit the client’s feelings & perception

Answer 18

OPEN-ENDED QUESTIONS

Question 19

to obtain facts and to focus on specific information

Answer 19

CLOSE-ENDED QUESTIONS

Question 20

to provide the client with a list of words to choose in describing symptoms, conditions/feelings

Answer 20

LAUNDRY LIST

Question 21

effective way to communicate and validate during the interview

Answer 21

REPHRASING

Question 22

the nurses can encourage verbalization by using well placed phrases

Answer 22

WELL-PLACED PHRASES

Question 23

COMPONENTS OF A COMPLETE HEALTH HISTORY

Answer 23

biographical data
reasons for seeking health care
history of present health concern
personal health history
family health history
review of systems for current health problems
lifestyle and health practices
developmental level

Question 24

personal data that distinguishes individual from one another.

Answer 24

biographical data

Question 25

o chief complaint o onset of present health concern o duration o course of the health concern o signs, symptoms, and related problems

Answer 25

reasons for seeking health care

Question 26

o allergies (reaction) o serious or chronic illness o recent hospitalizations o recent surgical procedures

Answer 26

history of present health concern

Question 27

personal topics such as sexual activities etc

Answer 27

personal health history

Question 28

o pertinent health status of family members o pertinent family history of heart disease, lung disease, cancer, hypertension, diabetes, obesity, mental illness, genetic disorders

Answer 28

family health history

Question 29

o activity/exercise, leisure and recreational activities o Sleep/rest o interpersonal relationships/resources o coping and stress management o environmental hazards

Answer 29

lifestyle and health practices

Question 30

o current significant physical and psychosocial changes/issues

Answer 30

developmental level

Question 31

promote effective communication among multi- disciplinary health care team members and to facilitate client care

Answer 31

DOCUMENTING DATA

Question 32

ASSESSMENT FORMS USED FOR DOCUMENTATION

Answer 32

* INITIAL ASSESSMENT FORMS * FREQUENT OR ONGOING ASSESSMENT FORMS * FOCUSED OR SPECIALTY AREA ASSESSMENT FORM

Question 33

it can be exposed/implied. A patient’s agreement to have a medical procedure after receiving full disclosure of risks, benefits, alternatives, and consequences

Answer 33

INFORMED CONSENT

Question 34

TYPES OF INFORMED CONSENT

Answer 34

Verbal Implied Written

Question 35

mutual decision making between both professional and patient over treatment option that the patient wishes to receive or not to receive

Answer 35

Purpose of informed consent

Question 36

* when an individual clearly states their agreement to an intervention procedure. * should be obtained if there is any doubt of a person’s implied consent to minor procedures

Answer 36

Verbal Informed consent

Question 37

* this is taken through participation * not explicitly given by the individual but is interfered from the person’s action and inactions

Answer 37

Implied informed consent

Question 38

must be obtained when procedures are: * invasive/ has significant potential complications / side effects * significant, irreversible side effects * requires surgical, medical, invasive radiology, oncology or endoscopy treatment

Answer 38

Written informed consent

Question 39

process of confirming or verifying that the subjective and objective data collected are reliable or accurate

Answer 39

VALIDATING DATA

Question 40

o excessive or insufficient eye contact o distraction and distance o standing

Answer 40

NON – VERBAL COMMUNICATION

Question 41

o biased or leading questions o rushing through the interview o reading the questions

Answer 41

VERBAL COMMUNICATION

Question 42

if client has hearing loss, speak slowly, face the client at all times, position yourself so that you are speaking on the side of the client that has the ear with better acuity

Answer 42

GERONTOLOGIC VARIATIONS IN COMMUNICATION

Question 43

o communication with the use of pictures may be helpful o it may be necessary to use an interpreter if you need to interview a client who does not speak your language

Answer 43

CULTURAL VARIATIONS IN COMMUNICATION

Question 44

o provide the client with simple, organized information o explain who you are along with your role and purpose o ask simple and concise questions o avoid becoming anxious o do not hurry and decrease external stimuli

Answer 44

WHEN INTERACTION WITH AN ANXIOUS CLIENT

Question 45

o approach this client in a calm, reassuring in control manner o allow client to ventilate feelings o if the client is out of control, do not argue or touch the client o obtain help from other health professionals as needed o avoid arguing and facilitate personal space o never allow the client to position himself between you and the door

