Chapter 1B

Question 1

Developing a plan of nursing care and outcome criteria
A. Nursing assessment
B. Planning
C. Nursing diagnostic phase
D. Collaborative problem

Answer 1

B. Planning

Question 2

Analysis of subjective & objective data to make a professional nursing judgment
A. Implementation
B. Nursing diagnostic phase
C. Evaluation

Answer 2

B. Nursing diagnostic phase

Question 3

Collection of subjective & objective data
A. Planning
B. Evaluation
C. Nursing assessment
D. Nursing diagnosis

Answer 3

C. Nursing assessment

Question 4

Sensations or symptoms that can be verified only by the client (e.g., pain)
A. Subjective data
B. Objective data

Answer 4

A. Subjective data

Question 5

Carrying out the plan of care
A. Planning
B. Nursing assessment
C. Implementation

Answer 5

C. Implementation

Question 6

Problem that requires the attention or assistance of other health care professionals
A. Collaborative problem
B. Referral problem

Answer 6

B. Referral problem

Question 7

Assessing whether outcome criteria have been met and revising the plan of care if necessary
A. Nursing assessment
B. Evaluation
C. Nursing diagnostic phase
D. Implementation

Answer 7

B. Evaluation

Question 8

Clinical judgement about individual, family, or community responses to actual or potential health problems and life processes

Answer 8

Nursing diagnosis
(collaborative problem or referral)

Question 9

Findings directly observed or indirectly observed through measurements (e.g., body temperature)

Answer 9

Objective data

Question 10

Physiologic complications that nurses monitor to detect their onset or changes in status

Answer 10

Collaborative problem

Question 11

What are some things that need to be validated ?

Answer 11

• discrepancies or gaps between subjective & objective data
  ex: client says that he’s happy, despite learning that he has terminal cancer
• discrepancies or gaps between what the patient says at one time vs another time
• findings that are highly abnormal

Question 12

It is the nurse’s job to identify areas in which data are missing… provide an example

Answer 12

98 lbs adult patient … nurse needs to know if the patient has always been that size, or is he depressed, or being abused etc.

Question 13

__________ are designed to ensure that the nurse gathers pertinent information needed to meet standards and guidelines of other institutions, and to develop a plan of care for the client. It involves both comprehensive, health, & medical records.

Answer 13

electronic health records “EHR

Question 14

Promotes the adoption and meaningful use of health information technology (HIT)

Answer 14

Health Information Technology for Economic and Clinical Health Act (HITECH Act)

Question 15

Most data start with __________ data and end with _________ data.

Answer 15

subjective
objective

Question 16

What are the two key things that need to be included in every documentation?

Answer 16

Nursing history (subjective)
Physical assessment (objective)

Question 17

The nurse should document only what the client tells, and what the nurse observes, not what the nurse interpret or infer from the data. (T/F)

Answer 17

True

Question 18

Biographical data, present health concerns/symptoms, personal health history, family history, and lifestyle & health practices are examples of _________ data.

Answer 18

subjective

Question 19

A physical examination, which include inspection, palpation, percussion, auscultation & etc. are examples of _________ data.

Answer 19

objective

Question 20

It is important to document using descriptive words rather than non-descriptive words. (T/F)

Answer 20

True

Question 21

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is…

Answer 21

ongoing & continuous

Question 22

Health assessment is divided into four steps:

Answer 22

• collecting subjective data
• collecting objective data
• validation of data
• documentation of data

Question 23

What are the 4 types of nursing assessment?

Answer 23

• initial comprehensive
• ongoing or partial
• focused or problem oriented
• emergency

Question 24

A(n) _____________ assessment involves collection of subjective data about the client’s perception of his or her health of all body parts & systems, past health history, family health history, and lifestyle and health practices as well as objective data

Answer 24

initial comprehensive

Question 25

A(n) ________________ assessment of the client consists of data collection that occurs after the comprehensive database is established… basically a mini-overview

Answer 25

ongoing or partial
ex: a partial assessment of a pt with lung cancer admitted to the hospital requires frequent assessment of resp. rate, oxygen saturation, lung sounds etc.

Question 26

A(n) _______________ assessment does not replace the comprehensive health assessment, it is performed when a comprehensive database exist for a client who comes to the health care agency with a specific health concern.

Answer 26

focused or problem oriented
NOTE: should only focus on he problem & not any other systems

Question 27

A(n) ___________ assessment is a very rapid assessment performed in life-threatening situations. In such situations, an immediate assessment is needed to provide prompt treatment.

emergency

Answer 27

emergency

Question 28

In an emergency, such as cardiac arrest, what is being evaluated?

Answer 28

Airway
Breathing
Circulation
The ABCs of nursing
the evaluation of the client’s airway, breathing, & circulation when cardiac arrest is suspected.

Question 29

The major & only concern during an emergency assessment is…..

Answer 29

to determine the status of the client’s life-sustaining physical functions

Question 30

What parts of the nursing process overlaps?

Answer 30

Assessment & evaluation
**assessment & evaluation are ongoing processes. . when the outcomes are not as anticipated, the nurse needs to revisit (reassess) all steps, collect new data, & formulate

Question 31

The purpose of a nursing health assessment is to collect holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment. (T/F)

Answer 31

True

Question 32

physiological, psychological, sociocultural, developmental, spiritual is what TYPE of data?

Answer 32

holistic data

Question 33

What type of data are included in HOLISTIC DATA?

Answer 33

physiological
psychological
sociocultural
developmental
spiritual