Podcast
Questions and Answers
Which of the following group of terms best defines assessing in the nursing process?
Which of the following group of terms best defines assessing in the nursing process?
- nurse focused, establishing nursing goals
- collection, validation, communication of patient data (correct)
- problem focused, time lapsed, emergency based
- design a plan of care, implement nursing interventions
A nurse performing triage in an emergency room makes assessments of patients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply.
A nurse performing triage in an emergency room makes assessments of patients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply.
- using the nursing process to diagnose a blocked airway (correct)
- carrying out a physicians order to intubate a patient
- interviewing a patient suspected of being a victim of abuse privately (correct)
- teaching a diabetic patient about the importance of proper foot care
- checking the data supplied by a patient with dementia with the family (correct)
- teaching a novice nurse the principles of triage
On admission, a physician diagnoses a patient with rheumatoid arthritis. The nurse uses assessments to make the nursing diagnosis of Chronic Pain. What is the nurse diagnosing?
On admission, a physician diagnoses a patient with rheumatoid arthritis. The nurse uses assessments to make the nursing diagnosis of Chronic Pain. What is the nurse diagnosing?
- the response of the patient to the illness (correct)
- the pathology of the illness
- knowledge from more experienced nurses
- information from a nursing textbook
The nurse completes a health history and physical assessment on a patient who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?
The nurse completes a health history and physical assessment on a patient who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?
Mrs. James comes to her healthcare providers office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do?
Mrs. James comes to her healthcare providers office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do?
A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the residents ability to breathe and then begins CPR. Why did the nurse assess respiratory status?
A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the residents ability to breathe and then begins CPR. Why did the nurse assess respiratory status?
A nurse performs an assessment of a patient in a long-term care facility and records baseline data. The nurse reassesses the patient a month later and makes revisions in the plan of care. What type of assessment is the second assessment?
A nurse performs an assessment of a patient in a long-term care facility and records baseline data. The nurse reassesses the patient a month later and makes revisions in the plan of care. What type of assessment is the second assessment?
Which of the following statements best describes the relationship between nursing diagnosis and medical diagnosis?
Which of the following statements best describes the relationship between nursing diagnosis and medical diagnosis?
Of the following information collected during a nursing assessment, which are subjective data?
Of the following information collected during a nursing assessment, which are subjective data?
A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?
A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?
Who or what is the primary source of information for a nursing history?
Who or what is the primary source of information for a nursing history?
A nurse is collecting information from Mr. Koeppe, a patient with dementia. The patients daughter, Sarah, accompanies the patient. Which of the following statements by the nurse would recognize the patients value as an individual?
A nurse is collecting information from Mr. Koeppe, a patient with dementia. The patients daughter, Sarah, accompanies the patient. Which of the following statements by the nurse would recognize the patients value as an individual?
What type of patient record data would the nurse find in the medical history and progress notes?
What type of patient record data would the nurse find in the medical history and progress notes?
A nurse is collecting data from a home care patient. In addition to information about the patients health status, what is another observation the nurse should make?
A nurse is collecting data from a home care patient. In addition to information about the patients health status, what is another observation the nurse should make?
Of the following data, what type would be collected during a physical assessment?
Of the following data, what type would be collected during a physical assessment?
A nurse is preparing to conduct a health history for a patient who is confined to bed. How should the nurse position herself?
A nurse is preparing to conduct a health history for a patient who is confined to bed. How should the nurse position herself?
Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview?
Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview?
Which of the following questions or statements would be an appropriate termination of the health history interview?
Which of the following questions or statements would be an appropriate termination of the health history interview?
Which of the following are examples of common factors that may influence assessment priorities? Select all that apply.
Which of the following are examples of common factors that may influence assessment priorities? Select all that apply.
After collecting data from a patient with respiratory distress, the nurse prioritizes the patient interventions to provide oxygen to the patient first. This is an example of which of the following models for organizing data?
After collecting data from a patient with respiratory distress, the nurse prioritizes the patient interventions to provide oxygen to the patient first. This is an example of which of the following models for organizing data?
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, I have been so constipated lately. How should the nurse respond?
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, I have been so constipated lately. How should the nurse respond?
