Chapter 1 - Book Qs, Blocks, Key Concepts, Pre-Quiz Flashcards
The three major frameworks to organize assessment findings include the functional assessment based on Gordon’s functional patterns, the systematic ___________ assessment, and body systems assessment.
head-to-toe
T / F Five nursing values are used by the nurse to guide professional roles.
TRUE
T / F The purpose of the nurse performing the health assessment is to discover symptoms that support the medical diagnosis.
FALSE
T / F According to the American Nurses Association, the professional nurse’s role involves four broad areas that define nursing practice.
TRUE
Evidence-based nursing provides individualized nursing care from best _____________ and scientific findings.
research
There are 10 areas of focus in the U.S. Department of Health and Human Services Healthy People 2020 which provides strategies based on health promotion and ___________ reduction strategies.
risk
Health assessment is the first step of the nursing process and includes the health assessment, which is _______________ data, and the physical assessment, which is ______________ data.
subjective, objective
T / F The type of assessment used during a life-threatening situation is the focused assessment.
FALSE
Diagnostic reasoning is a seven-step process of _____________________; the nurse gathers and clusters data, draws inferences, and develops nursing diagnoses.
critical thinking
T / F The nursing process consists of three parts: assessment, planning, and evaluation.
FALSE
Because all future care is based on the ____ _________, it is extremely important that its data is complete and accurate. This is one of the most important skills that you will use as a nurse.
health assessment
review this a few times
All life-threatening problems identified during the initial assessment require the initiation of ______ interventions:
- Provide assistance with circulation (cardiopulmonary resuscitation if needed).
- Open the patient’s airway.
- Assist the patient’s breathing.
- Protect the cervical spine if the patient is injured.
- Ensure that the disoriented or suicidal patient is safe.
- Provide pain management and sedation.
critical
The role of the professional nurse is to promote ___, prevent ____, treat human _____, and _____ for patients.
health
illness
responses
advocate
Nurses are providers, designers, managers, and coordinators of care as well as advocates and educators.
just read a couple times
Nursing values include = name all 5
respect, unity, diversity, integrity, and excellence.
Health can be conceptualized as a point between _____ and ______, as either a high or a low level of health.
wellness
illness
Healthy People is a United States government initiative to focus on ____ promotion and ____ reduction strategies.
health
risk
The four main goals of nursing are to
promote ____;
prevent ____;
treat human responses to health and illness;
and ______ for individuals, families, and communities.
health
illness
advocate
Steps of the nursing process include ______, diagnosing, setting goals and outcomes, planning, ________, and evaluating.
assessing
intervening
______ thinking is the key to resolving problems.
Critical
__________ is a process by which nurses use critical thinking to cluster the assessment information and to draw inferences and propose diagnoses.
Diagnostic reasoning
Types of assessments are _______, comprehensive, and focused assessments.
emergency
Organizing frameworks for assessment include _______, head-to-toe, and ___ ______.
functional
body systems
1) A patient is having adverse effects resulting from a medication. The nurse calls the primary care provider to request a change in the medication order. The nurse is functioning as a/an
educator.
advocate.
organizer.
counselor.
B. Advocate. Rationale: By voicing concerns about the patient, the nurse functions as an advocate to improve the quality of care.
Nurses advocate for underserved populations to reduce health disparities. This promotes
autonomy.
altruism.
respect.
human dignity.
C. Respect. Rationale: When nurses treat individuals, families, and communities to improve the disparities present in the health care system, they promote respect and social justice.
3) Nurses belong to the ANA as part of their:
ongoing professional responsibility.
role as manager of care.
wellness promotion for patients.
cultural education activities.
A. Ongoing professional responsibility. Rationale: Nurses continually learn and promote health as part of their ongoing professional responsibility.
The purpose of health assessment is to
obtain subjective and objective data.
intervene to correct difficulties.
outline appropriate care.
determine whether interventions are effective.
A. Obtain subjective and objective data. Rationale: Health assessment is the method by which nurses gather subjective and objective data.
The nurse documents the following information in a patient’s chart: “Cough and deep breathe every hour while awake.” This is an example of
evidence-based nursing.
priority setting.
comprehensive assessment.
nursing interventions.
D. Nursing interventions. Rationale: Nursing interventions are actions taken by the nurse to promote health. They usually begin with a verb and have a time frame.
The nurse provides teaching about smoking cessation to a 20-year-old man. The nurse assesses that the patient is concerned because his father died from lung cancer. Which theory would the nurse most likely use when providing teaching to this patient?
Health belief model
Diagnostic reasoning model
Cultural competence model
Body systems model
A. Health belief model. Rationale: The nurse will use the health belief model to assess the patient’s perspective about the relationship between smoking and lung disease. The patient’s family experience, he may have some personal beliefs that influence his motivation to stop smoking, which the nurse must assess.
Which of the following processes is the most important when providing nursing care to an ill patient?
Writing outcomes
Performing a focused assessment
Collecting objective data
Using critical thinking
D. Using critical thinking. Rationale: Assessment provides a solid foundation for care, but it is only one step in the nursing process. Critical thinking is used in all phases of the nursing process.
A patient is admitted to a hospital for surgery for colon cancer. What type of assessment is the nurse most likely to perform on admission?
Emergency
Focused
Comprehensive
Illness
C. Comprehensive. Rationale: Because surgery involves all body systems, it is important to perform a comprehensive assessment.
Which of the following are components of a comprehensive health assessment?
Nursing diagnoses
Goals and outcomes
Collaborative problems
Examination of body systems
D. Examination of body systems. Rationale: In a comprehensive assessment, the nurse collects subjective and objective data. These include a history of the current problem, medical history, and common symptoms, as well as a head-to-toe physical examination.
The nurse conducts the health history based on the patient’s responses to the medical diagnosis. This type of framework is based on the
functional framework.
objective framework.
coordinator framework.
collaborative framework.
A. Functional framework. Rationale: It is based on the functional framework. In the medical model, the provider evaluates the medical diagnosis, such as myocardial infarction. The provider may order some diagnostic tests to evaluate the extent of damage. The nurse assesses the patient’s response to the myocardial infarction, such as fluid retention or arrhythmias. Additionally, the nurse assesses functional abilities, such as coping, role performance, and activity tolerance.
T/ F
A health assessment includes both a health history and a physical assessment.
True
Rationale: A health assessment is made up of the following two parts: a health history and a physical assessment.
When are focused assessments conducted?
A. At different ages across the lifespan
B. After specific treatments are given
C. When a patient is in the acute care setting
D. Only in the outpatient setting
B. After specific treatments are given
Rationale: Patients also have focused assessments following treatments to monitor their effectiveness.
Which physical assessment framework promotes critical thinking?
A. Functional
B. Head-to-toe
C. Comprehensive
D. Body systems
D. Body systems
Rationale: A body systems approach is a logical tool for organizing data when documenting and communicating findings. This method promotes critical thinking and allows nurses to analyze findings as they cluster similar data.
