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NCM_101 | Health Assessment > Health Assessment, Health History, and Physical Examination > Flashcards

Health Assessment, Health History, and Physical Examination Flashcards

1
Q

The first and most critical phase of the nursing process

A

Health Assessment

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2
Q

On-going and continuous throughout all the phases of the nursing process

A

Health Assessment

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3
Q

The nurses analyzing the data and evaluating the client care outcomes

A

Nursing Process

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4
Q

Is circular, not linear

A

Nursing Process

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5
Q

Phases of the Nursing Process

A

Assessment
Diagnosis
Planning
Implementation
Evaluation

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6
Q

Collection of subjective data and objective data / Subjective Data / Objective Data

A

Assessment

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7
Q

Analysis of subjective data and objective data / NANDA
/ Actual, Risk, and Wellness

A

Diagnosis

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8
Q

Bound generation of solutions / ABC / High, Intermediate, and Low

A

Planning

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9
Q

Taking actions / SMART

A

Implementation

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10
Q

Assessing outcomes / Independent, Dependent, and Interdependent

A

Evaluation

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11
Q

The collection of holistic subjective and objective data

A

Focus of Health Assessment in Nursing

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12
Q

Composition of a Health Assessment

A

Health History
Physical Examination

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13
Q

Data of a Health Assessment

A

Physiological Manner
Psychological Manner
Sociocultural Manner
Developmental Manner
Spiritual Manner

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14
Q

Interdependent Factors of a Health Assessment

A

Mind
Body
Spirit

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15
Q

The organized information of each and every data

A

Framework for Health Assessment in Nursing

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16
Q

Four Sections of a Health Assessment

A

History of present health concern
Personal health history
Family health history
Lifestyle and health practices

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17
Q

The supposed knowledge of physiology

A

Using Evidence to Promote Health and Prevent Disease

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18
Q

Evidence-Based Health Promotion and Disease Prevention

A

Health People 2030
US Preventive Services Task Force / USPSTF

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19
Q

Aims to increase life span and improve quality of health for all Americans

A

Health People 2030

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20
Q

Determines risk versus benefits in screenings

A

US Preventive Services Task Force / USPSTF

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21
Q

The variation of the data collected

A

Types of Health Assessment

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22
Q

Four Basic Types of Nursing Assessment

A

Initial Comprehensive Assessment
Ongoing or Partial Assessment
Focused or
Problem-Oriented Assessment
Emergency Assessment

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23
Q

Collection of subjective data / Age, Risk Factors, Health Status, Health Promotion Practices, and Lifestyle

A

Initial Comprehensive Assessment

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24
Q

Composition upon comprehensive database / Acuity

A

Ongoing or Partial Assessment

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25
Q

Specific health concerns

A

Focused or
Problem-Oriented Assessment

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26
Q

Rapid life-threatening issues

A

Emergency Assessment

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27
Q

The client’s assessment phase of the nursing process

A

Steps of Health Assessment

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28
Q

Four Major Steps of Nursing Assessment

A

Collection of Subjective Data
Collection of Objective Data
Validation of Data
Documentation of Data

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29
Q

Functioned data / Biographical Information, History of Present Health Concern, Personal Health History, Family History, Health and Lifestyle Practices, and Review of Systems

A

Collection of Subjective Data

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30
Q

Physiological data / Physical Characteristics, Body Functions, Appearance, Behavior, Measurements, and Results of Laboratory Testing

A

Collection of Objective Data

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31
Q

Checked data

A

Validation of Data

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32
Q

Documented Data

A

Documentation of Data

33
Q

The flow of the nurse meeting the client

A

Preparing for the Assessment

34
Q

Nurse reviews the client’s medical record

A

Before

35
Q

Nurse educates self about client’s diagnoses or tests performed / Nurse reflects on personal feelings about client’s encounter / Nurse obtains needed materials for client’s assessment

A

During

36
Q

Nurse reviews the client’s status with others

A

After

37
Q

The nurse using clinical judgement on the client

A

Analyzing Cues to Identify Client Concerns

38
Q

Physiological complications

A

Collaborative Concern / Collaborative Problem

39
Q

Client problems

A

Client Concern / Nursing Problem

40
Q

Whole being alongside other healthcare professionals

A

Medicine or Discipline Concern / Referrals

41
Q

Process of Data Analysis

A

Identify abnormal cues and supportive cues
Cluster cues
Draw inferences and identify and prioritize client concerns
Propose possible collaborative problems to notify primary care provider
Identify need for referral to primary care provider
Document conclusions

42
Q

Collection of Data

A

Holistic Nursing Assessment
Medical Nursing Assessment

43
Q

The content of the data to be verified / Sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information

A

Subjective Data

44
Q

The communication process of the nurse and client for subjective data / Establishment of rapport and gathered information.

