Chapter 16 Nursing Assessment

Front 1

an approach to identify, diagnose, and treat human responses to health and illness.

Back 1

nursing process

Front 2

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..

Back 2

nursing assessment

Front 3

2 steps to nursing assessment---

Back 3

collection/verifying and analysis of all data

Front 4

the purpose of an assessment---

Back 4

Ask questions to establish a database about the client's perceived needs, health problems, and responses to these problems.

Front 5

name 2 types of data

Back 5

objective and subjective data

Front 6

type of data----clients verbal descriptions of the health problems. Only clients provide this---includes feelings, perceptions, and self-report of symptoms.

Back 6

subjective data

Front 7

type of data---observations or measurements of a client's health status. MUST BE CLEAR, PRECISE, AND CONSISTENT.

Back 7

objective data

Front 8

What is the best source of data?

Back 8

client

Front 9

name some sources of data.

Back 9

family, medical records, health care team members, literature review, nurse's experience

Front 10

during an interview the nurse needs to...

Back 10

introduce themselves, establish sense of caring, establish therapeutic relationship, gain insight about clients concerns and worries, determine client's goals,obtain cues about the data that require further investigation.

Front 11

What phase of the interview includes: introduction, explanation, nurse-client relationship?

Back 11

introduction phase

Front 12

What phase of the interview includes: gathering data, interview techniques, communication strategies, critical thinking?

Back 12

working phase

Front 13

What phase of the interview include: closing cues and summarization?

Back 13

termination pahse

Front 14

what are two types of interviews?

Back 14

focused and comprehensive

Front 15

type of interview---looking in on one subject, body part,

Back 15

focused

Front 16

type of interview----focused on everything; annual exams

Back 16

comprehensive

Front 17

what type of questions are these?
Tell me how you are feeling.
How does your discomfort affect your ability to get around?

Back 17

open-ended questions

Front 18

what type of questions are these?
do you feel like the medications are helping you?
on a scale of 0 to 10, what is your pain rating?

Back 18

closed-ended questions

Front 19

active listening that includes prompts such as "all-right, go on, or uh huh

Back 19

back-channeling

Front 20

identify patterns of information about a client;s health and illness by collecting data about all health dimension and then incorporating data from all dimensions allows you to develop a complete plan of care

Back 20

nursing health history

Front 21

What are some examples of biographical information?

Back 21

age, ethnicity, marital status, types of insurance

Front 22

What are some basic components of a nursing health history?

Back 22

biographical information, reason for seeking care, client expectations, present illness, documentations of history findings, and health, family, environmental, psychosocial, and spiritual history

Front 23

What are some examples of health history?

Back 23

previous surgeries, hospitalizations, what drugs they are taking, and allergies.

Front 24

what are some examples of family history?

Back 24

blood relatives having any hereditary illnesses

Front 25

what are some examples of environmental history?

Back 25

focus on client safety--where do you work? any risks?

Front 26

what is a psychosocial history?

Back 26

reveal clients support system. (family/friends)

Front 27

how to you validate collected data?

Back 27

compare with another source to determine accuracy.

Front 28

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

Back 28

data analysis

Front 29

The purpose of assessment is to:
1.) make a diagnostic conclusion
2.) delegate nursing responsibility
3.) teach the client about his or her health
4.) establish a database concerning the client

Back 29

4

Front 30

assessment date must be descriptive, concise, and complete. An assessment should not include
1.)subjective date from the client
2.) a detailed physical examination
3.)the use of interpersonal and cognitive skills
4.) inferences or interpretative statements not supported with data

Back 30

4

Front 31

The nurse asks a client, "Ms. Neil, describe for me your typical diet over a 24 hr day. What foods do you prefer? Have you noticed a change in your weight recently?" Which interview phase is this?

Back 31

Working --------------you are working to gather information

Front 32

during data clustering a nurse:
1.) provides documentation of nursing care
2.) reviews data with other health care providers
3.) makes inferences about patterns of information
4.) organizes cues into patterns that lead to identifying nursing diagnoses.

Back 32

4

Front 33

What type of interview techniques does the nurse use when asking "do you have pain or cramping?"
1.) active listening
2.) open-ended questioning
3.) closed-ended questioning
4.) problem-oriented questioning

Back 33

3

Front 34

what techniques encourage a client to tell his or her full story? select all that apply
1.) active listening
2.) back channeling
3.) use of open-ended questions
4.) use of closed ended questions

Back 34

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Front 35

you gather the following assessment data, which of the following cues form a pattern?
1.) client is restless
2.) fluid intake for 8 hrs is 800 mL
3.) client states feels short of breath
4.) client has drainage from surgical wound
5.) respiration are 24 minute and irregular
6.) client reports loss of appetite for over 2 weeks.

Back 35

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