CHAPTER 1

Question 1

The first and most critical phase of nursing process

Answer 1

Assessment

Question 2

If the data collection is inadequate, inaccurate clinical judgment may be made that adversely affect the remaining phases of the nursing process

Answer 2

Assessment

Question 3

Is ongoing and continuous throughout all phases of the nursing process

Answer 3

Assessment

Question 4

It is more than just gathering information about the health status of the client

Answer 4

Assessment

Question 5

It is analyzing and synthesizing those data making judgments and about effectiveness of nursing interventions and evaluating client care outcomes

Answer 5

Assessment

Question 6

Collecting subjective and objective data

Answer 6

Assessment

Question 7

Analyzing subjective and objective data to make and prioritize professional clinical judgments (client concerns, collaborative problems or referral)

Answer 7

Diagnosis

Question 8

Generating solutions, developing a plan and determining which outcomes need to be met first

Answer 8

Planning

Question 9

Taking action. prioritizing and implementing the planned intervention

Answer 9

Implementation

Question 10

Assessing whether outcomes have been met and revising the plan if the intervention did not make it difference

Answer 10

Evaluation

Question 11

What are the four basic types of nursing assessment

Answer 11

•Initial comprehensive assessment
•Ongoing or partial assessment
•Focused or problem oriented assessment
•Emergency assessment

Question 12

Involves collection of subjective data about the client’s perception of their health of all body parts of system, past health history, family history, and lifestyle and health practices

Answer 12

Initial comprehensive assessment

Question 13

Consists of data collection that occurs after the comprehensive database is established

Answer 13

Ongoing or partial assessment

Question 14

This consists of a mini overview of the client’s body systems and holistic health patterns of a follow up on health status

Answer 14

Ongoing or partial assessment

Question 15

Does not replace a comprehensive health assessment

Answer 15

Focused or problem oriented assessment

Question 16

It is performed when a comprehensive database exists for a client who comes to the healthcare agency with specific health concern

Answer 16

Focused or problem oriented assessment

Question 17

Consist of thorough assessment of a particular client problem and does not address areas not related to the problem

Answer 17

Focused or problem oriented assessment

Question 18

Is a very rapid assessment performed in life threatening solutions

Answer 18

Emergency assessment

Question 19

What are the four major steps of health assessment

Answer 19

Collection of subjective data
Collection of objective data
Validation of data
Documentation of data

Question 20

Sensation or symptoms, feelings, perceptions, desires, preference, beliefs, ideas, values, and personal information that can be elicited and verified only by the client

Answer 20

Collection of subjective data

Question 21

What are the six major areas of subjective data

Answer 21

•Biographical information
•History of present health concern
•Personal health history
•Family history
•Health and lifestyle practices
•Review of systems

Question 22

What are the six directly observes objective data

Answer 22

•Physical characteristics
•Body functioning
•Appearance
•Behavior
•Measurements
•Result of laboratory testing

Question 23

It is another source of ________is the clients medical health/record, which is the document that contains information about what other health care professionals, observed about the client.

Answer 23

Objective data

Question 24

It may also be observations noted by the family or SO

Answer 24

Objective data

Question 25

Is a crucial part of a assessment that often occurs along with collection of subjective and objective data

Answer 25

Validation of data

Question 26

It serves to ensure that the assessment process is not intended before all relevant data have been collected and helps to prevent documentation of inaccurate data

Answer 26

Validation of data

Question 27

It forms the database for the entire nursing process and provides data for all other members of the healthcare team

Answer 27

Documentation of data

Question 28

Is the phase in which the nurse identifies and cluster the cues collected to make clinical judgments

Answer 28

Analysis of data

Question 29

Is to collect holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment

Answer 29

Purpose of nursing health assessment

Question 30

Six major steps of process of data analysis

Answer 30

•Identify abnormal cues and supportive cues •Cluster cues •Draw inferences, and identify prioritize client concern •Propose possible collaborative problems to notify the primary care provider •Identify need for referral to primary care provider •Document conclusions