Ch11 Assessing Key Terms Nursing Fundamentals Bernardxb

Front 1

Assessing

Back 1

"the process of collecting, organizing, validating, and recording data (information) about a client's health status"

Front 2

Cephalocaudal

Back 2

proceeding in the direction from head to toe

Front 3

Closed questions

Back 3

restrictive question requiring only a short answer

Front 4

"Covert data (systems

Back 4

subjective data) ",information (data) apparent only to the person affected that can be described or verified only by that person

Front 5

Cues

Back 5

any piece of information or data that influences decisions

Front 6

Data

Back 6

information

Front 7

Database

Back 7

"all information about a client, includes nursing health history and physical assessment, physician's history, physical examination, and laboratory and diagnostic test results"

Front 8

Directive interview

Back 8

a highly structured interview that uses closed questions to elicit specific information

Front 9

Inferences

Back 9

interpretations or conclusions made based on cues or observed data

Front 10

Interview

Back 10

a planned communication; a conversation with a purpose

Front 11

Leading question

Back 11

a question that influences the client to give a particular answer

Front 12

Neutral question

Back 12

a question that does not direct or pressure a client to answer in a certain way

Front 13

Nondirective interview

Back 13

an interview using open-ended questions and empathetic responses to build rapport and learn client concerns

Front 14

Nursing process

Back 14

a systematic rational method of planning and providing nursing care

Front 15

Objective data

Back 15

"information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled"

Front 16

Open-ended questions

Back 16

questions that specify only the broad topic to be discussed and invite clients to discover and explore their thoughts and feelings about the topic

Front 17

Rapport

Back 17

a relationship between two or more people of mutual trust and understanding

Front 18

Review of systems

Back 18

see Screening examination

Front 19

Screening examination

Back 19

(review of systems) a brief review of essential functioning of various body parts or systems

Front 20

Signs

Back 20

see Overt data

Front 21

Subjective data

Back 21

data that are apparent only to the person affected; can be described or verified only by that person

Front 22

Symptoms

Back 22

see Covert data

Front 23

Validation

Back 23

"the determination that the diagnosis accurately reflects the problem of the client, that the methods used for data gathering were appropriate, and that the conclusion or diagnosis is justified by the data"