Assessment - Nursing Assessment, Diagnosis, and Planning

Question 1

Nurses begin their assessment by documenting a comprehensive nursing health ___.

Answer 1

history

Question 2

A detailed database that allows them to plan and carry out nursing care to meet clients’ needs. The goal of this is to focus on the client’s strengths and available support while also highlighting pressing or potential health challenges.

Answer 2

History

Question 3

As a nurse begins client assessment, he or she needs to think critically about what to assess. On the basis of the nurse’s clinical knowledge and experience and the client’s health ___ and responses, the nurse will determine what questions or measurements are appropriate.

Answer 3

history

Question 4

When a nurse first meets a client, the nurse makes a quick o___ overview or screening.

Answer 4

o-bservational

Question 5

Usually an o___ is based on a treatment situation. For example, a community health nurse assesses the neighbourhood and the community of the client; an emergency room nurse uses the circulation-airway-breathing (CAB) sequence; and an oncology nurse focuses on the client’s symptoms from disease and treatment and on the grief response.

Answer 5

o-verview

Question 6

Name, age, sex, date, and place of birth is this type of data.

Answer 6

Identifying data

Question 7

Relationship to client, any special circumstances, such as use of interpreter.

Answer 7

Source of history

Question 8

Explain why you are interviewing the client at the present time (e.g., the client has just been admitted to an inpatient unit or clinic).

Answer 8

Reason for health history interview

Question 9

General state of physical, mental, social, and spiritual health, and health goals. If an illness is present, gather data about the nature of the illness by conducting a symptom analysis.

Answer 9

Current state of health

Question 10

• Relationship status: single, married, partner, separated, widowed, divorced
• Number of children
• Developmental stage
• Current occupation
• Significant life experiences (e.g., education, previous occupations, financial situations, retirement, coping or stress tolerance, and measures normally used to reduce stress)
• Safety hazards (e.g., biological, chemical, ergonomic, physical, psychosocial, reproductive)
• Housing, environmental hazards (e.g., type of housing, location, living arrangements; specific hazards in the home or community)
• Safety measures (e.g., use of seat belts, helmets, presence of smoke detectors and fire extinguishers, and other measures related to specific hazards of work, community, and home)

Answer 10

Developmental variables

Question 11

Mental processes, relationships, support systems, statements regarding client’s feelings about self.

Answer 11

Psychological variables

Question 12

Rituals, religious practices, beliefs about life, client’s source of guidance in acting on beliefs, and the relationship with family in exercising faith.

Answer 12

Spiritual variables

Question 13

• Culture: values, beliefs, and practices related to health and illness
• Primary language and other languages spoken
• Recreation (exercise, hobbies, socializing, use of leisure time)
• Family and significant others, such as authorized representative, i.e., enduring power of attorney. Include family composition, relationships, special problems experienced by family, client’s and family’s response to stress, roles, and support systems. The family history provides information about family structure, interaction, and function that may be useful in planning care. For example, a cohesive, supportive family can help a client adjust to an illness or disability and should be incorporated into the plan of care. However, if the client’s family members are not supportive, it may be better not to involve them in care.
• Outline a family tree (genogram) to determine whether the client is at risk for genetic illnesses and to identify areas of health promotion and illness prevention

Answer 13

Sociocultural variables

Question 14

History of Past Illnesses and Injuries

• Include dates

Answer 14

Physiological Variables (Body Structure and Function)

Question 15

Current Medications

• Prescribed, over-the-counter, or illicit drugs. Include name, dosage, schedule, duration of and reason for use, and expected effects and adverse effects; if illicit drug, include type, amount, response, adverse reaction, drug-related accidents or arrests, attempts to quit

Answer 15

Physiological Variables (Body Structure and Function)

Question 16

Systematic method for collecting data on all body systems.

Answer 16

Review of systems

Question 17

Not all questions in each system may be covered in every history. Nevertheless, some questions about each system are included, particularly when a client mentions a symptom or sign.

Answer 17

Review of systems

Question 18

The nurse begins with questions about the usual functioning of each body system and any noted changes and follows with specific questions.

Answer 18

Review of systems

Question 19

Nurses also focus on measures taken by the client to promote and maintain health and those to prevent illness or injury. Therefore, after a set of questions is asked, the nurse will always follow up with a review of health p___ activities.