A

Interviewing

45
Q

Phases of the Interview

A

Preintroductory Phase
Introductory Phase
Working Phase
Summary and Closing Phase

46
Q

Nurse reviews the client’s medical record / Interview

A

Preintroductory Phase

47
Q

Nurse explains to the client

A

Introductory Phase

48
Q

Nurse listens, observes cues, and uses critical thinking towards the client

A

Working Phase

49
Q

Nurse summarizes the client’s supposed needs / Interventions

A

Summary and Closing Phase

50
Q

Communication During the Interview

A

Nonverbal Communication
Verbal Communication

51
Q

How the nurse is perceived by the client / Appearance, Demeanor, Facial Expression, Attitude, Silence, and Listening

A

Nonverbal Communication

52
Q

How the client is probed by the nurse / Open-Ended Questions, Closed-Ended Questions, Laundry List, Rephrasing, Well-Placed Phrases, Inferring, and Providing Information

A

Verbal Communication

53
Q

The variations of communication to be used

A

Special Considerations During the Interview

54
Q

Geriatric Care

A

Gerontologic Variations in Communication

55
Q

Culture Care

A

Cultural Variations in Communications

56
Q

Emotional Care

A

Emotional Variations in Communication

57
Q

The foundation of all clinical judgement

A

Complete Health History

58
Q

Seven Sections of Health History

A

Biographical Data
Reasons for Seeking Health Care
History of Present Health Concern
Personal Health History
Family Health History
Review of Systems for Current Health Problems
Lifestyle and Health Practices Profile

59
Q

Primary Source and all other Secondary Source

A

Biographical Data

60
Q

What and How Question and Answers

A

Reasons for Seeking Health Care

61
Q

Concern Description

A

History of Present Health Concern

62
Q

Earliest Beginnings

A

Personal Health History

63
Q

Genetics

A

Family Health History

64
Q

Highlighted Issues

A

Review of Systems for Current Health Problems

65
Q

Typical Day, Nutrition and Weight Management, Activity Level and Exercise, Sleep and Rest, Substance Use, Self-Concept and Self-Care Responsibilities, Social Activities, Relationships, Values and Beliefs System, Education and Work, Stress Levels and Coping Styles, and Environment

A

Lifestyle and Health Practices Profile

66
Q

COLDSPA

A

Character
Onset
Location
Duration
Severity
Palliative
Associated Factors

67
Q

The content of the data to be validated / Types and operation of equipment needed for the particular examination, preparation of the setting, oneself, and the client for the physical assessment, and the performance of the four examination techniques

A

Objective Data

68
Q

The essential embodiment of clinical judgements / Assessing own feelings and anxieties, preventing transmission of infectious agents.

A

Preparing Oneself

69
Q

General Principles of a Physical Assessment

A

Wash your hands
Always wear gloves
Discard pins
Wear your mask and protective eye googles

70
Q

The establishment of a nurse-client relationship

A

Approaching and Preparing the Client

71
Q

Respecting Client Desires and Requests

A

Present family or friend
Simple non-exposure of a certain body part

72
Q

The nurse’s thorough and complete assessment of the client

A

Physical Examination Techniques

73
Q

Four Basic Examination Techniques

A

Inspection
Palpation
Percussion
Auscultation

74
Q

Comfortable temperature / Good lighting / Look and observe before touching / Completely expose the body part you are inspecting / Color, patterns, size, location, consistency, symmetry, movement, behavior, odor, or sounds / Appearance of symmetric body parts or both sides of any individual body part

A

Inspection

75
Q

Texture / Temperature / Moisture / Mobility / Consistency / Strength of pulses / Size / Shape / Degree of tenderness / Light Palpation, Moderate Palpation, Deep Palpation, and Bimanual Palpation

A

Palpation

76
Q

Determining location, size, and shape / Determining density / Determining abnormal masses / Eliciting reflexes / Direct, Blunt, Indirect

A

Percussion

77
Q

Intensity / Pitch / Duration / Quality / Sound

A

Auscultation

78
Q

Documentation

A

Communication
Legal Evidence of Care
Education
Financial Billing
Evaluation of Quality Care Rendered
Research and Statistical Information

NCM_101 | Health Assessment (11 decks)

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