Intro to Assessment

Question 1

Types of Assessments:

Answer 1

1. Admission
2. Focused
3. Time-lapse
4. Emergency

Question 2

What are the phases of the interview?

Answer 2

1. Preparatory phase
2. Introductory phase
3. Maintenance phase
4. Concluding phase

Question 3

Preparatory phase:

Answer 3

Before the nurse meets the patient

Question 4

Introductory phase:

Answer 4

Begins when the nurse and patient meet

Question 5

Maintenance phase:

Answer 5

Nurse and patient work toward achieving the specific goal

Question 6

Concluding phase:

Answer 6

The interview is completed

Question 7

Two types of data:

Answer 7

Subjective, Objective

Question 8

Describe subjective data:

Answer 8

Patient’s feelings and statements about their health problems
-Symptoms: “I feel”

Question 9

Describe objective data:

Answer 9

Observable, perceptible, and measurable data.

-Signs: VS, labs, diagnostics, assessments

Question 10

Ex. Therapeutic communication, Offering self

Answer 10

opening up a convo; I am a good listener

Question 11

Ex. TC, Open-ended questions:

Answer 11

encourage people to open up and share

Question 12

Ex. TC, Opening remarks:

Answer 12

“What brought you in?”, “what’s on your mind?”

Question 13

Ex. TC, Restatement:

Answer 13

clarify client’s message by repeating same statement back to client

Question 14

Ex. TC, Reflection

Answer 14

assess what the client things about something; get pt to go a little deeper

Question 15

Ex. TC, Focusing

Answer 15

be direct, acknowledge what they need and focus back on goal

Question 16

Ex. TC, Encourage elaboration:

Answer 16

“Tell me more!”

Question 17

Ex. TC, Seek clarification

Answer 17

I want to understand more, ask for an example

Question 18

Ex. TC, Giving information:

Answer 18

Professional information; client still makes choice

Question 19

Ex. TC, Look at alternatives:

Answer 19

Promote pt decision making and autonomy

Question 20

Ex. TC, Summarizing

Answer 20

restate what you think pt is trying to get accross

Question 21

SBARR Stands for:

Answer 21

I= Introduce yourself
S= Situation
B= Background
A= Assessment
R= Recommendation 
R= Read Back

Question 22

S= Situation

Answer 22

“What’s going on right now?”

-pt name, unit, room #

Question 23

B= Background

Answer 23

“What are the circumstances leading to the situation?”

-Admission date/dx, allergies, baseline VA/assessment, code status, meds, labs

Question 24

A= Assessment

Answer 24

“What is your assessment of the problem?”

-Focused subjective and objective system assessments, impression

Question 25

R= Recommendation

Answer 25

“What is your recommendation?”

-Order change, referral, provider visit, etc.

Question 26

R= Read Back

Answer 26

Read back the order, restatement