Answer 19

p-romotion

Question 20

In the review of systems, asking how the client feels overall (“have you experienced any recent health changes or symptoms?”), fever, chills, malaise, pain, sleep patterns and disturbances, fatigue, recent alterations in weight is an example of:

Answer 20

general overall health state.

Question 21

In the review of systems, itching, colour or texture change, lesions, dryness and use of creams or lotions, changes in hair or nails is an example of:

Answer 21

integumentary.

Question 22

In the review of systems, visual acuity, blurring, eye pain, recent change in vision, discharge, excessive tearing, date of last examination is an example of:

Answer 22

ocular.

Question 23

In the review of systems, hearing loss, pain, discharge, dizziness, perception of ringing in ears, wax is an example of:

Answer 23

auditory.

Question 24

In the review of systems, nosebleeds, nasal discharge, nasal allergies, sinus problems, frequency of colds and usual method of treatment, sore throat and usual type of home remedy, hoarseness or voice changes is an example of:

Answer 24

upper respiratory.

Question 25

In the review of systems, use of tobacco (amount and number of years of smoking; exposure to tobacco smoke; if smoker, attempts to stop smoking), exposure to airborne pollutants, cough, sputum, wheezing, shortness of breath, tuberculosis test and results, date of last chest X-ray examination is an example of:

Answer 25

lower respiratory.

Question 26

In the review of systems, rashes, lumps, discharge, pain, and breast self-examination practices are examples of:

Answer 26

breasts and axillae.

Question 27

In the review of systems, pain and swelling are examples of:

Answer 27

lymphatic.

Question 28

In the review of systems, chest pain or distress, precipitating causes, timing and duration, relieving factors, dyspnea, orthopnea, edema, hypertension, exercise tolerance, circulatory problems, and varicose veins are examples of:

Answer 28

cardiovascular.

Question 29

In the review of systems, appetite, digestion, food intolerance, dysphagia, heartburn, abdominal pain, nausea or vomiting, bowel regularity, use of laxatives, change in stool colour or contents, constipation or diarrhea, flatulence, hemorrhoids, and rectal examinations are examples of:

Answer 29

gastrointestinal.

Question 30

In the review of systems, dietary pattern: calculating number of servings per day of each of the food groups and using Canada’s Food Guide to Healthy Eating for serving size restrictions to food choice; special diets; use of salt; calculating adequacy of fluid intake (should be 30 to 40 mL of fluid per kilogram of body weight); indicating sources of calcium and amounts per day; alcohol use (average number of ounces per week, recent changes in pattern of consumption) is apart of:

Answer 30

gastrointestinal.

Question 31

In the review of systems, painful urination; blood, stones, or pus in urine; bladder or kidney infections; difficulty stopping urinary stream; dribbling or hesitancy; sudden feeling of need to urinate; frequent urination; nocturia (having to get up to void during the night); incontinence are examples of:

Answer 31

urinary.

Question 32

In the review of systems, the following are examples of what system?
• Male: puberty onset, difficulty with erections, emissions, testicular pain, libido, infertility, urethral discharge, genital lesions, exposure to and history of sexually transmitted infections, testicular self-examinations, testicular lump or pain, hernias, sexual preference, birth control method, and safer sex practices used
• Female: menses (onset, duration, regularity, flow, discomfort, date of most recent menstrual period), age at menopause (occurrence of hot flashes, night sweats, vaginal discharge), date of last Pap smear, pregnancies (number, miscarriages, abortions), exposure to and history of sexually transmitted infections, sexual preference, birth control method, and safer sex practices used

Answer 32

Genital and reproductive

Question 33

In the review of systems, pain, joint stiffness or swelling, restricted motion, muscle wasting, weakness, general mobility, use of mobility aids, ability to perform activities of daily living are examples of:

Answer 33

musculoskeletal.

Question 34

In the review of systems, injury, headaches, dizziness, fainting, abnormalities of sensation or coordination, tremors, and seizures are examples of:

Answer 34

neurological.

Question 35

In the review of systems, excessive sweating, thirst, hunger, or urination; intolerance of heat or cold; changes in distribution of facial hair; thyroid enlargement or tenderness; unexplained weight change; and change in glove or shoe size are examples of:

Answer 35

endocrine.

