Chapter 16

Question 1

Assessment

Answer 1

Two steps:

a. Collection of information from primary source (the patient) and secondary sources (family members, health professionals, and medical records)
b. The interpretation and validation of data to ensure a complete database.

Question 2

Back channeling

Answer 2

Includes active listening prompts such as “all right”, “go on”, or “uh-huh”. These indicate that you have heard what the patient says and are interested in hearing the full story. Encourages a patient to give more details.

Question 3

Closed-ended questions

Answer 3

Limit answers to one or two words such as “yes” or “no” or a number or frequency of a symptom. Require short answers and clarify previous information or provide additional information. These questions do not encourage the patient to volunteer more information than you request. Helps in acquiring specific information about health problems such as symptoms, precipitating factors, or relief measures.

Question 4

Concomitant symptoms

Answer 4

Symptoms occurring along with primary symptoms. [ex: nausea being accompanied by pain]

Question 5

Cue

Answer 5

Information that you obtain through use of the senses.

Question 6

Database

Answer 6

Consists of the patient’s perceived needs, health problems, and responses to these problems.

Question 7

Functional health patterns: Health perception-health management pattern

Answer 7

Describes patient ’ s self-report of health and well-being; how patient manages health (e.g., frequency of health care provider visits, adherence to therapies at home); knowledge of preventive health practices.

Question 8

Functional health patterns: Nutritional-metabolic pattern

Answer 8

Describes patient ’ s daily/weekly pattern of food and fluid intake (e.g., food preferences or restrictions, special diet, appetite); actual weight; weight loss or gain.

Question 9

Functional health patterns: Elimination pattern

Answer 9

Describes patterns of excretory function (bowel, bladder, and skin.

Question 10

Functional health patterns: Activity-exercise pattern

Answer 10

Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living.

Question 11

Functional health patterns: Sleep-rest pattern

Answer 11

Describes patterns of sleep, rest, and relaxation

Question 12

Functional health patterns: Cognitive-perceptual pattern

Answer 12

Describes sensory-perceptual patterns; language adequacy, memory, decision-making ability

Question 13

Functional health patterns: Self-perception–self-concept pattern

Answer 13

Describes patient ’ s self-concept pattern and perceptions of self (e.g., self-concept/worth, emotional patterns, body image)

Question 14

Functional health patterns: Role-relationship pattern

Answer 14

Describes patient ’ s patterns of role engagements and relationships

Question 15

Functional health patterns: Sexuality-reproductive pattern

Answer 15

Describes patient ’ s patterns of satisfaction and dissatisfaction with sexuality pattern; patient ’ s reproductive patterns; premenopausal and postmenopausal problems

Question 16

Functional health patterns: Coping-stress tolerance pattern

Answer 16

Describes patient ’ s ability to manage stress; sources of support; effectiveness of the patterns in terms of stress tolerance

Question 17

Functional health patterns: Value-belief pattern

Answer 17

Describes patterns of values, beliefs (including spiritual practices), and goals that guide patient ’ s choices or decisions

Question 18

Inference

Answer 18

Your judgment or interpretation of the cues.

Question 19

Nursing health history

Answer 19

Gathered during either your initial or an early contact with a patient. It is a major component of assessment. Most health history forms are structured. Dimensions of gathering data for health history:

a. Physical and developmental: Perception of health status, past health problems and therapies, risk factors, activity and coordination, review of systems, developmental stage, effect of health status on developmental stage, members of household marital problems, growth and maturation, occupation, ability to complete activities of daily living (ADLs).
b. Emotional: Behavioral and emotional status, support systems, self-concept, body image, mood, sexuality, coping mechanisms.
c. Intellectual: Intellectual performance, problem solving, educational level, communication patterns, attention span, long-term and recent memory.
d. Social: financial status, recreational activities, primary language, cultural heritage, cultural influences, community resources, environmental risk factors, social relationships, family structure and support.
e. Spiritual: Beliefs and meaning, religious experiences, rituals and practices, fellowship, and courage.

Question 20

Nursing process

Answer 20

A critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness. Five steps:

a. Asses: Gather information about the patient’s condition
b. Diagnose: Identify the patient’s problems.
c. Plan: Set goals of care and desired outcomes and identify appropriate nursing actions.
d. Implement: Perform the nursing actions identified in planning.
e. Evaluate: Determine if goals and expected outcomes are achieved.

Question 21

Objective data

Answer 21

Observations or measurements of a patient’s health status. The measurement of objective data is based on an accepted standard such as the Fahrenheit or Celsius measure on a thermometer, inches or centimeters on a measuring tape, or known characteristics of behaviors.

Question 22

Open-ended questions

Answer 22

Prompts patients to describe a situation in more than one or two words. Leads to a discussion in which patients actively describe their health status. Strengthens your relationship with a patient because it shows that you want to hear the patient’s thoughts and feelings.

Question 23

Review of systems (ROS)

Answer 23

Systematic approach for collecting the patient’s self-reported data on all body systems. During the ROS ask the patient about the normal functioning of each body system and any noted changes. Taken as subjective data but later confirmed during physical examination.

Question 24

Subjective data

Answer 24

Patient’s verbal descriptions of their health problems. Only patients provide subjective data. Usually includes feelings, perceptions, and self-report of symptoms.

Question 25

Validation

Answer 25

The comparison of data with another source to determine data accuracy.