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46 Cards in this Set

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What four closely related activities does the assessment process involve?

-collect data
-organize data
-Validate data
-Document data
(Slide 1) fig 11-3 p.182
Define Assessing
-Data (information) gathered systematically
(Slide 2)
What are the 4 types of assessment?
-Initial nursing assessment
-Problem-focused assessment
-Emergency assessment
-Time-lapsed reassessment
(Slide 2)
nitial Assessments. When is it used and what is it for?
-Performed within a specified time period
-Establishes complete database
(Slide 3)
Problem-Focused Assessments. When is it used and what is it for?
-Ongoing process integrated with care
-Determines status of a specific problem
(Slide 3)
Emergency Assessments. When is it used and what is it for?
-Performed during physiologic or psychologic crises
-Identifies life-threatening problems
-Identifies new or overlooked problems
(Slide 3)
-Time-lapsed Reassessments. When is it used and what is it for?
-Occurs several months after initial
-Compares current status to baseline
(Slide 3)
Describe what Collecting Data means (6 components)
-Gathering information about client’s health status
-Must be systematic and continuous
-Includes past history and current problem
-Subjective or objective
-Primary or secondary source
-Establishes database
(Slide 4)
What is Subjective Data?
-Symptoms or covert data
-Apparent only to person affected
-Can be described only by person affected
-Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situations
(Slide 5)
What is Objective Data?
-Signs or overt data
-Detectable by an observer
-Can be measured or tested against an accepted standard
-Can be seen, heard, felt, or smelled
-Obtained through observation or physical examination
(Slide 6)
What is Sources of Data?
Primary and secondary sources(where you get your data)
Primary source is?
-The client
-The primary nurse
(Slide 7)
Secondary sources is?
-All other sources of data (support people, records, other health care professionals, literature)
-Should be validated, if possible
(Slide 7)
What are Methods of Data Collection?
-Examining (physical examination)
(Slide 8-10)
Define Observing
-Gathering data using the senses
(Slide 8)
bservation is used to obtain what types of data?
-Skin color (vision)
-Body or breath odors (smell)
-Lung or heart sounds (hearing)
-Skin temperature (touch)
(Slide 8)
Define Interview
- planned communication or a conversation with a purpose
(Slide 9)
Interviewing is used to (6)
-Get or give information
-Identify problems of mutual concern
-Evaluate change
-Provide support
-Provide counseling or therapy
(Slide 9)
What is Examining (physical examination)
-Systematic data-collection method
-Uses observation and inspection, auscultation, palpation, and percussion
(Slide 10)
What is included in a physical examination?
-Vital signs, height and weight
-Cephalocaudal approach
-Screening examination (review of systems)
(Slide 10)
What is Directive Approach to Interviewing?
-Nurse establishes purpose
-Nurse controls the interview
-Used to gather and give information when time is limited, e.g., in an emergency
(Slide 11)
hat is Nondirective Approach to Interviewing?
-Client controls the purpose, subject matter, and pacing
-Combination of directive and nondirective approaches is usually appropriate during information-gathering interview
(Slide 12)
Name the 2 Types of Interview Questions
-Closed questions
-Open-ended questions
Describe Closed questions
-Less effort and information from client
-“What medications did you take?”
-“Are you having pain now?”
-Leading question
(Slide 13)
Describe Open-ended questions
-Specify broad topic to discuss
-Invite longer answers
-Get more information from client
-Useful to change topics and elicit attitudes
- Neutral question
(Slide 13)
What are the 6 Factors in Interview Setting?
--Client free of pain
--Limited interruptions
--Comfortable environment
Limited distractions
-Seating arrangement
--Office or clinic
--Use easily understood terms
--Interpreter or translator
(Slide 14)
What are Nursing models frameworks (for Nursing Assessment)? (name 3 of 5)
-Gordon’s functional health pattern framework
-Orem’s self-care model
-Roy’s adaptation model
-NANDA International Taxonomy II
-Wellness models
(Slide 15)
What are Non-nursing models?
--Body systems model
--Maslow’s Hierarchy of Needs
--Developmental theories
(Slide 15)
What is Validating Data?
-Assessment complete
-Validation -determining that objective and related subjective data agree
(Slide 16)
How do you validate data?
-Clarify vague statements
-Double-check extreme data; use references as needed
-Determine which data can be overlooked
-Differentiate between cues and inferences
-Avoid jumping to conclusions
(Slide 16)
How Documenting the Assessment done?
-Record client data
-Record in factual manner; do not state interpretations
-Record subjective data with quotes in client’s own words
(Slide 17)
Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process?

A. Identifying major problems or needs
B. Organizing data in the client’s family history
C. Establishing short-term and long-term goals
D. Administering an antibiotic
*A. Correct. Identifying problems/needs is part of nursing diagnosis. For example, a client with difficulty breathing would have a nursing diagnosis of Impaired Gas Exchange related to constricted airways as manifested by shortness of breath (dyspnea).

B. Organizing family history is part of the assessment phase.
C. Establishing goals is a part of the planning phase.
D. Administering an antibiotic is part of the implementation phase.
Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care?

