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NSG 1100 > Unit 3: (Foundations of Assessment) > Flashcards

Unit 3: (Foundations of Assessment) Flashcards

1
Q

A patient tells you that they have a headache. What type of data is this?

A

Subjective data, It is what the patient experiences and communicates.

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2
Q

Upon entering the room, the nurse notices the patient to have pale skin and is diaphoretic. What type of data is this?

A

Objective; Observable and measurable.

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3
Q

A lab report reports the patients RBC count. What type of data is this?

A

1) Objective; observable and measurable.

2) Variable; can change over time.

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4
Q

A patient was born on 01/25/1945. What type of data is this?

A

Constant data; does not change over time.

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5
Q

Lab reports indicate a patients blood type is ‘A negative’. What type of information is this?

A

Constant data; does not change over time.

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6
Q

The nursing assistant reports a patients temperature is 101.5 axillary. What type of data is this?

A

1) Objective; measurable.

2) Variable; can change over time.

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7
Q

What type of data reveals a patients feelings, thoughts, and beliefs?

A

Subjective Data

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8
Q

A family member reports the patient was hospitalized in January last year. What type of source is this?

A

Secondary source (those other than patient).

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9
Q

A patient states they live at home independently. What type of data source is this?

A

Primary (source=patient)

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10
Q

What type of data is obtained from patients? (Not ‘source’)

A

Patients report SUBJECTIVE data.

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11
Q

A co-worker reports that your patient was NPO last week. What type of data source is this?

A

Secondary source (those other than the patient).

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12
Q

The chart reveals a patients religious preference as: ‘Other’. What type of data source is this?

A

Secondary (those other than patient).

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13
Q

A patient reports they are fearful about surgery. What type of data source is this?

A

Primary (source=patient)

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14
Q

An organized conversation with a patient to obtain information is termed what?

A

Interview

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15
Q

A nurse reading current and past medical records is in what phase of the interview?

A

Preparatory phase.

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16
Q

True -or- False:

Nonverbal communication is less important than verbal communication.

A

False

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17
Q

When addressing patient during an interview, how should the patient be addressed?

A

Address by family name (Mr/Ms/Mrs) unless asked to be called by a less formal name.

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18
Q

What is the primary goal of the introduction phase of the interview?

A

Establish therapeutic relationship with the patient.

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19
Q

A nurse who is introducing them self and providing the purpose of the interview is in what phase of the interview?

A

Introduction Phase.

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20
Q

What type of atmosphere is best for a patient interview?

A

Private and relaxed.

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21
Q

Information obtained from the interview is __________________.

A

Confidential.

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22
Q

A nurse asks a patient about their upcoming surgery. What stage of the interview is the nurse in?

A

Working stage: gathering information needed for subjective database.

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23
Q

When in the working phase of the interview, what does the nurse focus on?

A

Focus on patients health status.

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24
Q

Summarizing highlights and key points are done in what phase of the interview?

A

Termination

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25
Q

How do you terminate an interview?

A

1) Leave patient in a comfortable and safe environment.
2) Clue the interview is ending.
3) Thank the patient
4) Allow them the opportunity to ask final questions.

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26
Q

Give examples of biographical data.

A

Name, address, phone number, DOB…

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27
Q

What information provides the present concern/chief complaint?

A

Reason for seeking health care.

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28
Q

How do present concerns guide the assessment?

A

Present concerns should guide the assessment to gather the most relevant information. (Cardiopulmonary, GI, Neuro….)

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29
Q

How far into the past should the nurse assess a patients disease or condition?

A

Childhood-Present. (Pertaining to Present Concerns)

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30
Q

What information should be gathered in regards to family health history?

A

Genetic patterns of health, current state of health/chronic disease, and cause of death for deceased family.

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31
Q

A patient states they live in a fifth floor apartment with their daughter and grandson and two dogs. What information in their health history data is this pertaining to?

A

Environment (Home situation)

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32
Q

A patient exercises three times a week. What information in their health history data is this pertaining to?

A

Lifestyle (habits/acts that affect patients health).

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33
Q

A patient states they smoke a pack/day. What information in their health history data is this pertaining to?

A

Lifestyle (habits/acts that affect patients health).

34
Q

A patient states they want their son present before surgery for support. What information in their health history data is this pertaining to?

A

Psychosocial (deals with stress/coping styles)

35
Q

A patient states they do not have a primary care physician. What information in their health history data is this pertaining to?

A

Patterns of Healthcare

36
Q

When inspecting a body part, what should the nurse compare?

A

Left and Right sides.

37
Q

What is defined as the use of touch on the body to assess?

A

Palpation

38
Q

Striking one object against another to produce sound waves and vibrations is defined as?

A

Percussion.

39
Q

True or false: A nurse can use percussion to assess a patients abdomen.

A

False: Percussion is practiced by advanced practitioners.

40
Q

What can the nurse assess with palpation?

A

Temperature, moisture, edema, and tenderness.

41
Q

What is palpated last during an assessment? Why?

A

Painful areas are palpated last to prevent guarding.

42
Q

What can be assessed with olfaction?

