CHAPTER 3-NURSING PROCESS: ASSESSMENT

Question 1

assessment

Answer 1

is the systematic gathering of information related to the physical, mental, spiritual, socioeconomic and cultural status of an individual, group of community

Question 2

patient database

Answer 2

all the pertinent patient data obtained by nurses and other health professionals

Question 3

subjective data

Answer 3

(covert data, symptoms) is information communicated to the nurse by the client, family, or community

Question 4

objective data

Answer 4

(overt data, signs) are gathered from a physical assessment or from laboratory or diagnostic tests

Question 5

primary data

Answer 5

are the subjective and objective data obtained from the client: what the client says or what you observed

Question 6

secondary data

Answer 6

“second hand” for ex: medical record or from another care-giver

Question 7

initial (admission) assessment

Answer 7

is first completed when the client first comes to the healthcare agency

Question 8

ongoing assessment

Answer 8

performed as needed, at any time after the initial database is completed

Question 9

comprehensive assessment

Answer 9

provides holistic information about the clients overall health status

Question 10

focused assessment

Answer 10

obtain data about an actual, potential or possible problem that has been identified or suspected

Question 11

initial focused assessment

Answer 11

used to follow up on client-reported symptoms or unusual findings during first exam

Question 12

ongoing focused assessment

Answer 12

used to evaluate the status of existing problems and goals

Question 13

special needs assessment

Answer 13

is a type of focus assessment,provides in-dept information about a particular area of client functioning and often involves using a specially designed form

Question 14

observation

Answer 14

use of all your senses to gather and interpret patient and environmental data

Question 15

physical assessment

Answer 15

produces primarily objective data

Question 16

nursing interview

Answer 16

is purposeful, structured communication in which you question the patient to gather data for the nursing database

Question 17

directive interviewing

Answer 17

obtain factual, easily categorized information (age, sex) or in an emergency situation

Question 18

closed questions

Answer 18

are those answered with “yes” “no” or there short factual answer

Question 19

non-directive interviewing

Answer 19

you allow the patient to control the subject matter

Question 20

open-ended questions

Answer 20

specify a topic to be explored but phrase it broadly to encourage the patient to elaborate

Question 21

validate

Answer 21

verify data or double check it, helps ensure that it is complete and factual and that you have not jumped to conclusion

Question 22

framework

Answer 22

represents a particular way of thinking about clients and health, it indicates which information is significant and guides you in deciding which patient data to obseve

Question 23

body systems (medical) framework

Answer 23

useful for identifying medical problems

Question 24

maslow’s hierarchy of needs

Answer 24

basic needs must be met before higher needs can be addressed

Question 25

cues

Answer 25

what the client says and what you observe

Question 26

inferences

Answer 26

are judgements and interpretations about what the cues mean