Chapter 16: Nursing Assessment

Question 1

The deliberate and systematic collection of information about a patient to determine his or her current and past health and functional status and his or her present and past coping patterns. This is defined as what?

Answer 1

Assessment

Question 2

Active listening prompts such as alright, go on, or uh-huh. This is defined as what?

Answer 2

Back channeling

Question 3

• Questions that prompt a patient to give 1 or 2 word answers such as yes or no. This is defined as what?

Answer 3

Closed-ended questions

Question 4

Symptoms that appear along side the primary symptoms.. This is defined as what?

Answer 4

Concomitant symptoms

Question 5

Information you obtain through use of senses.

This is defined as what?

Answer 5

Cue

Question 6

The patients perceived needs health problems and responses to these problems.
This is defined as what?

Answer 6

Database

Question 7

Structured database format based on an accepted theoretical framework or practice standard. This is defined as what?

Answer 7

Functional health patterns

Question 8

Your judgment or interpretation of cues.

This is defined as what?

Answer 8

Inference

Question 9

Based on information you gain from the patients history you learn which components of the history to explore fully and which require less detail.
This is defined as what?

Answer 9

Nursing health history

Question 10

Critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness. This is defined as what?

Answer 10

Nursing process

Question 11

Observations of measurements of a patients health status. This is defined as what?

Answer 11

Objective data

Question 12

Prompts patients to describe a situation in depth. This is defined as what?

Answer 12

Open-ended questions

Question 13

Systematic approach for collecting the patients self recorded data on all body systems. This is defined as what?

Answer 13

Review of systems (ROS)

Question 14

Patients verbal descriptions of their health problems. This is defined as what?

Answer 14

Subjective data

Question 15

Comparison of data with another source to determine data accuracy. This is defined as what?

Answer 15

Validation

Question 16

What critical thinking process do professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses.

Answer 16

Nursing Process

Question 17

This is a standard of practice, which, when followed correctly, protects nurses against legal problems related to nursing care.

Answer 17

Nursing Process

Question 18

assessment, diagnosis, planning, implementation, and evaluation are all apart of what process? This process is dynamic and continuous; and, after more experience in practice, you learn to move back and forth among the various steps

Answer 18

Nursing Process

Question 19

Mr. Jacobs is a 58-year-old patient who had a radical prostatectomy (removal of prostate gland) for prostate cancer yesterday. He is married to Martha, who has been at his bedside most of the morning. His nurse, Tonya Moore, just started the day shift on the surgical unit and finds the patient lying flat in bed with arms tensed and extended along his sides. When Tonya checks the surgical wound and drainage device, she notes that Mr. Jacobs winces when she gently places her hands to palpate around the incisional area. She asks Mr. Jacobs when he last turned onto his side, and he responds, “Not since last night some time.” Tonya asks Mr. Jacobs if he is having incisional pain, and he nods yes, saying, “It hurts too much to move.” Tonya clarifies, “On a scale of 0 to 10 with 0 being no pain and 10 being the worst pain you have ever had, rate how you feel now.” Mr. Jacobs states, “Oh, this is at least a 7.” Tonya considers the information she has observed and learned from Mr. Jacobs to determine that he is in pain and has reduced mobility because of it. She decides that she needs to take action to relieve Mr. Jacobs’ pain so she can turn him more frequently and begin to get him out of bed for his recovery. This is an example of what process?

Answer 19

Nursing Process: Each time you meet a patient, you apply the nursing process, as Tonya did while caring for Mr. Jacobs, to provide appropriate and effective nursing care. The process begins with the first step, assessment, the gathering and analysis of information about the patient’s health status. You then make clinical judgments from the assessment to identify the patient’s response to health problems in the form of nursing diagnoses. Once you define appropriate nursing diagnoses, you create a plan of care. Planning includes setting goals and expected outcomes for your care and selecting interventions (nursing and collaborative) individualized to each of the patient’s nursing diagnoses. The next step, implementation, involves performing the planned interventions. After performing interventions, you evaluate the patient’s response and whether the interventions were effective. The nursing process is central to your ability to provide timely and appropriate care to your patients.

Question 20

This assessment includes two steps: 1. Collection of information from a primary source (the patient) and secondary sources (e.g., family members, health professionals, and medical record) 2. The interpretation and validation of data to ensure a complete database. The purpose of this is to establish a database about the patient’s perceived needs, health problems, and responses to these problems. In addition, the data reveal related experiences, health practices, goals, values, and expectations about the health care system.

Answer 20

Critical thinking in Nursing Assessment

Question 21

Tonya knows that Mr. Jacobs had his prostate gland removed. She reviewed her Med-Surg book and learned that a radial prostatectomy involves removal of a lot of tissue, including the prostate gland, seminal vesicles, part of the bladder neck, and lymph nodes. This knowledge helps her to recognize that considerable swelling can potentially create acute pain; thus she decides to inspect and palpate around Mr. Jacob’s incisional area. She also questions Mr. Jacob’s about how the discomfort affects his ability to turn or move in bed. This is an example of what of what type of thinking in assessment.?

