Assessment

Question 1

Five step of the nursing process

Answer 1

a. Assess
b. Diagnose
c. Plan
d. Implement
e. Evaluate

Question 2

Critical thinking approach to assessment

Answer 2

Collecting info from pt & from secondary source

Interpreting & validating the info

Question 3

Two stages of assessment

Answer 3

i. Collection & verification of data

ii. Analysis of data

Question 4

Sources of data (5 things)

Answer 4

i. Patient (interview, observation, PE)-best source of info
ii. Family & significant others (obtain pt agreement first)
iii. Health care team
iv. Medical records (pt history, lab work, Xray films)
v. Scientific literature (evidence about disease conditions, assessment techniques, standards)

Question 5

Information that you obtain through use of senses

Answer 5

Cue

Question 6

Example of Cue

Answer 6

Pt lies still with arms along side; tense

P! 7 out 10

Question 7

Type of assessments include

Answer 7

Patient centered interview
PE
Periodic assessment you make during rounds

Question 8

Judgement or interpretation your cues

Answer 8

Inference

Question 9

Example of inference

Answer 9

pain is serve, p! limiting mobility

Question 10

Patient centered interview

Answer 10

Motivational interviewing (used a lot in counseling)

Weight loss/weight gain, smoking habits

Question 11

What is involved in a patient centered interview

Answer 11

Motivational interviewing
Effective communication
Interview prep

Question 12

Phases of interview

Answer 12

i. Orientation & setting an agenda
ii. Working phase
iii. Termination –> a “skill”

Question 13

Prompts pt to describe a situation in more than one or two words

Answer 13

Open-ended questions

Question 14

Example of open-ended questions

Answer 14

What are your concerns about this?

Question 15

Leading questions

Answer 15

can be limiting information

Question 16

Back channeling (active listening)

Answer 16

prompts such as “all right” or “go on”

Question 17

Direct closed-ended questions

Answer 17

yes or no

Question 18

Pt telling his or her story
Encourage full description without trying to control the direction the story takes
What else is bothering you?

Answer 18

Probing

Question 19

Dimensions for gathering data for health history (5 things)

Answer 19

i. Physical & developmental
ii. Emotional
iii. Intellectual
iv. Social
v. Spiritual

Question 20

important aspect of observation include: (4 things)

Answer 20

i. Physical
ii. Developmental
iii. Psychological
iv. Social aspects of everyday living

Question 21

type of interview question does the nurse first use when assessing the reason for a patient seeking healthcare?

Answer 21

open-ended