Question 36

In the review of systems, anemia, bruising or bleeding easily, and transfusions are examples of:

Answer 36

hematological.

Question 37

In the review of systems, depression, mood changes, difficulty concentrating, nervousness, anxiety, suicidal thoughts, and irritability are examples of:

Answer 37

psychiatric.

Question 38

In the review of systems, communicable diseases (indicate disease and age at or year of onset), immunization status (indicate year of most recent immunization), and allergies (known allergens and reactions; MedicAlert identification worn) are examples of:

Answer 38

immunological.

Question 39

Information that a nurse obtains through use of the senses.

Answer 39

Cue

Question 40

One’s judgement or interpretation of cues. For example, a client’s crying is a cue that can imply fear or sadness. The nurse asks the client about any concerns and makes known any nonverbal expressions noticed in an effort to direct the client to share his or her feelings.

Answer 40

Inference

Question 41

As nurses collect data, they begin to categorize cues, make i___, and identify emerging patterns, potential problem areas, and solutions.

Answer 41

i-nferences

Question 42

Once the nurse asks a client a question or makes an observation, the information “branches” to an additional series of questions or observations. It is key that nurses an___ assessment questions or the overall assessment may be incomplete or the nurse may miss relevant problem areas. Nurses learn to hone these skills and an___ which questions to ask as they become more experienced in their practice.

Answer 42

an-ticipate x2

Question 43

Example of branching logic for selecting assessment questions.

Answer 43

Question 44

Client data can be categorized in two ways: s___ and o___.

Answer 44

s-ubjective / o-bjective

Question 45

Verbal descriptions of their health concerns.

Answer 45

Subjective data

Question 46

Obtained through the health history and the nurse’s questions and the explanation the client provides.

Answer 46

Subjective data

Question 47

Only clients provide this type of data.

Answer 47

Subjective

Question 48

Data that usually include feelings, perceptions, and self-reports of symptoms.

Answer 48

Subjective

Question 49

Although only clients provide subjective data relevant to their health condition, the data sometimes reflect p___ changes, which nurses further explore through objective data collection. For example, a client may state she feels nauseous. The nurse will then collect further data to support this symptom.

Answer 49

p-hysiological

Question 50

Observations or measurements of a client’s health status.

Answer 50

Objective data

Question 51

Inspection of the condition of a wound, description of an observed behaviour, and measurement of blood pressure are examples of this type of data.

Answer 51

Objective

Question 52

The measurement of this data is based on an accepted standard, such as the Celsius measure on a thermometer, centimetres on a measuring tape, or known characteristics of behaviours (e.g., anxiety or fear).

Answer 52

Objective

Question 53

True or false: objective data may be considered a normal or abnormal finding.

Answer 53

True

Question 54

When nurses collect this type of data, they apply critical thinking standards (e.g., whether the data are clear, precise, and consistent) to help interpret their findings. In the previous example of the subjective symptom of nausea, vomiting (emesis) would be a piece of this type of data that would support this symptom.

Answer 54

Objective

Question 55

Each s___ of data provides information about the client’s level of wellness, strengths, anticipated prognosis, risk factors, health practices and goals, and patterns of health and illness.

Answer 55

s-ource

Question 56

Include primary, secondary, and tertiary sources.

Answer 56

Sources of data

Question 57

The only primary source of data is the ___.

Answer 57

cleint

Question 58

Includes information from someplace other than the client, this may include family members and the client’s medical records.

Answer 58

Secondary sources of data

Question 59

Provides information outside the specific client’s frame of reference and are a result of the nurse’s or other health care team member’s response to care. Sources include textbooks, a nurse’s experience, and patterns noticed in other clients with similar presentations and conditions.

Answer 59

Tertiary sources of data

Question 60

Source example: client’s description of the presenting problem and medical history, narratives of health experiences.

Answer 60

Primary source

Question 61

Sources outside of the client

• Client chart

Examples: nursing notes/charting, physician progress notes, medication administration record, diagnostic and laboratory tests, interdisciplinary team notes. It is important to note that the client is dynamic and changing—chart data shows the client’s history and may not reflect the current health status of the client.

