30 Questions
What is the goal of nonverbal communication during the interview?
To maintain good eye contact and display a friendly facial expression
What is the primary purpose of taking notes during the interview?
To record biographic data and health history
During the summary and closing phase, what does the nurse do?
Summarizes information obtained during the working phase and validates problems
What type of questions are used to elicit the client's feelings and perceptions?
Open-ended questions
During the working phase, what does the nurse elicit from the client?
The client's comments about all of the above
What is the purpose of the nurse's silence during the interview?
To allow the nurse and client to organize and reflect thoughts
What is the purpose of verifying data with another health care professional?
To validate the accuracy of the collected data
What is the primary difference between EMR and EHR?
EMR is used for medical diagnoses and treatments, while EHR is used for client's comprehensive health status
What is the purpose of a focused or specialized assessment form?
To focus on a specific area of the body or a particular problem
What is the primary purpose of an initial assessment form?
To gather comprehensive health information about the client
Why is it important to compare subjective data with objective data?
To uncover discrepancies in the data
What is the benefit of using computer-based documentation systems?
It links to other documents and health care departments, eliminating repetition of similar data collection
What is a necessary condition for the examination setting to ensure the quality of the data collected?
A quiet area free of distractions
Why is validation of assessment data crucial?
It prevents premature closure of the assessment or collection of inaccurate data
What is one of the methods of validating data?
Rechecking through a repeat assessment
What is the purpose of providing a warm blanket in the examination setting?
To provide a comfortable room temperature
What is the purpose of using closed-ended questions?
To obtain facts and to focus on specific information
What type of question typically begins with the words 'how' or 'what'?
Open-ended questions
What may result from failure to validate data?
Premature closure of the assessment or collection of inaccurate data
What is the role of the mirror in the examination setting?
For client's self-examination of skin
What is an important aspect of providing information to the client?
Explaining that you will find out the answer for the client if you do not know
What is the purpose of the complete health history?
To identify nursing problems and provide a focus for the physical examination
What is an example of a Laundry List question?
Is the pain severe, mild, dull, sharp, cutting, or piercing?
What is the purpose of rephrasing in the questioning process?
To clarify information the client has stated and to reflect on what was said
What is the purpose of applying an allergy band and confirming prepopulated allergies in the EMR?
To prevent allergic reactions and ensure patient safety
What is the primary goal of reconciling medications promptly using electronic data confirmation from local pharmacies?
To confirm the accuracy of the patient's medication list
What is the purpose of recording the patient's chief complaint?
To identify the patient's probable medical diagnosis
What is included in the patient's past medical history documentation?
Prior hospitalizations and major illnesses and surgeries
What is the purpose of orienting the patient, caregivers, and family to the location and rights?
To inform the patient of their rights and responsibilities
What is the purpose of sending the patient's valuables to appropriate safe storage or sending them home with family?
To secure the patient's belongings according to institutional policies
Study Notes
Communication During the Interview
- Nonverbal Communication:
- Appearance: Ensure professional appearance
- Demeanour: Display poise when entering the room
- Facial Expression: Keep expression neutral and friendly
- Attitude: Maintain a non-judgmental attitude
- Silence: Allow time for reflection and organization of thoughts
- Listening: Maintain good eye contact, smile, and display an open, appropriate facial expression
- Verbal Communication:
- Open-ended questions: Used to elicit feelings and perceptions
Documentation
- Includes:
- Name, medical record number, age, date, time, probable medical diagnosis, chief complaint, and source of information (two patient identifiers)
- Past medical history:
- Prior hospitalizations and major illnesses and surgeries
- Assess pain:
- Location, severity, and use of a pain scale
- Allergies:
- Medications, foods, and environmental; nature of the reaction and seriousness
- Medications:
- Confirm accuracy of list, names, and dosages of medications
- Valuables:
- Record and send to appropriate safe storage or send home with family
- Rights:
- Orient patient, caregivers, and family to location, rights, and responsibilities
- Goal of admission and discharge goal
Documenting Data
- Computer-based documentation systems:
- Link to other documents and health care departments
- Electronic Medical Records (EMR):
- Supplied by physicians for medical diagnoses and prescribed treatments
- Electronic Health Records (EHR):
- Comprehensive health status of the client (emotional, physical, social, spiritual)
- Three types of assessment forms:
- Initial assessment form (nursing admission or admission database)
- Frequent or ongoing assessment forms (e.g., vital sign sheet, assessment flow chart)
- Focused or specialized assessment forms (e.g., pain scale chart, Braden scale chart)
Preparing for the Examination
- Preparing the physical setting:
- Comfortable, warm room temperature
- Private area free of interruptions
- Quiet area free of distractions
- Examination tools:
- Penlight
- Mirror
- Metric ruler
- Magnifying glass
- Wood's light
Validating Assessment Data
- Steps of validation:
- Deciding whether data require validation
- Determining ways to validate the data
- Identifying areas for which data are missing
- Methods of validation:
- Recheck through a repeat assessment
- Validate through comparison with objective data
Types of Questions
- Open-ended questions:
- Begin with "how" or "what"
- Example: "How have you been feeling lately?"
- Closed-ended questions:
- Begin with "when" or "did"
- Example: "When did your headache start?"
- Laundry list:
- Provide a list of words for the client to choose from
- Rephrasing:
- Clarify information and reflect on what was said
- Example: "You are thinking that you have a serious illness?"
- Inferring:
- Elicit the most accurate data possible from the client
Complete Health History
- Lays the groundwork for identifying nursing problems and provides a focus for the physical examination
- Has eight sections, which can be modified or shortened when necessary
Test your knowledge of the different phases of nursing assessment, including the introductory phase, working phase, and summary and closing phase. Learn about the importance of taking notes and maintaining confidentiality during the assessment process.
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