A nurse who collected and organized data during a patient history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future?
A nurse who collected and organized data during a patient history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future?
What is the primary purpose of validation as a part of assessment?
What is the primary purpose of validation as a part of assessment?
Which of the following examples of patient data needs to be validated? Select all that apply.
Which of the following examples of patient data needs to be validated? Select all that apply.
A student takes an adult patients pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the student do next?
A student takes an adult patients pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the student do next?
Which of the following entries would be an example of appropriate documentation?
Which of the following entries would be an example of appropriate documentation?
Flashcards
Assessing in Nursing
Assessing in Nursing
Collection, validation, and communication of patient data.
Critical Thinking in Assessment
Critical Thinking in Assessment
Activities which involves interviewing, problem-solving, and verifying dementia patient data.
Nursing Diagnosis Focus
Nursing Diagnosis Focus
Determining how the patient is responding to the illness.
Purpose of Initial Assessment
Purpose of Initial Assessment
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Focused Assessment
Focused Assessment
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Assessing Respiratory Status
Assessing Respiratory Status
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Time-Lapsed Assessment
Time-Lapsed Assessment
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Nursing Diagnosis
Nursing Diagnosis
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Subjective Data
Subjective Data
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Objective Data
Objective Data
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Study Notes
- Assessing in the nursing process involves the collection, validation, and communication of patient data.
Critical Thinking Activities Linked to Assessment
- Interviewing a patient suspected of being a victim of abuse privately requires critical thinking.
- Checking the data supplied by a patient with dementia with the family involves critical thinking.
- Using the nursing process to diagnose a blocked airway relies on critical thinking skills.
Nursing Diagnosis vs. Medical Diagnosis
- The nursing diagnosis is based on the patient's response to the medical diagnosis.
- Assessments help nurses make nursing diagnoses, like Chronic Pain, based on the patient's response to an illness such as rheumatoid arthritis.
Purpose of Initial Assessment
- An initial assessment's purpose is to establish a database to identify problems and strengths.
- A health history and physical are completed on a patient admitted for surgery.
Types of Assessment
- An initial assessment gathers comprehensive data.
- A focused assessment gathers data about a specific problem that has been previously addressed, such as abdominal pain.
- An emergency assessment identifies life-threatening problems requiring immediate attention, such as a resident who begins to choke.
- A time-lapsed assessment reassesses a patient after a period to make revisions in the plan of care.
Sources of Information
- The patient is the primary source of information for a nursing history.
- For a patient with dementia, statements that recognize the patient's value as an individual are important
Objective vs. Subjective Data
- Objective data is observable and measurable, such as the inability to palpate a femoral pulse.
- Subjective data includes the patient's feelings and descriptions, such as nausea and abdominal pain.
Data from Patient Records
- The medical history and progress notes contain findings of the physicians assessment and treatment.
Home Care Assessment
- Additional observation to make is the safety of the immediate environment
- Collecting data involves assessing color, moisture, and temperature of the skin.
- Position for health history is sitting at a 45-degree angle to the bed
Appropriate Interview Techniques
- In eliciting further information: "Tell me more about what caused your pain."
- In terminating the interview, ask: "Can you think of anything else you would like to tell me?"
Factors Influencing Assessment Priorities
- A patient's diet and exercise program
- A patient's developmental stage
- A patient's need for nursing
Models for Organizing Data
- Prioritizing interventions based on a patient's need for oxygen is an example of the Hierarchy of Human Needs.
Responding to Patient Concerns
- When a patient says, "I have been so constipated lately," ask: "Do you take anything to help your constipation?"
Improving Data Collection
- Determine specific purpose of data collection
Purpose of Validation
- The primary purpose of validation as part of assessment is to identify data to be validated.
Data Requiring Validation
- A patient has trouble reading an informed consent, but states he does not need glasses.
- An elderly patient explains that the black and blue marks on his arms and legs are due to a fall.
- Following a MVA, the teenage driver with alcohol on his breath states that he was not drinking.
Addressing Abnormal Findings
- If a student finds an adult patient's pulse is 20 beats/min, the student should ask the instructor or staff nurse to take the pulse.
Appropriate Documentation
- Complains of abdominal pain. Probably constipated.
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