Chapter 1: Importance of Health Assessment Flashcards

1
Q

Standards of Practice

A

The first six standards are based on the nursing process (i.e.,
assessment, diagnosis, outcome identification, planning,
implementation, and evaluation

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2
Q

signs

A

are objective data observed, felt, heard, or measured.
Examples of signs include rash, enlarged lymph
nodes, and swelling of an extremity.

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3
Q

Standard 5: Implementation

A

The registered nurse implements the identified plan.
5A: Coordination of Care—The registered nurse coordinates
care delivery.
5B: Health Teaching and Health Promotion—The registered
nurse uses strategies to promote health and a safe
environment.
5C: Consultation—The graduate level–prepared specialty
nurse or APRN provides consultation to influence the
identified plan, enhance the ability of others, and effect
change.
5D: Prescriptive Authority and Treatment—The APRN uses
prescriptive authority, procedures, referrals, treatments,
and therapies in accordance with state and federal laws
and regulations.

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4
Q

symptoms

A

are subjective data perceived and reported by
the patient. Examples of symptoms include pain, itching,
and nausea.

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5
Q

clinical judgment

A

“an interpretation
or conclusion about a patient’s needs, concerns, or health
problems and/or the decision to take action (or not), use or
modify standard approaches, or improvise new ones asdeemed appropriate by the patient’s response.”

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6
Q

According to Tanner

A

clinical judgment is
influenced more by the nurse’s experiences, knowledge, attitudes,
and perspectives than the data alone

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7
Q

the process of clinical

judgment includes four components

A

noticing, interpreting,

responding, and reflecting.

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8
Q

Primary prevention

A

Protection to prevent occurrence of disease Immunizations, pollution control, nutrition, exercise

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9
Q

secondary prevention

A

Early identification of disease before it
becomes symptomatic to halt the
progression of the pathologic process Screening examinations and self-examination
practices (e.g., colorectal screening, mammography,
blood pressure screening)

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10
Q

tertiary prevention

A
Minimize severity and disability from
disease through appropriate therapy for
chronic disease   Diabetes mellitus management
Cardiac rehabilitation
Hypertension management
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11
Q

comprehensive assessment

A

This involves a detailed
history and physical examination performed at the onset of
care in a primary care setting or on admission to a hospital
or long-term care facility. The comprehensive assessment
encompasses health problems experienced by the patient;
health promotion, disease prevention, and assessment for
problems associated with known risk factors; or assessment
for age- and gender-specific health problems

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12
Q

problem based/focused assessment

A

The problem based
or problem-focused assessment involves a history
and examination that are limited to a specific problem or
complaint (e.g., a sprained ankle). This type of assessment
is most commonly used in a walk-in clinic or emergency
department, but it may also be applied in other outpatient
settings. Although the focus of data collection is on a specific
problem, the potential impact of the patient’s underlying
health status also must be considered.

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13
Q

episodic/follow up assessment

A

This type of assessment
is usually done when a patient is following up with a
health care provider for a previously identified problem. For
example, a patient treated by a health care provider for
pneumonia might be asked to return for a follow-up visit
after completion of antibiotics. An individual treated for an
ongoing condition such as diabetes is asked to make
regular visits to the clinic for episodic assessment

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14
Q

shift assessment

A

When individuals are hospitalized,
nurses conduct assessments each shift. The purpose of
the shift assessment is to identify changes in a patient’s
condition from baseline; thus the focus of the assessment
is largely based on the condition or problem the patient is
experiencing. Adapting an assessment to the hospitalized
patient is discussed in

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15
Q

screening assessment

A

A screening assessment, or
screening examination, is a short examination focused on
disease detection. A screening examination might be performed
in a health care provider’s office (as part of a comprehensive
examination) or at a health fair. Examples
include blood pressure screening, glucose screening, cholesterol
screening, and colorectal screening.

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16
Q

Health promotion

A

is
behavior motivated by the desire to increase well-being and
actualize human health potential.

17
Q

Health protection

A

is behavior
motivated by a desire to actively avoid illness, detect it
early, or maintain functioning within its constraints

18
Q

Standard 1: Assessment

A

The registered nurse collects comprehensive data pertinent

to the health care consumer’s health and/or the situation.

19
Q

Standard 2: Diagnosis

A

The registered nurse analyzes the assessment data to determine
the diagnoses or issues.

20
Q

Standard 3: Outcome Identification

A

The registered nurse identifies expected outcomes for a plan
individualized to the health care consumer or the
situation.

21
Q

Standard 4: Planning

A

The registered nurse develops a plan that prescribes strategies
and alternatives to attain expected outcomes

22
Q

Standard 6: Evaluation

A

The registered nurse evaluates progress toward attainment

of outcomes

23
Q

The Institute of Medicine identified five core competencies as essential for health care professionals to demonstrate how to respond effectively to patient care needs:

A

provide patient-centered care, work in interdisciplinary teams, use evidence-based practice, apply quality improvements, and use informatics

24
Q

Pain assessment, review of symptoms, surgical history, and social history are considered

A

subjective data

25
Q

The context of care refers the

A

circumstances or situations related to the health care delivery. This may be related to the setting or environment; it might relate to physical, psychological, or socioeconomic circumstances involving patients, or the expertise of the nurse