Module 4

Question 1

What is objective data?

Answer 1

is what you are seeing as a nurse

Question 2

what is subjective data?

Answer 2

is the patient telling you what happened or the family is telling you what happened

Question 3

What are examples of subjective data?

Answer 3

“I feel pain” I am very tired”

Question 4

Who is the primary of source of data you are getting information from?

Answer 4

The patient

Question 5

Who is the Secondary source-

Answer 5

patients family or significant others, record and health care team

Question 6

What is the 3rd source?

Answer 6

literature and nurse experiences- to find out more about the patients condition you must look it up or find books for more clear information

Question 7

Methods of data collection

Answer 7

Set up therepeutic interview
Nursing health history
Physical examaition- one from the nurse and one from the physician

Question 8

What is the interview process?

Answer 8

Where you get information from your patient

Question 9

What do you do during the interview process?

Answer 9

Introduce yourself and tell them the purpose of the information
Do the interview in a private room and make sure the information is private
Gather information and do the nursing health history. Ask questions that are the least sensitive first. Ex: what are their allergies, where they are from etc
As you are gathering the information, you summarize important points and ask the patient if the points that you wrote are accurate

Question 10

What are the components of nursing health history

Answer 10

Biographical information of the patient
Health history of the patient
Family history
Client expectations-
Make sure the client understands why they are there
Review of systems- nervous system, central ns etc, digestive system
Spiritual health