Assessing

Question 1

A systematic, rational method of planning and providing individualized nursing care

Answer 1

Nursing Process

Question 2

PURPOSES OF NURSING PROCESS
- Identify a client’s (1) __________ and actual or potential healthcare problems
- Establish plans to meet identified (2) ___________
- Deliver specific (3) ____________

Answer 2

(1) health status
(2) needs
(3) nursing interventions

Question 3

Collecting, organizing, validating, and documenting data

Answer 3

Assessing

Question 4

Analyzing and synthesizing data

Answer 4

Diagnosing

Question 5

Determining how to prevent, reduce, or resolved identified priority client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner

Answer 5

Planning

Question 6

Carrying out or delegating and documenting the planned nursing interventions

Answer 6

Implementing

Question 7

Measuring the degree to which goals or outcomes have been achieved and identifying factors that postively or negatively influence goal achievement

Answer 7

Evaluating

Question 8

To establish a database about the client’s responses to health concerns or illness and the ability to manage healthcare needs

Answer 8

Assessing

Question 9

To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions

Answer 9

Diagnosing

Question 10

To develop an individualized care plan that specifies client goals or desired outcomes and related nursing interventions

Answer 10

Planning

Question 11

To assist the client to meet desired goals or outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning

Answer 11

Implementing

Question 12

To determine whether to continue, modify, or terminate the plan of care

Answer 12

Evaluating

Question 13

The nursing process is __________. The nurse organizes the plan of care according to client problems rather than nursing goals

Answer 13

client centered

Question 14

The nursing process is an adaptation of __________ and __________ theory.

Answer 14

problem solving / systems

Question 15

Is involved in every phase of the nursing process

Answer 15

Decision-making

Question 16

The nursing process is __________ and __________. It requires the nurse to communicate directly and consistenly with clients and families to meet their needs.

Answer 16

interpersonal and collaborative

Question 17

The _____________ characteristic of the nursing process means that it can be used as a framework for nursing care in all types of healthcare settings.

Answer 17

universally applicable

Question 18

Nurses must utilize __________ throughout the delivery of nursing care. By reflecting, the nurse determines whether the outcome of care was appropriate

Answer 18

clinical reasoning

Question 19

Assessing is the systematic and continuous:
C - __________
O - __________
V - __________
D - __________ of data

Answer 19

Collection
Organization
Validation
Documentation

Question 20

Nursing assessments focus on a client’s ___________. It should include, the client’s perceived needs, health problems, related experience, health practices, values, and lifestyle.

Answer 20

responses to a health problem

Question 21

Is the process of gathering information about a client’s health status

Answer 21

Data Collection

Question 22

Contains all the information about a client

Answer 22

Database

Question 23

TRUE OR FALSE:
The database of a patient includes the following:
- Nursing health history
- Physical assessment
- Primary care provider’s history and physical examination
- Results of laboratory and diagnostic tests
- Material contributed by relatives

Answer 23

FALSE
It should include MATERIAL CONTRIBUTED BY OTHER HEALTH PERSONNEL

Question 24

Performed within specified time after admission to a healthcare agency

Answer 24

Initial assessment

Question 25

Ongoing process integrated with nursing care

Answer 25

Problem-focused assessment

Question 26

During any physiologic or psychologic crisis of the client

Answer 26

Emergency assessment

Question 27

Several months after initial assessment

Answer 27

Time-lapsed reassessment

Question 28

To establish a complete database for problem identification, reference, and future comparison

Answer 28

Initial assessment

Question 29

To determine the status of a specific problem identified in an earlier assessment

Answer 29

Problem-focused assessment

Question 30

To identify life-threatening problems and new or overlooked problems

Answer 30

Emergency assessment

Question 31

To compare the client’s current status to baseline data previously obtained

Answer 31

Time-lapsed reassessment

Question 32

Nursing admission assessment

Answer 32

Initial assessment

Question 33

Hourly assessment of client’s fluid intake and urinary output in an intensive care unit (ICU)

Answer 33

Problem-focused assessment

Question 34

Assessment of client’s ability to perform self-care while assissting a client to bathe

Answer 34

Problem-focused assessment

Question 35

Rapid assessment of an individual’s ABCs during a cardiac arrest

Answer 35

Emergency assessment

Question 36

Assessment of suicidal tendencies or potential or violence

Answer 36

Emergency assessment

Question 37

Reassessment of a client’s functional health patterns in a home care or outpatient setting or, in a hospital, at shift change

Answer 37

Time-lapsed reassessment

Question 38

Client’s name, address, age, sex, marital status, occupation, religious preference, healthcare financing, and usual source of medical care

Answer 38

Biographic Data

Question 39

“What is troubling you?” “Describe the reason you came to the hospital or clinic today.”

Answer 39

Chief Complaint

Question 40

Illness Immunizations Allergies Accidents Hospitalizations Medications

Answer 40

Past History

Question 41

To ascertain risk factors for certain diseases, the ages of siblings, parents, and grandparents and their current state of health, or, if they are deceased, the cause of death, are obtained

Answer 41

Family History of Illness

Question 42

Personal Habits Diet Sleep patterns Activities Instrumental ADLs Recreation

Answer 42

Lifestyle

Question 43

Family relationships and friendships Ethnic affiliation Educational history Occupational history Economic status Home and neighborhood conditions

Answer 43

Social Data

Question 44

Major stressors Usual coping pattern Communication style

Answer 44

Psychologic Data

Question 45

All healthcare resources the client is currently using and has used in the past

Answer 45

Patterns of Healthcare

Question 46

Symptoms or covert data that are apparent only to the individual affected and can be described or verified only by that individual

Answer 46

Subjective Data

Question 47

Signs or overt data that are detectable by an observer or can be measured or tested against an accepted standard

Answer 47

Objective Data

Question 48

The best source of data is usually the __________, unless they are too ill, young, or confused to communicate clearly

Answer 48

client

Question 49

Family members, friends, and caregivers who know the client well often can supplement or verify information provided by the client

Answer 49

Support People

Question 50

Are especially important source of data for a client who is very young, unconscious, or confused.