• Family members/significant others

Answer 61

Secondary sources

Question 62

Provides information on the client’s frame of reference (e.g., illness conditions):

• Relevant literature
• Nurse’s experience (e.g. accepted commonalities among clients with similar physical and emotional responses)

Answer 62

Tertiary sources

Question 63

A client is usually the nurse’s ___ source of information.

Answer 63

best

Question 64

Clients who are conscious, alert, and able to answer questions correctly provide the most ___ information about their health care needs, lifestyle patterns, current and past illnesses, perception of symptoms, and changes in activities of daily living.

Answer 64

accurate

Question 65

Nurses always need to consider the s___ for their assessment. It is important that the client has privacy and feels safe in disclosing health information.

Answer 65

s-etting

Question 66

The nurse must also take the current situation into account when taking a health history. For example, a client experiencing acute symptoms in an emergency department will ___ offer as much information as one who comes to an outpatient clinic for a routine check-up. It is imperative that the nurse demonstrate a caring presence with the client by actively listening to the client’s concerns and engaging in caring behaviours while completing an assessment.

Answer 66

not

Question 67

True or false: family members and significant others can be the most knowledgeable sources of information for infants or children, critically ill adults, and mentally challenged, disoriented, or unconscious clients.

Answer 67

True

Question 68

It is important to note that the nurse includes the family only when appropriate. A client may ___ always want the nurse to question the family or may not wish to reveal certain information in front of family members. It is important for the nurse to ask the client p___ if he or she would like the family present during a health history and to always ask permission to have family or other health providers in the room while conducting a physical assessment.

Answer 68

not / p-rivately

Question 69

Spouses or close friends often sit in during an assessment and provide their view of the client’s health problems or needs. They not only supply information about the client’s current health status but are able to tell when ___ in the client’s status occurred.

Answer 69

changes

Question 70

Are often well informed because of their experiences living with the client and observing how health problems affect daily living activities.

Answer 70

Family members

Question 71

It is important to note the difference between using the family as a source of data and family nursing. Family nursing is a comprehensive primary care approach to the health of the entire family that extends b___ collecting additional data about the client.

Answer 71

b-eyond

Question 72

Health Care Team.
Nurses frequently communicate with other health care team members in gathering information about clients. In the acute care setting, the ___-___-___ report is a way for nurses from one shift to communicate information to nurses on the next shift. When nurses, physicians, physiotherapists, social workers, or other staff consult about a client’s condition, they typically have information about the client. This information may include how the client is interacting within the healthcare environment, the client’s physical or emotional reactions to treatment, the result of diagnostic procedures or therapies, and how the client responds to visitors. Every member of the team is a ___ of information for identifying and verifying information about the client.

Answer 72

change / of / shift

source

Question 73

A source of the client’s medical history, laboratory and diagnostic test results, current physical findings, and the medical treatment plan.

Answer 73

Medical record

Question 74

Data in a ___ record offers a baseline and ongoing information about the client’s response to illness and progress to date. Information in a client’s ___ record is confidential.

Answer 74

medical x2

Question 75

A valuable tool for checking the consistency and similarities of personal observations.

Answer 75

Medical record

Question 76

Nurses complete the assessment database by reviewing nursing, medical, and pharmacological ___ about a client’s present health status. This review increases their knowledge about the client’s diagnosed problems, expected symptoms, treatment, prognosis, and established standards of therapeutic practice. A knowledgeable nurse obtains relevant, accurate, and complete information for the assessment database.

Answer 76

literature

Question 77

Nurses utilize the client interview, nursing health history, physical examination findings, and results of laboratory and diagnostic tests to establish a client’s ___ database.

Answer 77

assessment

Question 78

The first step in establishing a database is to collect subjective information by ___ the client.

Answer 78

interviewing

Question 79

An organized conversation with the client.

Answer 79

Interview

Question 80

The initial formal ___ involves obtaining the client’s health history and information about the current illness.

Answer 80

interview

Question 81

During the initial ___, the nurse has the opportunity to do the following:

• Introduce him- or herself to the client, explain the nurse’s role, and explain the role of other health care providers during care
• Establish a caring therapeutic relationship with the client
• Obtain insight into the client’s concerns and worries
• Determine the client’s goals and expectations of the health care system
• Obtain cues about which parts of the data collection phase necessitate further in-depth investigation

Answer 81

interview

Question 82

The nurse and the client become partners during the ___, rather than the nurse controlling the it.

