Fundamentals: Chapter 16

Question 1

Define the Nursing Process

Answer 1

A 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.

Question 2

How often does a nurse apply the nursing process?

Answer 2

each time you meet a patient

Question 3

What is 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?

Answer 3

assessment

Question 4

What provides the basis for planning and implementing nursing interventions and evaluating the outcomes of care?

Answer 4

clearly defining your patients’ problems

Question 5

What are the two steps of the nursing assessment?

Answer 5

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

Question 6

What is the purpose of the assessment?

Answer 6

to establish a database about the patient’s perceived needs, health problems, and responses to these problems

Question 7

Why is critical thinking a vital part of the assessment?

Answer 7

It allows you to see the big picture when you form conclusions or make decisions about a patient’s health condition.

Question 8

What is information that you obtain through use of the senses?

Answer 8

cue

Question 9

What is your judgment or interpretation of the information you obtain through use of the senses?

Answer 9

inference

Question 10

What are the 11 functional health patterns?

Answer 10

Health perception

Nutritional-metabolic pattern

Elimination pattern

Activity-exercise pattern

Sleep-rest pattern

Cognitive- perceptual pattern

Self perception-Self concept pattern

Role-relationship pattern

Sexuality-reproductive pattern

Coping-stress tolerance pattern

Value-belief pattern

Question 11

Who can provide subjective data?

Answer 11

only the patients

Question 12

What is subjective data?

Answer 12

the patients’ verbal descriptions of their health problems

Question 13

What data is usually included in subjective data?

Answer 13

feelings

perceptions

pt. self report of symptoms

Question 14

What is objective data?

Answer 14

observations or measurements of a patient’s health status.

Question 15

What is the difference between subjective data and objective data?

Answer 15

A nurse uses subjective data (from patient) to guide objective observations.

Question 16

What is usually your best source of information?

Answer 16

the patient

Question 17

What 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 17

patient-centered interview

Question 18

What are the 4 steps for an initial patient-centered interview?

Answer 18

1. Setting the stage
2. Gathering information
3. Collecting the assessment/nursing health history
4. Terminating the interview

Question 19

Which phase of an interview is setting the stage?

Answer 19

Orientation

Question 20

Why do we use open-ended questions?

Answer 20

They prompt patients to describe a situation in more than one word which leads to a discussion in which patients actively describe their health status

Question 21

How can the interviewer reinforce interest in what the patient has to say?

Answer 21

Good eye contact and listening skills

Question 22

When would an interviewer use closed-ended questions?

Answer 22

To help the interviewer acquire specific information about health problems such as symptoms, precipitating factors and/or relief measures

Question 23

What does an assessment with cultural competence involve?

Answer 23

A conscientious understanding of your patient’s culture so you can offer better care within differing value systems and act with respect and understanding without imposing your own attitudes and beliefs.

Question 24

When does a nurse gather a nursing health history?

Answer 24

During either the initial contact or early contact with the patient.

Question 25

What is the term for symptoms that patients experience along with their primary symptoms?

Answer 25

concomitant symptoms (i.e nausea + pain)

Question 26

What is the systematic approach for collecting the patient’s self-reported data on all body systems?

Answer 26

review of symptoms (ROS)

Question 27

How does a nurse validate assessment data?

Answer 27

compare the data with another source to determine accuracy

Question 28

What is the last part of a complete assessment?

Answer 28

Data documentation

Question 29

What are the 4 types of nursing assessment?

Answer 29

Comprehensive initial

Focused

Emergency

Time-lapsed