Chapter 16 Nursing Assessment Vocab

Front 1

Assessment, p. 231

Back 1

the deliberate and systematic collection of data to determine a client's current and past health status and functional status and to determine the client's present and past coping patterns

Front 2

Back channeling, p. 239

Back 2

includes active listening prompts such as “all right,” “go on,” or “uh-huh.” These indicate that you have heard what the client says and are attentive to hear the full story.

Front 3

Closed-ended questions, p. 239

Back 3

limit the client's answers to one or two words such as “yes” or “no”

Front 4

Cue, p. 233

Back 4

information that you obtain through use of the senses.

Front 5

Data analysis, p. 243

Back 5

involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a reasoned conclusion about the client's responses to a health problem.

Front 6

Database, p. 231

Back 6

client's perceived needs, health problems, and responses to these problems. In addition, the data reveal related experiences, health practices, goals, values, and expectations about the health care system.

Front 7

Functional health patterns, p. 233

Back 7

represents the interaction of the client and the environment, which Gordon calls biopsychosocial integration.

Front 8

Inference, p. 233

Back 8

is your judgment or interpretation of those cues. For example, a client crying is a cue that possibly implies fear or sadness

Front 9

Interview, p. 236

Back 9

is an organized conversation with the client.

Front 10

Nursing health history, p. 237

Back 10

includes data about the client's current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness

Front 11

Nursing process, p. 231

Back 11

is a professional nurse's approach to identify, diagnose, and treat human responses to health and illness

Front 12

Objective data, p. 233

Back 12

are observations or measurements of a client's health status. Inspection of the condition of a wound, a description observed behavior, and the measurement

Front 13

Open-ended questions, p. 239

Back 13

prompts clients to describe a situation in more than one or two words.

Front 14

Review of systems (ROS), p. 241

Back 14

is a systematic method for collecting data on all body systems

Front 15

Standards, p. 243

Back 15

a way of reference or measurement of a condition or health issues

Front 16

Subjective data, p. 233

Back 16

clients' verbal descriptions of their health problems. Only clients provide subjective data.

Front 17

validation, p242

Back 17

of assessment data is the comparison of data with another source to determine data accuracy.