Podcast
Questions and Answers
What is the primary purpose of a health assessment?
What is the primary purpose of a health assessment?
Which of the following is NOT one of the seven facets or dimensions of health?
Which of the following is NOT one of the seven facets or dimensions of health?
Which role of the nurse focuses on providing health education tailored to a patient’s understanding?
Which role of the nurse focuses on providing health education tailored to a patient’s understanding?
What is included as the first component of a comprehensive health history?
What is included as the first component of a comprehensive health history?
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Which aspect of health assessment emphasizes gathering both subjective and objective data?
Which aspect of health assessment emphasizes gathering both subjective and objective data?
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What does wellness primarily focus on?
What does wellness primarily focus on?
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What does the role of the nurse as a delegator entail?
What does the role of the nurse as a delegator entail?
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Which of the following is NOT considered a primary source of history?
Which of the following is NOT considered a primary source of history?
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Which step is crucial when assessing a patient’s problem within a health assessment?
Which step is crucial when assessing a patient’s problem within a health assessment?
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In the context of history of present illness, which factor is considered pertinent positive information?
In the context of history of present illness, which factor is considered pertinent positive information?
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What is the purpose of a genogram in family history assessment?
What is the purpose of a genogram in family history assessment?
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During a review of systems, which approach is recommended when asking questions?
During a review of systems, which approach is recommended when asking questions?
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Which of the following is NOT included in the past medical history section?
Which of the following is NOT included in the past medical history section?
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What is the first step in preparing for a successful patient interview?
What is the first step in preparing for a successful patient interview?
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What is the primary objective of conducting a physical examination?
What is the primary objective of conducting a physical examination?
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Which of the following factors is least likely to be included in health patterns assessments?
Which of the following factors is least likely to be included in health patterns assessments?
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Which technique involves the use of verbal and nonverbal cues to understand the patient's emotions?
Which technique involves the use of verbal and nonverbal cues to understand the patient's emotions?
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What type of assessment focuses on both the physical and psychological aspects of a patient's health?
What type of assessment focuses on both the physical and psychological aspects of a patient's health?
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What is the goal of discussing the plan of care during the termination phase of the interview?
What is the goal of discussing the plan of care during the termination phase of the interview?
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Which action primarily helps to establish rapport with the patient?
Which action primarily helps to establish rapport with the patient?
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What does pertinent negative information refer to in a healthcare assessment?
What does pertinent negative information refer to in a healthcare assessment?
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Which of the following is most likely included in the comprehensive health assessment?
Which of the following is most likely included in the comprehensive health assessment?
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What does the technique of validation achieve during the patient interview?
What does the technique of validation achieve during the patient interview?
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Which interviewing technique is used to ensure the interviewer understands the important points of the patient's story?
Which interviewing technique is used to ensure the interviewer understands the important points of the patient's story?
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What should be adjusted prior to conducting a physical examination with a patient?
What should be adjusted prior to conducting a physical examination with a patient?
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Which questioning approach involves starting with general inquiries and progressively becoming more specific?
Which questioning approach involves starting with general inquiries and progressively becoming more specific?
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What is the purpose of using transitions during an interview?
What is the purpose of using transitions during an interview?
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What is an important factor in empowering patients during the interview process?
What is an important factor in empowering patients during the interview process?
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What is the primary goal of adjusting the lighting and environment during a physical examination?
What is the primary goal of adjusting the lighting and environment during a physical examination?
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Which of the following techniques is specifically used to assess skin elevation and depression?
Which of the following techniques is specifically used to assess skin elevation and depression?
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Which of the following is NOT one of the four goals for organizing a comprehensive or focused examination?
Which of the following is NOT one of the four goals for organizing a comprehensive or focused examination?
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Which statement is true regarding the components of inspection during a physical examination?
Which statement is true regarding the components of inspection during a physical examination?
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What is a critical consideration when performing percussion during an examination?
What is a critical consideration when performing percussion during an examination?
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What is the primary purpose of a focused or problem-oriented assessment?
What is the primary purpose of a focused or problem-oriented assessment?
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Which of the following is true about follow-up assessments?
Which of the following is true about follow-up assessments?
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What type of assessment is conducted in response to a life-threatening situation?
What type of assessment is conducted in response to a life-threatening situation?
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Which of the following is NOT a component of the O-L-D-C-A-R-T-S mnemonic?
Which of the following is NOT a component of the O-L-D-C-A-R-T-S mnemonic?
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What type of data includes information that patients verbally express?
What type of data includes information that patients verbally express?
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Which phase in the health interview is focused on building trust and rapport with the patient?
Which phase in the health interview is focused on building trust and rapport with the patient?
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Which of the following best describes the aim of the communication process in nursing?
Which of the following best describes the aim of the communication process in nursing?
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Which of the following types of assessment assesses physiological function?
Which of the following types of assessment assesses physiological function?
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What is the main focus when collecting patient information to protect their privacy?
What is the main focus when collecting patient information to protect their privacy?
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What does the assessment of 'circulation, airway, and breathing' prioritize?
What does the assessment of 'circulation, airway, and breathing' prioritize?