Answer 45

WHEN INTERACTING WITH AN ANGRY CLIENT

Question 46

o express interest in understanding of the client & responding a neutral manner o do not try to communicate in an upbeat, encouraging manner

Answer 46

INTERACTING WITH DEPRESSED CLIENT

Question 47

o if you are not sure that you are being manipulated, obtain objective opinion from another colleague or health care professional o provide a structure and set limits o differentiate manipulation and a reasonable request

Answer 47

INTERACTING WITH A MANIPULATIVE CLIENT

Question 48

o set firm limits on overt sexual client behavior and avoid responding to subtle seductive behavior o if the overt sexuality continues, do not interact without business

Answer 48

INTERACTING WITH A SEDUCTIVE CLIENT

Question 49

o ask simple questions in non-judgmental manner o allow time for ventilation of elements and feelings as needed o make referrals as appropriate. If you do not feel comfortable in discussing sensitive topics

Answer 49

DISCUSSING SENSITIVE ISSUES (SEXUALITY, DYING, AND SPIRITUALITY)

Question 50

STEPS ON DATA ANALYSIS

Answer 50

* identify strengths and abnormal data * cluster data * draw inferences * propose possible nursing diagnosis * check for defining characteristics * confirm or rule out diagnosis * document conclusions

Question 51

TYPES OF NURSING DIAGNOSIS

Answer 51

* actual/problem focused nursing diagnosis * wellness/health promotion nursing diagnosis * risk/possible nursing diagnosis * syndrome diagnosis * collaborative problems and referrals

Question 52

MARJOY GORDON’S FUNCTIONAL HEALTH PATTERN

Answer 52

NUTRITIONAL – METABOLIC PATTERN ELIMINATION PATTERN ACTIVITY – EXERCISE PATTERN SLEEP – REST PATTERN COGNITIVE – PERCEPTUAL PATTERN SELF – PERCEPTION PATTERN ROLE – RELATIONSHIP PATTERN SEXUALITY – REPRODUCTIVE PATTERN COPING – STRESS MANAGEMENT PATTERN VALUES – BELIEF PATTERN

Question 53

o determines how the client perceives and maintains his or her health o assess compliance with current and past nursing and medical recommendation

Answer 53

HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

Question 54

o determine the client’s dietary habits and intake and metabolic needs o assess the conditions of hair, skin, nails, teeth, and mucous membranes

Answer 54

NUTRITIONAL – METABOLIC PATTERN

Question 55

o determine the adequacy and function of the client’s bowl and bladder and urinary routines and habits for elimination o assess for any urinary and bowel problems

Answer 55

ELIMINATION PATTERN

Question 56

o determine the client’s activities of daily living, occupation, leisure and exercise pattern

Answer 56

ACTIVITY – EXERCISE PATTERN

Question 57

o determine the client’s perception of the quality of his/her sleep and relaxation and energy levels o assess methods used to promote relaxation and sleep

Answer 57

SLEEP – REST PATTERN

Question 58

o determine the functionality status of the five senses o assess devices and methods used to assist the client with deficits in any of the sensory organs

Answer 58

COGNITIVE – PERCEPTUAL PATTERN

Question 59

o determine how the client perceives his/her situation, classify health goals

Answer 59

SELF – PERCEPTION PATTERN

Question 60

o determine 2 aspects: 1. Communication, what language does the client use and understand; 2. Relationship, is the client living alone or with family, support system and access to family life such as role discipline, finances, communication pattern, parenting and marital difficulties

Answer 60

ROLE – RELATIONSHIP PATTERN

Question 61

o determine the client’s fulfillment of sexual needs and perceived level of satisfaction o assess reproductive pattern, developmental level and perceived problems which relates sexual activities, relationship and self-concept

Answer 61

SEXUALITY – REPRODUCTIVE PATTERN

Question 62

o determine the client’s ability to understand, communicate, remember and able to make decisions, changes and obstacles that the client experiences that could affect his or her decisions and how the client use coping mechanisms in times of crisis/stress

Answer 62

COPING – STRESS MANAGEMENT PATTERN