Chapter 1 - Impotance of Health Assessment

Question 0

Heath assessment includes

Answer 0

A. Health history - subjective data
B. Physical exam - objective data
C. Documentation

Question 1

Systematic method of collecting and analyzing data

Answer 1

Health Assessment

Question 2

4 C’s of documentation

Answer 2

Clear
Complete
Correct
Concise

Question 3

6 steps of the nursing process

Answer 3

1. Assessment
2. Diagnosis
3. Outcome
4. Planning
5. Implementing
6. Evaluation

Question 4

Data collected based on what the pt feels/communicates (subjective)

Answer 4

Symptom

Question 5

Data based on clinical findings collected during physical exam (objective)

Answer 5

Sign

Question 6

Signs and/or symptoms collected utilizing inspection, palpitation, percussion, auscultation

Answer 6

Clinical manifestation

Question 7

Documentation of Data

Answer 7

Improves plan of care.
Legal document of pt’s health status, baseline for evaluation, changes and decisions related to care.
Must be accurate, concise, and without bias or opinion.

Question 8

Amount of information gained during a health assessment depends

Answer 8

Context of care
Patient need
Expertise of the nurse

Question 9

Context of care

Answer 9

Refers to circumstances or situation related to HC delivery
May be related to the setting or environment
May be related to the physical, psychological, or socioeconomic circumstances involving the pt

Question 10

Types of Assessment

Answer 10

Comprehensive health assessment
Problem-based or focused health assessment
Episodic assessment
Screening assessment

Question 11

Comprehensive health assessment

Answer 11

Head to toe

Question 12

Problem-based or focused health assessment

Answer 12

Focus on specific problem

Question 13

Episodic assessment

Answer 13

Follow up care

Question 14

Screening assessment

Answer 14

Based on lifestyle habits

Question 15

Type of health assessment performed by the nurse is driven by pt’s need. Must be prepared to conduct appropriate level of assessment.

Answer 15

Patient Need

Question 16

Experience that is gained with specialization within a given area of practice

Answer 16

Expertise of the nurse

Question 17

Clinical reasoning and judgment

Answer 17

The nurse must analyze and interpret data before initiating a plan of care
The outcome of a health assessment is a portrait of the pt physical status, health beliefs, and activities to maintain health, support system, health problems, and available resources to maintain health.

Question 18

Organization and clustering of data that allows problems to be clearly apparent

Answer 18

Data organization

Question 19

Format that can be used of data collection and organization

Answer 19

System format - cardiovascular, musculoskeletal, etc.

Conceptual format - oxygenation, perfusion, mobility

Question 20

Data analysis, interpretation, and clinical judgement includes:

Answer 20

Identifying abnormal findings.
Correctly interpreting findings to select appropriate plan of care.
Applying clinical judgment to interpret or make conclusions regarding pt needs, concerns, or health problems.
After understanding the situation, the nurse responds by determining appropriate interventions.

Question 21

Health promotion and health protection

Answer 21

Central component of nursing.
Begins with health assessment to identify pt health status, practices, and risk factors.
Interpretation of data allows the nurse to target health promotion needs.

Question 22

Behavior motivated by desire to increase well-being and actualize health potential (proactive)

Answer 22

Health promotion

Question 23

Behavior motivated by desire to avoid illness, detect illnesses early and maintain functioning when ill (reactive)

Answer 23

Health protection

Question 24

3 levels of health promotion

Answer 24

Primary Secondary Tertiary

Question 25

Preventing disease from developing through promoting health lifestyle (diet, exercise, immunization)

Answer 25

Primary level of health promotion

Question 26

Screening efforts to promote early detection of disease | BP screen, PAP, colonoscopy

Answer 26

Secondary level of health promotion

Question 27

Minimizing disability from acute to chronic illness or injury and allowing for most productive life within limitations (already has disease, management of disease to decrease severity)

Answer 27

Tertiary level of health promotion

Question 28

4 overarching goals

Answer 28

1. Attain high quality, longer lives free of preventable disease, disability, injury, and premature death. 2. Achieve health quality, eliminate disparities, and improve the health of all groups. 3. Create social and physical environments that promote good health of all groups. 4. Promote quality of life, healthy development, and healthy behaviors across all life stages.