Ch. 6

Question 1

Observation

Answer 1

Gather significant information about a patient’s emotional condition and health status by observing the patients affect, clothing, personal hygiene and obvious physical conditions (limp or open wound)
Use senses of sight, hearing and smell; helps to guide further aspects of the assessment

Question 2

Patient interview

Answer 2

Formal, structured discussion where the nurse questions the patient to obtain demographic info, data about current health concerns and medical and surgical histories
Includes developmental, cultural, ethnic and spiritual factors

Question 3

Orientation phase

Answer 3

Should establish the preferred patient name.
Nurse provides a personal introduction and states the purpose - establishes trust and affects future interactions.
Environment and timing are crucial

Question 4

Life span (orientation)

Answer 4

Consider the patients generational cohort, which influences behavior and willingness to share personal information

Question 5

Culture, ethnicity and religion (orientation)

Answer 5

Affect willingness of patient interaction.
Nurses explain need for info that may be considered intimate.
Privacy must be provided.
Traditional treatments should be explored.
Obtain interpretation if language barrier exists.

Question 6

Gender (orientation)

Answer 6

Personal space, communication patterns and gender considerations should be incorporated.
Requests for same gender nurses should be honored.

Question 7

Morphology (orientation)

Answer 7

Physical assessment requires patient cooperation.
Positioning may be difficult for some people (obese patients)
Adjusting locations for assessments/examinations may be necessary.

Question 8

Disability (orientation)

Answer 8

Paralyzed patients.
If mentally disabled patients, ask care provider.
Make any required adaptations during assessment

Question 9

Working phase

Answer 9

Nurse must stay focused on the purpose.
Needs to individualize the process on the basis of health of the patient and concerns that emerge during the course of the interview.
Active, engaged listening.
How the patient shares info, is more important than what patient says.

Question 10

Health history (working)

Answer 10

Includes all pertinent info that can guide the development of patient-centered care

Question 11

Review of systems (working)

Answer 11

Asking patients questions pertaining to each body system.

Question 12

Termination phase

Answer 12

End of the interview process.
Summarizing and validating the info covered with the patient.
Allow opportunity for patient to interject any other pertinent info not covered.
Describe the next steps.

Question 13

Inspection

Answer 13

Use vision, hearing and smell to assess physical characteristics of a whole person and individual body systems.

Question 14

Palpitation

Answer 14

Uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness

Question 15

Percussion

Answer 15

Tapping the patients skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures

Question 16

Auscultation

Answer 16

Listening with the assistance of a stethoscope to sounds made by organs or systems (heart, blood vessels, lungs and abdominal)

Question 17

Cannot be delegated

Answer 17

Initial and ongoing assessments.

Initial patient assessments of unstable patients.

Question 18

Can be delegated

Answer 18

Routine assessment of vital signs of a stable patient.

- first nurses must: determine stability and complexity, verify capability of UAP, collaborate to confirm completion

Question 19

Comprehensive assessment

Answer 19

Thorough interview, health history, review of systems and extensive physical head-to-toe assessment (evaluation of cranial nerves and sensory organs).

Question 20

Focused assessment

Answer 20

Brief individualized physical exam conducted at the beginning of an acute care setting work shift to establish current patient status OR during ongoing patient encounters in response fo a specific patient concern

Question 21

Emergency assessment

Answer 21

Done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes.
Based on quick survey of accident or illness onset, followed by narrowly focused physical exam or critical injuries or symptoms and signs

Question 22

Level 1

Answer 22

Critical: life-threatening condition

Question 23

Level 2

Answer 23

Emergent: imminently life-threatening condition

Question 24

Level 3

Answer 24

Urgent: potentially life-threatening condition

Question 25

Level 4

Answer 25

Nonurgent: stable health condition

Question 26

Level 5

Answer 26

Fast track: less urgent

Question 27

Primary data

Answer 27

Direct from patients

Question 28

Secondary data

Answer 28

Comes from family, friends or other members of the health care team

Question 29

Subjective data

Answer 29

Spoken info or symptoms that cant be authenticated

Question 30

Objective data

Answer 30

Signs.
Can be measured or observed.
Observation, physical exams, or lab tests

Question 31

Cue

Answer 31

Hint or indication of a potential disease process or disorder

Question 32

Data interpretation

Answer 32

Careful observation and attention to detail.
Avoid inferences - based on personal preferences, past experiences, generalizations or outdated and inaccurate health care info

Question 33

Accurate interpretation

Answer 33

Requires that the nurse has a wide breadth of knowledge, including disease processes, vital sign parameters, and normal values and outcomes for lab tests.

Question 34

Body system model

Answer 34

Organizes data on the basis of each system of the body:
Integumentary, respiratory, cardiovascular, nervous, reproductive, musculoskeletal, gastrointestinal, genitourinary, and immune.

Question 35

Head-to-toe model

Answer 35

Ensures that all areas of concern are addressed

Question 36

Gordon’s functional health patterns

Answer 36

Assessment data is based on areas of function.
Focuses on patients strengths.
Ex. Health and exercise, nutrition and metabolism, cognition and perception.

Question 37

Identify methods used during the assessment phase

Answer 37

observation; patient interview; a health history; review of systems; physical exam

Question 38

Describe techniques used during physical assessment

Answer 38

Inspection, palpitation, percussion, auscultation.

Performed one at a time.

Question 39

Differentiate among the three types of physical assessments

Answer 39

Complete: admission to hospital, initial visits, or annual physical.
Focused: beginning of each shift, or depending on patients condition.
Emergency: triage, quick, and determine care priorities

Question 40

Which action by a patient marks the beginning of the physical assessment process?

Answer 40

Greeting the nurse in the exam room

Question 41

Which factors should be taken into consideration by the nurse before and during a patient interview?

Answer 41

Distance between nurse and patient, traditional treatments used by patient, gender preference, physical condition

Question 42

Which action by the nurse is most appropriate during the orientation phase of the patient interview?

Answer 42

Ask which name a patient prefers to be called during care to build trust and to show respect

Question 43

Which activity by the nurse best demonstrates part of the working phase of a patient interview?

Answer 43

Including selected family members in care planning

Question 44

Which entry in a patients EMR best indicates the need for a nurse to gather secondary rather than primary subjective date?

Answer 44

When a patient is comatose

Question 45

Which link of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process?

Answer 45

Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?

Question 46

Which cue by a patient can be validated by a lab and diagnostic test result?

Answer 46

Deeply sighing with fatigue

Question 47

A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively?

Answer 47

Functional health patterns model

Question 48

When initiating a physical exam, which action should the nurse take first?

Answer 48

Assess the patients vitals

Question 49

If the nurse discovers that a patients right elbow is swollen and painful during an exam, which action should the nurse take first?

Answer 49

Inspect the patients left elbow to compare its appearance