Answer 50

Support People

Question 51

To gather data by using the senses

Answer 51

Observing

Question 52

Planned communication, or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy

Answer 52

Interview

Question 53

In a __________, the nurse asks the client specific questions to collect information related to the client’s problem. This allows for collection of information previously missed and yields more in-depth information

Answer 53

Focused Interview

Question 54

- Is highly structured and elicits specific information - Nurse established and controls the interview - Clients have limited opportunity to ask questions or discuss concerns - Used when time is limited

Answer 54

Directive Interview

Question 55

- Rapport-building interview - The nurse allows the client to control the purpose, subject matter, and pacing

Answer 55

Nondirective Interview

Question 56

Is an understanding between two or more people

Answer 56

Rapport

Question 57

A combination of __________ and __________ approaches is usually appropriate during the information-gathering interview

Answer 57

directive and nondirective

Question 58

- Used in the directive interview - Restrictive and generally require only “yes” or “no” or short factual answers

Answer 58

Closed Questions

Question 59

- Associated with the nondirective interview - Invites clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings - Specifies only the broad topic to be discussed

Answer 59

Open-ended Questions

Question 60

“What medication did you take?” “Are you having pain now?” “How old are you?” “When did you fall?”

Answer 60

Closed Questions

Question 61

“How have you been feeling lately?” “What brought you to the hospital?” “What would you like to talk about today?”

Answer 61

Open-ended questions

Question 62

- A question the client can answer without direction or pressure from the nurse - Open-ended and used in nondirective interviews - “How do you feel about that?”; “What do you think led to the operation?”

Answer 62

Neutral Question

Question 63

- Questions that are usually closed and directs the client’s answer - Directive interview - “You’re stressed about the surgery tomorrow, aren’t you?”

Answer 63

Leading Question

Question 64

Try to avoid asking __________ questions. These questions can be perceived as a form of interrogation by the client.

Answer 64

“why”

Question 65

Nurses need to plan interviews with clients when the client is physically comforable and free of pain, and when interruptions by friends, family, and other health professionals are minimal

Answer 65

Time

Question 66

A well-lit, well-ventilated room that is relatively free of noise, movements, and distractions encourages communication

Answer 66

Place

Question 67

By standing and looking down at a client who is in bed or in a chair, the nurse risks intimidating the client.

Answer 67

Seating Arrangement

Question 68

When a client is in bed, the nurse can sit at a __________ angle to the bed.

Answer 68

45-degree

Question 69

The __________ between the interviewer and interviewee should be neither too small nor too great.

Answer 69

distance

Question 70

Is the study of use of space

Answer 70

Proxemics

Question 71

Most people feel comfortable maintaining a distance of __________ during an interview.

Answer 71

2-3 feet

Question 72

Failure to communicate in _________ the client can understand is a form of discrimination.

Answer 72

language

Question 73

TRUE OR FALSE: The nurse must convert complicated medical terminology into common English usage, and interpreters or translators are needed if the client and the nurse do not speak the same language or dialect.

Answer 73

TRUE

Question 74

Can be the most important part of the interview because what is said and done at that time sets the tone for the remainder of the interview

Answer 74

The Opening

Question 75

The purpose of the opening are to establish _________ and _________ the interviewee

Answer 75

rapport and orient

Question 76

Is a process of creating goodwill and trust

Answer 76

Establishing rapport

Question 77

Where the client communicates what he or she thinks, feels, knows, and perceives in response to questions from the nurse

Answer 77

The Body

Question 78

The nurse terminates the interview when the needed information has been obtained

Answer 78

The Closing

Question 79

TRUE OR FALSE: In some cases, the client terminates the interview, for example, when deciding to not give any more information for some other reason

Answer 79

TRUE

Question 80

The ___________ or head-to-toe approach begins the examination at the head; progresses to the neck, thorax, abdomen, and extremities; and ends at the toes

Answer 80

cephalocaudal

Question 81

- Is a brief review of essential functioning of various body parts or systems - Data is measured against norms or standards - Nursing admission assessment form

Answer 81

Screening Examination / Review of Systems

Question 82

Used to assist clients to identify health risks and to explore lifestyle habits and health behaviors, beliefs, values, and attitudes that influence the level of wellness

Answer 82

Wellness Model

Question 83

Frameworks and models form other disciplines that are narrower than the model required in nursing

Answer 83

Nonnursing Models

Question 84

Model focused on abnormalities of the following anatomic systems

Answer 84

Body Systems Model

Question 85

Model the clusters data pertaining to the following: - Physiologic needs - Safety and security needs - Love and belonging needs - Self-esteem needs - Self-actualization needs

Answer 85

Maslow’s Hierarchy of Needs

Question 86

The act of “double-checking” or verifying data to confirm that it is accurate and factual

Answer 86

Validation

Question 87

- Are subjective or objective data that can be directly observed by the nurse - What the client says or what the nurse can see, hear, feel, smell, or measure

Answer 87

Cues

Question 88

- Are the nurse’s interpretation or conclusions made based on the cues - e.g. Nurse observes the cues that an incision is red, hot, and swollen; thus saying that the incision is infected

Answer 88

Inferences

Question 89

- Completes the assessment phase - Is essential and should include all data collected about the client’s health status

Answer 89

Documentation

Question 90

TRUE OR FALSE: Data are recorded in a factual manner and interpreted by the nurse

Answer 90

FALSE The nurse must NOT INTERPRET THE DATA maintain accuracy of it