Patient Assessment

Question 1

Initial (baseline) Assessment

Answer 1

Assessment gathered soon after admission to HC facility.

Provides baseline

Question 2

Problem-focused (or system-specific) assessment

Answer 2

Performed as an ongoing process and integrated with nursing care to determine status of a specific problem identified earlier.

Question 3

Emergency assessment

Answer 3

Performed during physical or psychological crisis to identify life-threatening, new, or overlooked problems

Question 4

Ongoing assessment

Answer 4

Performed to compare the patient’s current status to baseline data previously obtained

Question 5

Subjective data

Answer 5

Symptoms or data that can only be described or verified by the patient. i.e. feelings, pain, etc.

Question 6

Objective data

Answer 6

Data that is detectable and can be measured

Question 7

Primary data

Answer 7

Data that is obtained directly from the patient unless the pt is too ill, young, or confused to communicate clearly

Question 8

Secondary data

Answer 8

Data obtained from family members, other HC professionals, records, reports and relevant literature.

Question 9

Physical examination includes what four techniques?

Answer 9

Inspection, auscultation, palpation, and percussion.

Question 10

Palpation

Answer 10

Examination of the body using the sense of touch. Determines the following characteristics: texture, temp, vibration, position, size, consistency, mobility, distention, pulsation, presence of pain

Question 11

Percussion

Answer 11

Involves the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt

Question 12

Auscultation

Answer 12

Process of listening to sounds produced within the body. Sounds are described according to pitch, intensity, duration, and quality

Question 13

Failure to engage

Answer 13

Parental failure to engage the infant, or smile at the infant, limits opportunities for positive feedback from the infant and frustrates the infant, resulting in decreased attempts to interact.
Infant may lag significantly behind on milestones when not receiving appropriate stimulation

Question 14

Overnutrition

Answer 14

Rate of weight gain is accelerated
Caregivers don’t learn to read infants’ cues and assume every cry is hunger
Cultural beliefs may indicate that a plump baby is healthy, leading to overfeeding

Question 15

Hydrocephalus

Answer 15

Enlargement of the head caused by inadequate drainage of CSF.
Early diagnosis/intervention needed to prevent or diminish serious neurological effects

Question 16

Mini-Mental Status Examination (MMSE)

Answer 16

Useful for detecting the early stages of cognitive impairment and dementia in the client. Assesses orientation, memory and language functions.