Chapter 11

Question 1

Data

Answer 1

reflect how health functioning is enhanced by health promotion or compromised by illness/injury

Question 2

database

Answer 2

• includes all the pertinent patient information collected by the nurse and other health care professionals.
• enables the nurse to partner with patients to develop a comprehensive and effective plan of care.

Question 3

Four Types of Nursing Assessments

Answer 3

• Initial comprehensive
• Focused
• Emergency
• Time-lapsed

Question 4

focused assessment

Answer 4

the nurse gathers data about a specific problem that has already been identified

Question 5

An initial comprehensive assessment

Answer 5

Performed shortly after admittance to hospital

Question 6

emergency assessment

Answer 6

Performed when a physiologic or psychological crisis presents

Question 7

A time-lapsed assessment

Answer 7

is scheduled to compare a patient’s current status to the baseline data obtained earlier

Question 8

Medical assessments

Answer 8

target data pointing to pathologic conditions

Question 9

Nursing assessments

Answer 9

focus on the patient’s response to health problems

Question 10

Objective data

Answer 10

• Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
• For example, elevated temperature, skin moisture, vomiting

Question 11

Subjective data

Answer 11

• Information perceived only by the affected person

- For example, pain experience, feeling dizzy, feeling anxious

Question 12

Characteristics of Data

Answer 12

• Purposeful
• Complete
• Factual and accurate
• Relevant

Question 13

Four Phases of a Nursing Interview

Answer 13

Preparatory phase
Introduction
Working phase
Termination

Question 14

Purpose of a Nursing Physical Assessment

Answer 14

• Appraisal of health status
• Identification of health problems
• Establishment of a database for nursing intervention

Question 15

Problems Related to Data Collection

Answer 15

• Inappropriate organization of the database
• Omission of pertinent data
• Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data
• Failure to establish rapport and partnership
• Recording an interpretation of data rather than observed behavior
• Failure to update the database

Question 16

When to Verify Data

Answer 16

• When there is a discrepancy between what the person is saying and what the nurse is observing
• When the data lack objectivity

Question 17

Documentation of Data

Answer 17

• Immediately give verbal reporting of data whenever a critical change in the patient’s health status is assessed.
• Enter initial database into computer or record in ink on designated forms the same day patient is admitted.
• Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner.
• Use good grammar and standard medical abbreviations.
• Whenever possible, use patient’s own words.
• Avoid nonspecific terms subject to individual interpretation or definition.