Ch. 3: Assessment-MJ

Question 1

What is the definition of assessment?

Answer 1

The systematic gathering of information related to physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community

Question 2

What are some of the features of an assessment?

Answer 2

Collecting data
Categorizing data
Recording data
Using a systematic and ongoing process

Question 3

What is the purpose of assessment?

Answer 3

To obtain enough data to allow you to help the patient

Question 4

Assessment is the first phase of the nursing process. Why must data be accurate and complete during this step?

Answer 4

Because the remainder of the nursing process rests on this foundation of data

Question 5

Define: The information communicated to the nurse by the client, family, or community

Answer 5

Subjective data

Question 6

Define: Data gathered through physical assessment or from lab or diagnostic tests

Answer 6

Objective

Question 7

Subjective or objective: Covert data

Answer 7

Subjective

Question 8

Subjective or objective: Overt data

Answer 8

Objective

Question 9

Subjective or objective: Signs

Answer 9

Objective

Question 10

Subjective or objective: Symptoms

Answer 10

Subjective

Question 11

Subjective or objective data:
“I’ve been having a lot of pain in my abdomen”
“My throat hurts when I swallow”

Answer 11

Subjective

Question 12

Subjective or objective data:
“Suprapubic area firm to light palpation. Lower abdomen semisoft”
“White patches noted at the back of the throat and tonsillar area reddened and swollen”

Answer 12

Objective

Question 13

_____ data can be measured or observed by the nurse or other healthcare providers

Answer 13

Objective

Question 14

What are examples of objective data?

Answer 14

Vitals
X-ray results
Skin color
Urine output

Question 15

You need to sometimes use _____ data to validate ____ data.

Answer 15

Use objective data to validate subjective data

Question 16

What kind of assessment is this: Completed when the client first comes to the healthcare agency

Answer 16

Initial (admission) assessment

Question 17

What do you do for the initial assessment?

Answer 17

1. Obtain data for why the person came in for nursing/medical assistance
2. Complete comprehensive assessment if clients condition permits
3. Data gathered here provides guidance for care and need for further assessment

Question 18

When is an ongoing assessment preformed?

Answer 18

As needed at any time after the initial database is completed; make at least some observations at every contact with the client

Question 19

Initial or ongoing assessment: Which one reflects the dynamic state of the client? Example?

Answer 19

Ongoing; vital signs may rapidly change and serve as important indicators of developing or resolving health problems

Question 20

A _____ assessment is also called a global assessment, patient database, or nursing database.

Answer 20

Comprehensive

Question 21

A comprehensive assessment provides ______ information about the clients overall health status

Answer 21

Holistic

Question 22

What does the comprehensive assessment include?

Answer 22

• Sub and obj data about the clients body systems and functional abilities
• Emotional status
• Spiritual health
• Psychosocial health

Question 23

Observation, physical assessment, and the nursing interview are all included in the ______ assessment

Answer 23

Comprehensive

Question 24

Define: The deliberate use of all of your senses to gather and interpret patient and environmental data

Answer 24

Observation

Question 25

Physical assessment (or examination) produces primarily OBJECTIVE data and uses 4 techniques. What are they?

Answer 25

Inspection Palpation Percussion Auscultation

Question 26

What is the nursing interview?

Answer 26

A purposeful, structured communication in which you question the patient to gather SUBJECTIVE data for the nursing database

Question 27

Why is a focus assessment preformed

Answer 27

Preformed to obtain data about an actual, potential, or possible problem that has been identified or is suspected; focuses on a particular topic, body part, or functional ability rather than overall health status

Question 28

When is the initial focused assessment used?

Answer 28

To follow up on client-reported symptoms or unusual findings during the first exam (admission to hospital)

Question 29

When is an ongoing focused assessment used?

Answer 29

To evaluate the status of existing problems and goals

Question 30

What kind of assessment is a special needs assessment?

Answer 30

A type of FOCUSED assessment

Question 31

What type of assessment provides in-depth information about a particular area of client functioning and often involves using a specially designed form.

Answer 31

Special needs assessment

Question 32

The Joint Commission requires certain special needs assessments for all clients. Examples?

Answer 32

Nutrition status and pain

Question 33

When should you preform a special needs assessment?

Answer 33

Any time assessment cues suggest risk factors or problems in an area of client functioning

Question 34

What are 9 types of special needs assessments?

Answer 34

``` Functional ability assessment Nutritional assessment Pain assessment Cultural assessment Spiritual health assessment Psychosocial assessment Wellness assessment Family assessment Community assessment ```