Collecting and Analyzing Data

Question 1

what is a holistic nursing assessment

Answer 1

collects holistic subjective and objective data to determine overall level of functioning in order to make professional clinical judgement

Question 2

what is a physical medical assessment

Answer 2

focuses mainly on physiologic development status

Question 3

what is a initial comprehensive assessment

Answer 3

collection of subjective data about perception of health of body parts/systems, past med hx, family hx, and lifestyle and health practices

Question 4

what is an ongoing/partial assessment

Answer 4

data collection that occurs after comprehensive database is established

Question 5

what is a focused/problem-orientated assessment

Answer 5

assessment of particular problem, doesn’t cover areas not related to problem

Question 6

what is an emergency assessment

Answer 6

very rapid assessment used life-threatening situations

Question 7

what are the 5 phases of nursing process

Answer 7

assessment, diagnosis, planning, implementation, evaluation (ADPIE)

Question 8

what is phase I of nursing process

Answer 8

assessment: collecting subjective and objective data

Question 9

what is phase II of nursing process

Answer 9

diagnosis: analyzing all data to make professional nursing judgment (diagnosis, collaborative problem, refferal)

Question 10

what is phase III of nursing process

Answer 10

planning: determining outcome criteria and developing plan; SMART (specific, measurable, attainable, realistic, timely)

Question 11

what is phase IV of nursing process

Answer 11

implementation: carrying out plan

Question 12

what is phase V of nursing process

Answer 12

evaluation: assessing whether outcome criteria have been met and revising plan as necessary

Question 13

what are the phases of subjective interviewing

Answer 13

pre-intro, intro, working, summary and closing

Question 14

what happens in pre-intro phrase

Answer 14

nurse reviews med record which may reveal past health hx and CC before meeting with pt to assist with interview

Question 15

what happens in intro phase

Answer 15

explain purpose of interview, discuss kind of questions being asked, explain note taking, assure HIPAA, develop trust and rapport

Question 16

what happens in working phase

Answer 16

collection of following subjective data (complete/comprehensive health hx or CHH):
biographical data
CC
HPI
personal past health hx
family hx
lifestyle and health practices
developmental level (pediatrics)
review of body systems for health problems

Question 17

what happens in summary and closing phase

Answer 17

summarize info obtained, validate problems and goals with pt
identify and discuss possible plans to resolve problem, other concerns/questions

Question 18

what is biographical data

Answer 18

name, address, phone, self-identified gender and pronoun, identify hx provider, DOB, birthplace, race/ethnicity, primary and secondary languages, marital status, religious/spiritual practices, education, occupation, partners/support persons, insurance and/or availability

Question 19

mnemonic used to gather HPI

Answer 19

COLDSPA (Concerns character, Onset, Location, Duration, Severity, Pattern, Associated factors)

Question 20

what is reviewed during ROS

Answer 20

HEENT (Head/sinuses, eyes, ears, nose, throat/mouth), respiratory (lungs), cardiac, thorax/breasts, GI/GU, anus/rectum/prostate, musculoskeletal, integumentary/derm (skin, hair, nails), neurological, lymphatic

Question 21

what should you do before physical exam (PE)

Answer 21

introduce yourself, describe steps of examination, respect client’s wishes, explain importance of exam and need for position changes, communicate timeline and purpose of exam phases, leave room when pt is changing, begin exam with less invasive procedures

Question 22

how do you conduct a general survey

Answer 22

visually make observations of person/system being assessed, observe general disposition, demeanor, and behavior (mental health/neuro system), observe clothes and speech and responses, orientation to person and place and time and surroundings/location, look and observe before touching all systems, normal vs abnormal behavior for age and development

Question 23

what are 4 PE techniques

Answer 23

inspection, auscultation, palpation, percussion