ASSESSMENT

Question 1

data collection to establish

Answer 1

database

Question 2

is the systematic and continuous collection, validation, and documentation of data (information)

Answer 2

assessing

Question 3

What are the activities of assessment?

Answer 3

Establish database
obtain a nursing health history
conduct physical assessment
review of patient records
review of nursing literature
consultation of support persons
consultation of health professionals

Question 4

What are the components of assessment?

Answer 4

Data Collection
Data Validation
Data Organization
Communication of Data (Kozier)
Documentation of Data (Taylor)

Question 5

What are the two types of data?

Answer 5

subjective and objective data

Question 6

information perceived only by the client or by the affected person

Answer 6

subjective data

Question 7

cannot be perceived or verified by another person

Answer 7

subjective data

Question 8

Subjective data is also called as ?

Answer 8

symptoms or covert data

Question 9

consist of information given verbally by the patient

Answer 9

subjective data

Question 10

observable or measurable data that can be seen, heard, smelled, or felt by someone other than the person experiencing them

Answer 10

objective data

Question 11

can be observed by one person and can be verified by another person observing the same patient

Answer 11

objective data

Question 12

obtained through observation or physical examination (IPPA)

what is IPPA?

Answer 12

Objective data
Inspection
Palpation
Percussion
Auscultation

Question 13

Objective data is also called as

Answer 13

Signs or Overt Data

Question 14

What are the sources of data or information

Answer 14

client or patient
support people like family members, SO
Client or patient record like
- medical history
- consultations
- reports or laboratory
- reports of therapies by other health care professional
- nursing and other health care literature

Question 15

What are the characteristics of data?

Answer 15

complete
factual and accurate
relevant

Question 16

What are the types of assessment?

Answer 16

Initial assessment
Problem focused assessment
Emergency assessment
Time-lapsed Assessment

Question 17

Nursing assessments focus on a ________ to a health problem.

Answer 17

client’s response

Question 18

process of gathering information about client’s health status

systematic and continuous

Answer 18

Data collection

Question 19

all information about the client

Answer 19

database

Question 20

To gather data using senses

Answer 20

observation

Question 21

What are the senses involved in observation of the patient?

Answer 21

vision
touch
hearing
smell

Question 22

What should the nurse observe of the patient?

Answer 22

clinical signs of client distress
threats to clients safety, real or anticipated
presence and functioning of associated equipment
the immediate environment, including the people

Question 23

it is a planned communication or a conversation with a purpose

Answer 23

interview

Question 24

What are the three types of interview?

Answer 24

Focused interview
Directive interview
Nondirective interview

Question 25

nurses ask specific questions to the client’s problem

Answer 25

focused interview

Question 26

it is highly structured elicits specific information emergency situation

Answer 26

directive interview

Question 27

rapport building interview

Answer 27

non-directive interview

Question 28

an understanding between two people

Answer 28

rapport

Question 29

What are the four types of interview question?

Answer 29

Closed Open Neutral leading

Question 30

In planning for the interview and setting, one must consider the following factors?

Answer 30

Time place seating arrangement distance language

Question 31

The place where the interview is conducted must be

Answer 31

well-lighted well-ventilated free from noise, movement, distractions

Question 32

What should be the appropriate distance of the patient from the nurse?

Answer 32

at least 3-4 feet

Question 33

the study of use of space

Answer 33

proxemics

Question 34

What are the stages of interview

Answer 34

Opening or introduction body or development closing

Question 35

In closing the interview, what should a nurse do?

Answer 35

1. offer to ask questions 2. use “well_____ end” 3. thank the client 4. express concern for the person’s welfare and future 5. plan for the next meeting 6. summary to verify accuracy and agreement

Question 36

Upon examining a patient, what should you do first?

Answer 36

first- observe the overall appearance and health status second - vital signs third - cephalocaudal or head to toe approach

Question 37

brief review of essential functioning of various body parts or systems

Answer 37

screening examination or review of systems

Question 38

Organizing data is also called as

Answer 38

nursing health history nursing assessment nursing database form

Question 39

What are the conceptual models and Frameworks in organizing data?

Answer 39

Gordon’s 11 functional health Orem’s Self Care Model Roy’s Adaptation Model

Question 40

What are the four observable categories according to Orem’s Self Care Model?

Answer 40

physiological self-concept role function interdependence

Question 41

Used to identify health risks and explore lifestyle

Answer 41

wellness models

Question 42

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

Answer 42

validation

Question 43

subjective and objective data that can be directly observed by the nurse

Answer 43

cues

Question 44

These are nurse’s interpretation or conclusions made on the cues

Answer 44

inferences

Question 45

records client data

Answer 45

documenting data

Question 46

Diagnosis is

Answer 46

analyzing and synthesizing

Question 47

In this phase, nurses use critical thinking skills to interpret or analyze assessment data and identify client strength and health problems

Answer 47

diagnosis

Question 48

is used to interpret or analyze assessment data and identify client strength and health problems

Answer 48

Diagnosis

Question 49

The standard NANDA name for the diagnosis are called

Answer 49

Diagnostic Labels

Question 50

causal relationship between a problem and its related or risk factors

Answer 50

etiology

Question 51

a clinical judgment concerning a human response to health con- ditions/life processes, or a vulnerability for that response, by an indi- vidual, family, group, or community”

Answer 51

nursing diagnosis

Question 52

are responsible for mak- ing nursing diagnoses

Answer 52

Registered nurse

Question 53

is a judgment made only after thorough, sys- tematic data collection.

Answer 53

nursing diagnosis

Question 54

is a client problem that is present at the time of the nursing assessment

Answer 54

actual diagnosis

Question 55

relates to clients’ preparedness to implement behaviors to improve their health condition.

Answer 55

health promotion diagnosis

Question 56

is a clinical judgment that a prob- lem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.

Answer 56

risk nursing diagnosis

Question 57

is assigned by a nurse’s clinical judg- ment to describe a cluster of nursing diagnoses that have similar interventions

Answer 57

syndrome diagnosis

Question 58

What are the three components of nursing diagnosis

Answer 58

Problem and its definition the etiology the defining characteristics

Question 59

is to direct the formation of client goals and desired outcome

Answer 59

diagnostic labels

Question 60

are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement

Answer 60

qualifiers

Question 61

What are the qualifiers used in nursing diagnosis?

Answer 61

deficient impaired decreased ineffective compromised

Question 62

identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care.

Answer 62

etiology

Question 63

are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label.

Answer 63

defining characteristics

Question 64

Nursing diagnosis describes a

Answer 64

client’s physical socio-cultural psychological spiritual responses

Question 65

CUC

Answer 65

Chronic Ulcerative Colitis

Question 66

CA

Answer 66

Cancer

Question 67

CVA

Answer 67

Cerebral Vascular Accident

Question 68

What is the Diagnostic Process?

Answer 68

Analyzing data Identifying health problem and risks and strength (focus area) Formulating diagnostic statements

Question 69

R/t

Answer 69

Related to

Question 70

PIH

Answer 70

Pregnancy Induced Hypertension