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Study Notes
Health Assessment
- Health is a state in which a person can live to their full potential
- Illness is a person's unique response to a disease
- Wellness is an active state, focused on maximizing potential
- Health assessment purpose is to determine a patient's health status, risk factors, and education needs to develop a nursing care plan
- Provide specific cues for health problems
- Nurses collect comprehensive data pertinent to the patient's health situation
- Comprehensive health history includes all aspects of health
- Complete physical examination is part of health assessment
Steps in Identifying Patient Problems
- Holistic care focuses on the whole person, including community/family, sexual, physical, psychological, and social needs
- Assessment involves health and physical assessments
- Observation and measurement is a crucial part of the process
- Procedures and investigations are also necessary steps
7 Facets/Dimensions of Health
- Physical health
- Emotional health
- Social well-being
- Cultural influences
- Spiritual influences
- Environmental influences
- Developmental level
- Note: Ability to adapt without compromising facets is crucial for health maintenance. Health is not constant and cannot be taken for granted.
Role of the Nurse
- Caregiver: Performs health-related activities a sick person cannot do independently
- Educator: Provides health teaching relevant to each client's needs and knowledge base
- Collaborator: Works with others to achieve a common goal
- Delegator: Assigns tasks to others
Assessment (Subjective/Objective Data)
- A systematic approach to gathering information about a patient's physiological, psychological, sociological and spiritual status
- Health Assessment
- Physical Assessment
Components of Health History
- First step in patient assessment: Collection of subjective and objective data
- Identify patient strengths and areas of health care needs
- Provides the basis for identifying nursing problems and focusing physical exam
- A framework for organizing patient information (written/verbal)
- Seven components of a comprehensive health history
- Identifying data and source of the history
- Chief complaints
- History of Present Illness (HPI)
- Past history
- Family history
- Review of the system
- Health patterns
Identifying Data
- Age
- Date of birth
- Gender
- Occupation
- Marital relationship
- Education level
- Primary language spoken and read
- Source of history
- Patient (primary)
- Family member (secondary)
- Friend (secondary)
- Letter of referral (secondary)
- Medical record (secondary)
Reason for Seeking Health Care/Chief Complaint
- Reason for the client's visit
- Focus on the most significant concern and answer the question "Why are you here?"
- Encourage the client to discuss fears and feelings about needing healthcare
Subjective vs. Objective Data
- Subjective data comes from the patient (symptoms)
- Objective data is gathered through observation and examination (signs)
- Examples of both are provided
History of Present Illness
- Chronological account of the patient's chief complaint and surrounding events
- Includes self-treatment (OTC drugs), past occurrences of symptoms, pertinent positive/negative information, risk factors, or other related information
Past History
- Allergies
- Medications (name, dose/route, frequency)
- Home remedies/nonprescription drugs
- Childhood illnesses
- Adult illnesses (medical, surgical, accidents, psychiatric)
- Health maintenance (immunizations, screening tests, safety measures, risk factors-tobacco, environmental hazards, substance abuse, alcohol)
Family History
- Siblings, parents, grandparents, and children
- Age and health
- Cause of death
- Documents of presence or absence of specific illnesses (e.g., hypertension, CAD)
Review of the System
- Series of questions about all body systems
- May uncover problems not related to the present illness
- Initial questions are general and become more specific
Review of Systems (Sample Questions)
- Covers multiple body systems, asking about symptoms
- General, skin, head, eyes, ears, nose, throat, neck, breasts, respiratory, cardiovascular, gastrointestinal
Physical Examination
- Process to obtain objective data from the patient
- Purpose is to determine changes in a patient's health status and how to respond to a problem, as well as promote healthy lifestyle and wellbeing
Four Basic Types of Assessment
- Comprehensive health assessment: Involves a complete health history and physical exam to provide a full picture of the patient's health status
- Focused or problem-oriented assessment: Addresses a specific problem or current health concern
- Follow-up history: Form of a focused assessment to evaluate a patient problem after treatment or by a second-shift nurse to follow up on earlier shift concerns
- Emergency assessment (rapid, focused): Conducted when addressing a life-threatening or unstable condition, prioritizing systemic issues such as circulation, airway, and breathing
Standard Precautions
- Universal precautions to prevent exposure to blood and body fluids, protecting healthcare professionals and patients
Cardinal Techniques of Examination
- Inspection (detailed visual observation using lighting): Physical appearance, behavior, movement, facial expression, mood, body build, skin conditions, eye movements, and symmetry of thorax.
- Palpation (assessing through touch): Skin elevation, depression, warmth, tenderness, lymph nodes, pulses, contours, sizes of organs, and masses, crepitus in the joints
- Percussion (striking body parts to produce sound waves): Resonance or dullness from underlying tissue/organs
- Auscultation (listening to body sounds using a stethoscope): Heart, lung, and bowel sounds, location, timing, duration, pitch, intensity
Preparing for the Physical Examination
- Reflect on approach and avoid biases. Adjust environment (lighting, environment). Ensuring equipment is available and in good working order, making the patient comfortable & determine sequence.
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Description
This quiz explores the critical concepts of health assessment, focusing on determining a patient's health status and identifying care needs. Key areas include holistic care, comprehensive health history, and the facets of health that contribute to overall wellness. Test your knowledge on the processes and steps involved in health assessments.