A

Breath, drains/drainage, bowel and bladder odors.

43
Q

A nurse places the stethoscope on a patients gown to assess breath sounds. Why is this incorrect?

A

The stethoscope should be placed directly on skin, not on clothing.

44
Q

While auscultating, the nurse notes a low sound. What is being identified? (Pitch, Intensity, Quality, or Duration)

A

Pitch (HIGH/LOW)

45
Q

While auscultating, the nurse notes gurgling and swishing. What is being identified? (Pitch, Intensity, Quality, or Duration)

A

Quality

46
Q

While auscultating, the nurse notes long sounds. What is being identified? (Pitch, Intensity, Quality, or Duration)

A

Duration

47
Q

While auscultating, the nurse notes soft sounds. What is being identified? (Pitch, Intensity, Quality, or Duration)

A

Intensity/Amplitude.

48
Q

What acronym is used as a guideline for assessment?

A 
SOLER:
S-Sit facing the patient.
O- Open posture
L- Lean toward patient
E- Establish and maintain eye contact
R- Relax
49
Q

What does assessing the orientation of the patient do?

A

Gauges awareness of surroundings.

50
Q

What does active listening require?

A

Hearing and Interpreting

51
Q

Why is it important for the nurse to individualized attention to the patient?

A

If the nurse fails to give the patient individual/undivided attention, they may miss or misinterpret information.

52
Q

How can a nurse encourage the patient to share information openly?

A

Allowing the patient to complete their comments and thoughts without interruption or interpretation.

53
Q

Would a nurse wanting to obtain specific data ask open ended questions or close ended questions?

A

Close ended questions.

54
Q

Would a nurse wanting a patient to share their feelings openly ask close ended questions or open ended questions?

A

Open ended questions.

55
Q

What type of answers require more than yes/no?

A

Open ended questions.

56
Q

What type of questions should be avoided, and why?

A

‘WHY’ questions because they make the patient defensive and suggest criticism.

57
Q

What type of questions allow for short, specific information?

A

Close ended questions.

58
Q

What type of questions may be useful with anxiety or communication difficulties/barriers.

A

Close ended questions.

59
Q

What considerations should the nurse use when selecting terminology?

A

Consider age, knowledge, and culture.

60
Q

What will speaking in at a rapid pace cause the patient to feel?

A

Frustration

61
Q

A nurse who is aware of how their voice is rising and falling is monitoring what?

A

Cadence

62
Q

How does tone affect your message?

A

Tone of voice affects the meaning of your message.

63
Q

How can a nurse clarify their question or message?

A

Asking simple, brief questions.
Selecting words that convey meaning.
Match verbal to nonverbal.

64
Q

What special considerations are made regarding the timing and relevance of verbal communication?

A
  • Messages should be relevant and important to the situation at hand.
  • Consider the presence of others.
65
Q

When looking for nonverbal communication, what area of the body should the nurse pay most attention to?

A

The face- most expressive with non verbal communication.

66
Q

What form of nonverbal communication shows trust and willingness to communicate?

A

Eye contact

67
Q

What considerations are made with space and nonverbal communication.

A

Nonverbal communication can cue how comfortable a person is with sharing their personal space.

68
Q

How would a nurse communicate with patients who have language differences?

A

Interpreter, communication/picture board….

69
Q

How would a nurse communicate with a patient with visual impairments?

A

Glasses/eye wear, large print, speak clearly….

70
Q

How would a nurse communicate with a patient that has hearing impairment?

A

Ensure hearing aids are in and working, communication/picture boards, writing on paper, speaking slowly and clearly….

71
Q

How would a nurse communicate with a patient that is cognitively impaired?

A

Choose words carefully-with appropriate meaning…..

72
Q

How would a nurse communicate with a patient that has speech impairments?

A

Listen carefully, be patient, ask simple close ended questions to clarify and collect data….

73
Q

How does nurse communicate with a patient that is unresponsive?

A

Speak clearly and explain who you are, and what you are doing….

74
Q

A nurse is gathering vital signs, health history, and list of medications for a new admission. What assessment approach is the nurse using?

A

Initial=First

75
Q

A patient is complaining of pain. The nurse asks the patient to identify the location and severity of the pain. What assessment approach is the nurse using?

A

Problem Focused Assessment

76
Q

The nurse is administering medication and make many observations about the patient and environment. What type of assessment approach is the nurse using?

A

General Survey=ongoing

77
Q

The patient has stopped breathing, and the nurse begins to assess pulses and airway. What assessment approach is the nurse using?

A

Emergency Assessment

78
Q

The nurse is asking a patient specific questions to obtain information pertaining to their current health complaint. What assessment approach is the nurse using?

A

Problem-focused Assessment

79
Q

A patient is admitted for surgery, and the nurse performs a head-to-toe assessment. What type of assessment approach is being used?

A

Initial Assessment

80
Q

A patient complains they are having trouble breathing. The nurse auscultates the lungs for breath sounds. What type of assessment approach is being used?

A

Problem Focused Assessment

NSG 1100 (22 decks)

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