Med-Surg Chp 4 Interviewing and Assessment Key terms Flashcards
Listening with a stethoscope for normal and abnormal sounds generated by organs and structures such as the heart, lungs, intestines, and major arteries.
auscultation
that which the client perceives to be a health problem that needs treatment.
chief complaint
asked during a client interview that requires only “yes” or “no” answers. See also open-ended questions.
closed questions
information obtained during a client interview about the client’s religious affiliation, cultural background, and health beliefs.
cultural history
Detailed information about one body system or problem.
focused assessment
determination of how well a client can manage activities of daily living.
functional assessment
technique used for carrying out an examination by beginning at the top of the body and progressing downward. See also systems method.
head-to-toe method
systematic and thorough observation of a client and specific areas of a client’s body.
inspection
facts obtained during a client’s assessment through observation, physical examination, and diagnostic testing. See also subjective data.
objective data
asked during a client interview that requires discussion. See also closed questions.
open-ended questions
assessing the characteristics of an organ or body part by touching and feeling it with the hands or fingertips.
palpation
information obtained during a client interview regarding a client’s childhood diseases, previous injuries, major illnesses, prior hospitalizations, surgical procedures, and drug history.
past health history
tapping a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures.
percussion
information obtained during a client interview about the client’s age, occupation, religious affiliation, cultural background, marital status, and home and working environments.
psychosocial history
Examination of a client’s body structures.
physical assessment