A. Proposes hypotheses
B. Generates desired outcomes
C. Reviews results of laboratory tests
D. Documents care
A. Hypotheses are generated during diagnosing.
B. Outcomes are set during planning.
*C. Correct. During assessment, data are collected, organized, validated, and documented.
D. Documentation occurs throughout the nursing process.
Which of the following elements is best categorized as secondary subjective data?
A. The nurse measures a weight loss of 10 pounds since the last clinic visit.
B. Spouse states the client has lost all appetite.
C. The nurse palpates edema in lower extremities.
D. Client reports severe pain when walking up stairs.
A. Weight is objective data that can be measured or validated.
*B. Correct. Secondary data comes from any other source (chart, family) besides the client. Subjective data are covert (reported or an opinion).
C. Edema is objective data that can be measured or validated.
D. What the client reports is primary data.
The nurse wishes to determine the client’s feelings about a recent diagnosis. Which interview question is most likely to elicit this information?
A. “What did the doctor tell you about your diagnosis?”
B. “Are you worried about how the diagnosis will affect you in the future?”
C. “Tell me about your reactions to the diagnosis.”
D. “How is your family responding to the diagnosis?”
A. This question just seeks factual information.
B. This question can be answered with a single word.
*C. Correct. Eliciting feelings requires open-ended questions that seek more than just factual information and cannot be answered with a single word.
D. The family can provide indirect information about the client but is not likely to provide the most accurate information.
Which of the following is an example of the assessment phase of the nursing process?

The nurse:
A. Observes that a patient is nauseated after receiving a medication.
B. Changes the bed linens after a patient spills milk in the bed.
C. Asks a patient how much of his lunch he ate.
D. Works with a patient to set wellness goals.
Answer: C

Rationale: Asking a patient how much lunch he ate provides subjective data. Observing nausea
after an intervention (i.e., giving medication), although it involves assessment, is really a part of
the evaluation phase. Changing bed linens is implementation, and helping a patient set goals is
planning (goals).
The client states: “My lips feel numb and I can’t see very well.” What kind of data is

A. Subjective, from the primary source
B. Objective, from the primary source
C. Subjective, from a secondary source
D. Objective, from a secondary source
Answer: A

Rationale: What the client tells you is subjective data. Primary source data, whether subjective
or objective, are obtained from the client; secondary are from all sources other than the client.
What is one reason for performing ongoing assessments? To:

A. Establish the data base
B. Obtain the nursing history
C. Complete a comprehensive assessment
D. Evaluate the status of an identified health problem
Answer: D

Rationale: Ongoing assessments are done to evaluate changes or progress in already identified
health problems, or to identify new problems. Obtaining a history, completing comprehensive
assessment, and establishing a data base are all part of the initial assessment.
Which data is from a primary source?

A. The client’s pulse is counted at 100.
B. A nursing note states the patient has been sleeping.
C. The primary care provider tells you the patient has cancer.
D. The client’s husband says she is becoming more forgetful.
Answer: A

Rationale: The pulse is counted directly from the patient, so it is primary data. Primary source
data are obtained directly from the patient and can be subjective or objective. All other data are
secondary source information.
How are primary source subjective data obtained?

A. Observations made by the nurse
B. Interviewing the patient
C. Physical examination of the patient
D. Reading the patient’s health record
Answer: B

Rationale: Primary source data are obtained from the patient; subjective data are obtained from the patient’s verbal statements. An interview produces verbal statements from the patient. Observations and physical examination produce objective data. The medical record is a secondary source.
When interviewing a patient, which should the nurse do to obtain the best information?

A. Use only nondirective interviewing techniques and open questions
B. Guide conversation to general topics and follow up with specific questions
C. Have the patient fill out the agency’s printed nursing history form
D. Ask a list of specific questions word for word from the history form
Answer: B

Rationale: The nurse should guide conversation to general topics and follow up with specific questions. Failure to use some directive questions can result in missing some data, especially regarding feelings; it would allow the client to ramble and include too much irrelevant information. If the client writes his information, he is less likely to include psychosocial and affective data, and will probably provide fewer details in other areas as well. A rigid, automatic approach, as when reading a list, does not encourage the client to elaborate, and will probably result in less information.
Which one is subjective data?

A. The client’s face is red.
B. You see the client clutching his abdomen.
C. The nursing assistant says the client appears to be in pain.
D. The client states she feels nauseated.
Answer: D

Rationale: Client statements are subjective data. A red face must be observed by the nurse. The
nurse would observe the client clutching his abdomen. The nursing assistant is stating her
Which of the following is/are subjective data? Choose all that apply.

A. The patient’s head measures 20 cm.
B. The patient weighs 180 lb on the unit’s scale.
C. The patient tells you that he weighs 165 lb.
D. The patient states he slept poorly last night.
Answer: C, D

Rationale: Subjective data are information given verbally by the patient—what the patient tells
you, what the patient states. The head measurement and weight were performed by a care
provider, not stated by the patient
What is the purpose of nursing assessment? To:

A. Identify health problems and plan patient care
B. Offer suggestions to the patient for improving her health
C. Determine the cause of the patient’s medical diagnosis
D. Demonstrate nursing autonomy and accountability
Answer: A

Rationale: Data are used to formulate nursing diagnoses, which are the basis for the plan of care.
Offering suggestions is a nursing intervention rather than an assessment. The primary care provider is responsible for determining the cause of a medical diagnosis. Autonomy is not
demonstrated merely by data collection, but by application of the entire nursing process. The nurse can delegate some data collection to unlicensed assistive personnel.
When the nurse strikes the body surface to elicit sound or vibration, what examination
technique is being used?

A. Inspection
B. Palpation
C. Percussion
D. Auscultation
Answer: C

Rationale: Percussion is done by striking the body surface to elicit sound or vibration.
Inspection is visual examination – assessing with the sense of sight. Palpation is examination of
the body using the sense of touch. Auscultation is the process of listening to sounds produced
within the body, usually with a stethoscope.
Which activity occurs in the assessment phase of the nursing process?

A. Checking the client’s skin color
B. Writing the plan of care
C. Asking the client if the medication relieved his pain
D. Helping the client to ambulate to the bathroom
Answer: A

Rationale: Observing the skin is done to collect data, and occurs in the assessment phase.
Writing the care plan is a part of the planning outcomes and interventions phase. Asking about pain after a medication intervention is evaluation. Helping the client ambulate is implementation.