Answer 82

interview

Question 83

Consists of three phases, similar to that of a therapeutic relationship: orientation, working, and termination.

Answer 83

Interview

Question 84

A successful ___ requires preparation.

Answer 84

interview

Question 85

The nurse collects any available information about the client and then creates a favourable environment for the ___.

Answer 85

interview

Question 86

True or false: an environment in which the client is comfortable and relaxed helps the nurse conduct a good interview.

Answer 86

True

Question 87

The nurse must ask the client if he or she would like to conduct the interview alone or if the client would like to include ___ ___.

Answer 87

family members or secondary sources

Question 88

True or false: the nurse selects a place private enough to enable the client to be comfortable when providing personal information.

Answer 88

True

Question 89

During the ___ phase of the interview, the nurse introduces him- or herself, describes the nurse’s position, and explains the purpose of the interview. It is imperative that nurses explain to clients ___ they are collecting data (e.g., for a nursing history or for a focused assessment) and assure them that any information obtained will remain c___ and will be used only by healthcare providers.

Answer 89

orientation / why / c-onfidential

Question 90

In the ___ phase of the interview, nurses gather information about the client’s health status. The nurse does this by focused questioning and other communication strategies such as active listening, paraphrasing, and summarizing to promote a clear interaction.

Answer 90

working

Question 91

The use of ___-ended questions encourages clients to describe their health histories in detail (working phase).

Answer 91

open

Question 92

Nurses use ___-ended questions whenever they want to explore broader issues and have clients describe their history in their own words (working phase).

Answer 92

open

Question 93

Can help to determine the client’s priorities and primary concerns during the working phase of an interview because sometimes these can be different from what the nurse initially thinks the concern is.

Answer 93

Open-ended questions

Question 94

___-ended questions can all be answered by “yes” or “no” (or a choice of answers that the nurse provides); these should be limited to issues in which the nurse does not need additional information from the client.

Answer 94

Closed

Question 95

While open-ended questions can elicit more information about a client’s histories and perceptions of his or her health, closed-ended questions can help a client who is in ___ pain or distress identify his or her emergent or priority needs.

Answer 95

acute

Question 96

___-ended question exmaples:

Tell me how you are feeling.
Your discomfort affects your ability to get around in what way?
Describe how your spouse or partner has been helping you.
Give me an example of how you get relief from your pain at home.

Answer 96

Open

Question 97

examples:

Do you feel as if the medication is helping you?
Who is the person who helps you at home?
Do you understand why you are having the X-ray examination?
Has the warm compress given you relief from your back pain?
Are you having pain now?
On a scale of 0 to 10, with 0 being no pain at all and 10 being the worse possible pain, how would you rate your pain?

Answer 97

Closed

Question 98

During the ___ phase, the nurse obtains a nursing health history by exploring the client’s current illness, health history, and expectations of care.

Answer 98

working

Question 99

The objective for collecting a health ___ is to identify patterns of health and illness, risk factors for physical and behavioural health problems, changes from normal function, and available resources for adaptation.

Answer 99

history

Question 100

True or false: the initial interview is normally the most extensive.

Answer 100

True

Question 101

Their purpose is to update the client’s status and focus more on changes in previously identified problems and identify new problems.

Answer 101

Ongoing interviews

Question 102

In this phase of the interview, the nurse provides the client clues that the interview is coming to an end.

Answer 102

Termination pahse

Question 103

The nurse may say, “I want to ask just two more questions” or “we will be finished in about 2 minutes” in this phase of the interview.

Answer 103

Termination

Question 104

This phase of the interview helps the client maintain direct attention without being distracted by wondering when the interview will end.

Answer 104

Termination

Question 105

This phase of the interview gives the client an opportunity to ask questions.

Answer 105

Termination

Question 106

In this phase of the interview, the nurse summarizes the important points and asks the client whether the summary was accurate.

Answer 106

Termination

Question 107

The interview should end in a friendly manner, such as the nurse telling the client ___ the nurse will return to provide care.

Answer 107

when

Question 108

A skillful interviewer adapts interview strategies on the basis of the client’s res___.

Answer 108

res-ponses

Question 109

Nurses successfully gather relevant health data when they are ___ for the interview and able to carry out each interview phase with minimal interruption.

Answer 109

prepared