Answer 21

Critical thinking in nursing assessment: Prior clinical experience contributes to the skills of assessment. For example, Tonya cared for a patient with surgical incision pain in the past and knows that pain is often disabling and limits a patient’s normal motion. This experience allows Tonya to thoroughly assess the extent to which pain affects the patient’s ability to move and eventually get out of bed, an important step in Mr. Jacob’s recovery. Validation of any abnormal assessment findings and personal observation of assessments performed by skilled professionals help you become competent in assessment. You also learn to apply standards of practice and accepted standards of “normal” for physical assessment data when assessing patients. Use of critical thinking attitudes such as curiosity, perseverance, and confidence ensure you complete a comprehensive database

Question 22

You perform assessment to gather information needed to make an accurate judgment about a patient’s current condition.
Your information comes from:
The patient, through interview, observations, and physical examination.
Family members or significant others’ reports and response to interviews.
Other members of the health care team.
Medical record information (e.g., patient history, laboratory work, x-ray film results, multidisciplinary consultations).
Scientific literature (evidence about assessment techniques and standards).
This is an example of what data?

Answer 22

Data Collection

Question 23

A patient crying possibly implies fear or sadness. You ask the patient about any concerns and make known any nonverbal expressions you notice in an effort to direct the patient to share his or her feelings. This is an example of what?

Answer 23

A cue. , always try to interpret cues from the patient to know how in depth to make your assessment.

Question 24

Describes patient’s self- report of health and well-being; how patient manages health (e.g., fre- quency of health care provider visits, adherence to therapies at home); knowledge of preventive health practices. Which Gordons Model of 11 Functional Health patterns is this?

Answer 24

Health perception–health management pattern

Question 25

Describes patient’s daily/weekly pattern of food and fluid intake (e.g., food preferences or restrictions, special diet, appetite); actual weight; weight loss or gain.
Which Gordons Model of 11 Functional Health patterns is this?

Answer 25

Nutritional-metabolic pattern

Question 26

This describes patterns of excretory function (bowel, bladder, and skin)
Activity-exercise pattern: Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living. Which Gordons Model of 11 Functional Health patterns is this?

Answer 26

Elimination pattern

Question 27

Describes patterns of sleep, rest, and relaxation. Which Gordons Model of 11 Functional Health patterns is this?

Answer 27

Sleep-rest pattern

Question 28

Describes sensory-perceptual patterns; language adequacy, memory, decision-making ability.Which Gordons Model of 11 Functional Health patterns is this?

Answer 28

Cognitive-perceptual pattern:

Question 29

Describes patient’s self-concept pattern and perceptions of self (e.g., self-concept/worth, emotional patterns, body image) Which Gordons Model of 11 Functional Health patterns is this?

Answer 29

Self-perception–self-concept pattern

Question 30

Describes patient’s patterns of role engagements and relationships. Which Gordons Model of 11 Functional Health patterns is this?

Answer 30

Role-relationship pattern

Question 31

Describes patient’s patterns of satisfaction and dissatisfaction with sexuality pattern; patient’s reproductive patterns; premenopausal and postmenopausal problems. Which Gordons Model of 11 Functional Health patterns is this?

Answer 31

Sexuality-reproductive pattern

Question 32

Describes patient’s ability to manage stress; sources of support; effectiveness of the patterns in terms of stress tolerance. Which Gordons Model of 11 Functional Health patterns is this?

Answer 32

Coping–stress tolerance pattern

Question 33

Describes patterns of values, beliefs (including spiritual practices), and goals that guide patient’s choices or decisions. Which Gordons Model of 11 Functional Health patterns is this?

Answer 33

Value-belief pattern

Question 34

As a nurse you use _______________,interview the nursing health history, physical examination, and results of laboratory and diagnostic tests to collect data for a patient’s assessment database. This interview is an approach for obtaining from patients the data that are needed to foster a caring nurse-patient relationship, adherence to interventions, and treatment effectiveness.

Answer 34

Patient-Centered Interview

Question 35

(1) setting the stage
(2) gathering information about the patient’s chief concerns or problems and setting an agenda
(3) collecting the assessment or a nursing health history
(4) terminating the interview.
These are steps in which type of interview?

Answer 35

An initial patient- centered interview involves:

Question 36

, “So, why did you come to the hospital today?” or “Tell me about the problems you’re having.” This is an example of what type of question

Answer 36

Open-Ended Questions

Question 37

Patient, Family members, health care team

Answer 37

Reliable Sources of Data

Question 38

This review increases your knowledge about the patient’s diagnosed problems, expected symptoms, treatment, prognosis, and established standards of therapeutic practice. This is an example of what type of data?

Answer 38

Scientific Journal

Question 39

Your patients’ verbal descriptions of their health problems. usually include feelings, perceptions, and self-report of systems. This is an example of what type of data

Answer 39

Subjective Data

Question 40

observations or measurements of a patient’s health status. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of what type of data?

Answer 40

Objective Data