chap 1

Question 1

ANA standard 1

Answer 1

registered nurse collects comprehensive data pertinent to the patient’s health/situation

Question 2

ANA standard 2

Answer 2

registered nurse analyzes the assessment data to determine the diagnosis

Question 3

what do nurses use to arrive at professional clinical judgements?

Answer 3

communication and physical assessment techniques

Question 4

nursing process

Answer 4

• assessment
• diagnosis
• planning
• implementation
• evaluation

Question 5

assessment

Answer 5

collect data

Question 6

diagnosis

Answer 6

analyze data & make judgments

Question 7

planning

Answer 7

develop a plan

Question 8

implementation

Answer 8

carry out plan

Question 9

evaluation

Answer 9

assess outcome & adjus

Question 10

most crucial step in nursing process

Answer 10

assessment

Question 11

holistic nursing assessment

Answer 11

-collects holistic subjective data and objective data

Question 12

physical medical assessment

Answer 12

focuses on the client’s physiologic development status

Question 13

nurses collect data on

Answer 13

• physiological well-being
• psychological well-being
• sociocultural well-being
• developmental data
• spiritual well-being

Question 14

framework for health assessment

Answer 14

helps organize info & promotes collection of holistic data

Question 15

types of health assessments

Answer 15

• initial comprehensive assessment
• ongoing/partial assessment
• focused/problem oriented assessment
• emergency assessment

Question 16

initial comprehensive assessment

Answer 16

• completed when pt has been admitted to floor
• obtain all possible info about pt
• complete database for problem id and care planning
• past hx
• allergies
• all pertinent physical findings

Question 17

ongoing/partial assessment

Answer 17

data collection that occurs after the comprehensive database

Question 18

focused/problem oriented assessment

Answer 18

thorough assessment of particular client problem

Question 19

emergency assessment

Answer 19

rapid focused assessment

Question 20

steps of health assessment

Answer 20

• collection of subjective data
• collection of objective data
• validation of data
• documentation data

Question 21

subjective data

Answer 21

things pt tell you about that you cannot observe

Question 22

collection of subjective data

Answer 22

• biographical info
• history of present health concerns
• personal health history
• family history
• health & lifestyle practices
• review of systems

Question 23

objective data

Answer 23

info that is seen, heard, felt, or smelled

Question 24

collection of objective data

Answer 24

• physical characteristics
• body functions
• appearance
• behavior
• measurements
• results of laboratory testing

Question 25

physical examination techniques

Answer 25

inspection, palpation, percussion, auscultation

Question 26

inspection

Answer 26

act of examining/reviewing

Question 27

palpation

Answer 27

examiner's hands are used to feel the texture, size, consistency, and location of body parts

Question 28

percussion

Answer 28

tapping on a surface to determine difference in the density of the underlying structure

Question 29

auscultation

Answer 29

listening w/ stethoscope

Question 30

analysis

Answer 30

- identify abnormal data - cluster data - draw inferences & identify problems - propose possible nursing diagnosis - defining characteristics of diagnosis - confirm/rule out diagnosis - document conclusions

Question 31

models to analyze health promotion and disease prevention

Answer 31

- health belief model | - penders health promotional model