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| The ____ _____ is a professional nurse's approach to identify, diagnose, and treat human responses to health and illness |
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| assessment, diagnosis, planning, implementation, and evaluation are all part of what |
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| ____ is 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 |
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| Nursing assessment includes two steps: |
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Collection and verification of data from a primary source
The analysis of all data as a basis for developing nursing diagnoses |
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| The purpose of assessment is to establish a______ about the client's perceived needs, health problems, and responses to these problems |
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| While_____ _____ about a client, you will synthesize relevant knowledge, recall prior clinical experiences, apply critical thinking standards and attitudes, and use standards of practice to direct your assessment in a meaningful and purposeful way |
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| A ___ is information that you obtain through use of the senses. |
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| An ____is your judgment or interpretation of cues (Figure 16-3). For example, a client crying is a cue that possibly implies fear or sadness. |
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| focus on the client's presenting situation and begin with problematic areas, such as back pain, difficulty breathing, or apprehension over a procedure. Then ask the client follow-up questions to clarify and expand your assessment. This is an example of what approach to an assessment |
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| problem-oriented approach |
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| wo primary sources of data, |
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| subjective and objective. |
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| are your clients' verbal descriptions of their health problems. Only clients provide subjective data. |
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| observations or measurements of a client's health status. Inspection of the condition of a wound, a description of an observed behavior, and the measurement of blood pressure are examples of |
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| a _____ is usually your best source of information. |
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| ____ _____and significant others are primary sources of information for infants or children, critically ill adults, and mentally handicapped, disoriented, or unconscious clients. |
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| WHAT has a privacy rule that came into effect on April 14, 2003, to set standards for the protection of health information |
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| The Health Insurance Portability and Accountability Act (HIPAA) of 1996 |
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| an ______ is an organized conversation with the client. |
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| The ____ ____ involves obtaining the client's health history and information about the current illness. |
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| HIPAA) through the Privacy Rule protects all individually identifiable health information. Protected health information (PHI) includes |
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demographic data that identifies the individual (e.g., birth date, social security number [SSN], address, medical record number) and relates to any of the following:
• An individual's past, present, or future physical or mental health or condition
• The provision of health care to the individual
• The past, present, or future payment for provision of health care to the individual |
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| the _______ phase begins with introducing yourself and your position and explaining the purpose of the interview. |
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| the ___ ____ ___ 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. |
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| As in the other phases of the interview, the _____ _____ requires skill on the part of the interviewer. Give your client a clue that the interview is coming to an end. |
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| During an interview obtain information about a client's : (5 things) |
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| physical, developmental, emotional, intellectual, social, and spiritual dimensions |
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| _____ _____ 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. |
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| The ___ ___ ____ is a systematic method for collecting data on all body systems |
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| _______ of assessment data is the comparison of data with another source to determine data accuracy. For example, you observe a client crying and logically infer it is related to hospitalization or a medical diagnosis |
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| a ___ ____ is a set of signs or symptoms that you group together in a logical way. |
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| 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 |
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1. 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 |
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2. Assessment data must be descriptive, concise, and complete. An assessment should NOT include:
1. Subjective data 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 |
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3. A nurse assesses a client who comes to the pulmonary clinic. “Tell me what medications you are on for your breathing problem. I see from your last visit that Dr. Russell recommended routine exercise. Can you also tell me how successful you have been following his plan?” The nurse's assessment covers which of Gordon's functional health patterns?
1. Value-belief pattern
2. Cognitive-perceptual pattern
3. Coping–stress tolerance pattern
4. Health perception–health management pattern |
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4. The nurse asks a client, “Ms. Neil, describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?” This series of questions would likely occur during which phase of a client interview?
1. Working
2. Orientation
3. Termination |
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5. 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 |
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6. What type of interview techniques does the nurse use when asking the question, “Do you have pain or cramping?” (Choose all that apply.)
1. Active listening
2. Open-ended questioning
3. Closed-ended questioning
4. Problem-oriented questioning |
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7. What techniques encourage a client to tell his or her full story? (Choose all that apply.)
1. Active listening
2. Back channeling
3. Use of open-ended questions
4. Use of closed-ended questions |
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8. You gather the following assessment data, which of the following cues form a pattern? (Choose all that apply.)
1. Client is restless.
2. Fluid intake for 8 hours is 800 mL.
3. Client states feels short of breath.
4. Client has drainage from surgical wound.
5. Respirations are 24 per minute and irregular.
6. Client reports loss of appetite for over 2 weeks. |
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