The Nurse’s Role in Health Assessment

Question 1

the first and most critical phase of the nursing process.

Answer 1

Assessment

Question 2

Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ??? and ??? throughout all phases of the nursing process

Answer 2

ongoing and continuous

Question 3

The nursing process should be thought of as ???, not linear

Answer 3

circular

Question 4

Phases of the Nursing Process

Answer 4

assessment
diagnosis
planning
implementation
evaluation

Question 5

[ADPIE] The arrow between ??? and ??? goes in both directions because these are ongoing processes as well as separate phases.

Answer 5

Assessment and Evaluation

Question 6

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

Answer 6

Diagnosis

Question 7

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

Answer 7

Planning

Question 8

Taking action. Prioritizing and implementing the planned interventions

Answer 8

Implementation

Question 9

Assessing whether outcomes have been met and revising the plan if the interventions did not make a difference

Answer 9

Evaluation

Question 10

A comprehensive health assessment consists of both a
??? and ???

Answer 10

health history and physical examination

Question 11

The purpose of a nursing health assessment is to collect ??? and ??? to determine a client’s overall level of functioning in order to make a ???

Answer 11

• holistic subjective and objective data
• professional clinical judgment.

Question 12

are considered to be interdependent factors that affect a person’s level of health (3)

Answer 12

The mind, body, and spirit

Question 13

ADLs

Answer 13

activities of daily living

Question 14

The nurse, in particular, focuses on how the client’s health status affects ??? and how those affect the
client’s health.

Answer 14

activities of daily living (ADLs)

Question 15

helps to organize information and
promotes the collection of holistic data. This, in turn, provides clues that help to determine human responses.

Answer 15

A nursing framework

Question 16

The questions asked in each physical system’s chapter focus on that particular body system and are broken down into four sections:

Answer 16

History of present health concern
Personal health history
Family history
Lifestyle and health practices

Question 17

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

Answer 17

Data analysis

Question 18

The end result of this data analysis
portion of the nursing process is identification of (3)

Answer 18

client concerns,
collaborative problems,
and/or referrals.

Question 19

The four basic types of nursing assessment are:

Answer 19

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

Question 20

involves collection of subjective data about the client’s perception of their health of all body parts or systems, past health history, family history, and lifestyle and health practices (which include information related to the client’s overall functioning) as well as objective data gathered during a step-by-step physical examination.

Answer 20

initial comprehensive assessment

Question 21

subjective and objective data regarding functional health and body systems

Answer 21

total health assessment

Question 22

needed when the client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared.

Answer 22

total health assessment

Question 23

An ??? of the client consists of data collection that occurs after the comprehensive database is established

Answer 23

ongoing or partial assessment

Question 24

does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern.

Answer 24

focused or problem-oriented assessment

Question 25

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

Answer 25

focused or problem-oriented assessment

Question 26

a very rapid assessment performed in life-threatening situations

Answer 26

emergency assessment

Question 27

situations where emergency assessment is done

Answer 27

choking, cardiac arrest, drowning

Question 28

example of an emergency assessment is the evaluation of the client’s ??? when cardiac arrest is suspected.

Answer 28

airway, breathing, and circulation (known as the ABCs)

Question 29

The assessment phase of the nursing process has four major steps:

Answer 29

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

Question 30

Before actually meeting the client and beginning the nursing health assessment, the nurse should review the ?

Answer 30

client’s medical record, if available

Question 31

are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client

Answer 31

Subjective data

Question 32

To elicit accurate subjective data, learn to use effective ?? skills with a variety of clients in different settings.

Answer 32

interviewing

Question 33

subjective or objective? biographical information

Answer 33

subj

Question 34

subjective or objective? history of present health concern

Answer 34

subj

Question 35

subjective or objective? personal health history

Answer 35

subj

Question 36

subjective or objective? family history

Answer 36

subj

Question 37

subjective or objective? health & lifestyle practices

Answer 37

subj

Question 38

subjective or objective? review of systems

Answer 38

subj

Question 39

subjective or objective? physical characteristics (skin color, posture, etc.)

Answer 39

obj

Question 40

subjective or objective? body functions (HR, RR, etc.)

Answer 40

obj

Question 41

subjective or objective? appearance (dress, hygiene)

Answer 41

obj

Question 42

subjective or objective? behavior

Answer 42

obj

Question 43

subjective or objective? measurements

Answer 43

obj

Question 44

subjective or objective? lab test results

Answer 44

obj

Question 45

This type of data is obtained by general observation and by using the four physical examination techniques

Answer 45

objective data

Question 46

four physical examination techniques:

Answer 46

inspection, palpation, percussion, and auscultation

Question 47

data that may also be observations noted by the family or significant others about the client

Answer 47

Objective

Question 48

a crucial part of assessment that often occurs along with collection of subjective and objective data. It serves to ensure that the assessment process is not ended before all relevant data have been collected and helps to prevent documentation of inaccurate data

Answer 48

Validation of assessment data

Question 49

is an important step of assessment because it forms the database for the entire nursing process and provides data for all other members of the health care team

Answer 49

Documentation of assessment data

Question 50

is defined in this textbook as a problem of a client who may be an individual, family, group, or community.

Answer 50

A client concern

Question 51

client concern other term

Answer 51

nursing problem

Question 52

are defined as certain “physiological complications that nurses monitor to detect their onset or changes in status

Answer 52

Collaborative problems

Question 53

occur because nurses assess the “whole” (physical, psychological, social, cultural, and spiritual) client, often identifying problems that require the assistance of other health care professionals.

Answer 53

Referrals

Question 54

To identify client concerns, collaborative problems, or need for referral, you must go through the steps of ?

Answer 54

data analysis

Question 55

This process requires diagnostic reasoning skills, often called critical thinking

Answer 55

data analysis

Question 56

process of data analysis: -Identify ??? cues and ??? cues. Cluster cues. -Draw ??? and identify and prioritize ???. -Propose possible ??? to notify primary care provider. -Identify need for ??? to primary care provider. -???

Answer 56

- abnormal; supportive - inferences; client concerns - collaborative problems - referral - Document conclusions