18 Questions
Which of the following is a secondary source of data?
Records and reports
What is considered objective data in healthcare?
Blood pressure reading
In an interview, which approach is highly structured and involves direct questions?
Directive interview
During an interview, which stage focuses on the initial interaction and setting the tone?
The opening or introduction
Which of the following is NOT a technique used in a physical examination for data collection?
Questioning
How does a nurse primarily organize assessment data?
Systematically
What is the purpose of validating data during the assessment phase?
To ensure the information gathered is accurate and complete
Which of the following is the primary task of the diagnosis phase in the nursing process?
Using critical thinking skills to interpret assessment data
What is the official NANDA definition of a nursing diagnosis?
A clinical judgment concerning a human response to health conditions or life processes
What is the purpose of documenting data during the assessment phase?
To record the client's health history and assessment data
Which of the following is an example of a risk nursing diagnosis?
A potential problem that may develop if adequate care is not given
What is the purpose of using NANDA guidelines during the diagnosis phase?
To define or refine nursing diagnoses
Which type of data can be described only by the person affected?
Subjective data
When is an emergency assessment typically performed?
During an emergency situation
Which type of data can be measured or tested against an accepted standard?
Objective data
What is the purpose of a problem-focused assessment?
To determine the status of a specific problem identified earlier
When is a time-lapsed reassessment typically performed?
Several months after initial assessment
What distinguishes subjective data from objective data?
Subjective data are clear only to the person affected, objective data are detectable by an observer
Study Notes
Types of Nursing Assessments
- Initial nursing assessment: performed within a specified time after admission to establish a complete database for problem identification
- Problem-focused assessment: determines the status of a specific problem identified in an earlier assessment
- Emergency assessment: performed during emergency situations to identify life-threatening situations
- Time-lapsed reassessment: compares the client's current health status with previously obtained data
Data Collection
- Includes health history, physical examination, laboratory and diagnostic test results, and material contributed by other health personnel
- Two types: subjective data and objective data
- Subjective data: symptoms or covert data, clear only to the person affected (e.g., itching, pain, feelings of worry)
- Objective data: signs or overt data, detectable by an observer or measurable against an accepted standard (e.g., vital signs, laboratory results)
Validation and Documentation of Data
- Validation: verifying the accuracy and completeness of gathered information
- Documentation: recording client data, essential for accuracy and completeness
Nursing Diagnosis
- Definition: a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response
- Status of nursing diagnosis: actual, health promotion, and risk
- Actual diagnosis: a client problem that exists at the time of assessment
- Health promotion diagnosis: relates to clients' preparedness to improve their health condition
- Risk nursing diagnosis: a clinical judgment that a problem does not exist, but risk factors indicate a potential problem
Sources and Methods of Data Collection
- Primary source: the client
- Secondary sources: family members, health professionals, records, laboratory and diagnostic results
- Methods: observation, interview, and examination
- Observation: gathering data using the senses (vision, smell, hearing)
- Interview: a planned communication or conversation with a purpose (directive and nondirective approaches)
- Examination: a systematic data collection method to detect health problems using techniques of inspection, palpation, percussion, and auscultation
Learn about different types of nursing assessments including initial nursing assessment, problem-focused assessment, and emergency assessment. Understand the purpose and procedures for each type of assessment.
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