Nursing Health Assessment Quiz

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Questions and Answers

What is the primary purpose of the pre-interview phase?

  • To summarize important points
  • To obtain patient information
  • To set the stage for a smooth interview (correct)
  • To establish trust with the patient

Establishing the agenda for the interview is part of the introduction phase.

True (A)

What are the three categories into which a patient's information is organized?

Past, Present, Family history

The patient's _________ includes fears or concerns about their health problem.

<p>feelings</p> Signup and view all the answers

Match the symptom attributes with their descriptions:

<p>Onset = When did it start? Location = Where is it? Duration = How long does it last? Characteristics = What is it like?</p> Signup and view all the answers

Which of the following is NOT one of the seven attributes of a symptom?

<p>Complications (A)</p> Signup and view all the answers

The termination phase of the interview involves summarizing important points and discussing the plan of care.

<p>True (A)</p> Signup and view all the answers

The acronym FIFE stands for the ______ of the patient's perspective.

<p>feelings, ideas, function, expectations</p> Signup and view all the answers

Which of the following is NOT one of the '7 facets' of health?

<p>Mental health (D)</p> Signup and view all the answers

Health is solely defined as the absence of disease.

<p>False (B)</p> Signup and view all the answers

What are the two main components of a nursing health assessment?

<p>Health history and physical examination</p> Signup and view all the answers

The __________ involves systematic data collection to evaluate a person's health status.

<p>nursing health assessment</p> Signup and view all the answers

What is the first step of the nursing process?

<p>Assessment (D)</p> Signup and view all the answers

Match each facet of health with its description:

<p>Physical health = How the body works and adapts Emotional health = Positive outlook and emotions Social well-being = Supportive relationships with family and friends Cultural Influence = Favorable connections to promote health</p> Signup and view all the answers

What is the primary purpose of the nursing health assessment?

<p>To determine a patient’s health status and needs for education (C)</p> Signup and view all the answers

The nursing diagnosis is formulated solely based on the patient's reported symptoms.

<p>False (B)</p> Signup and view all the answers

Past medical records are not useful in collecting information during the health history.

<p>False (B)</p> Signup and view all the answers

What is the purpose of the evaluation step in the nursing process?

<p>To determine if the goals have been attained.</p> Signup and view all the answers

A focused assessment primarily gathers information about the patient’s _______.

<p>problem</p> Signup and view all the answers

What should be done with the information obtained during the health assessment?

<p>Document it in the patient's medical records</p> Signup and view all the answers

Match the types of health assessments with their definitions:

<p>Comprehensive assessment = A thorough assessment during admission Focused assessment = Limited assessment addressing a specific problem Follow-up history = Assessing patient after treatment or intervention Emergency history = Rapid assessment focusing on immediate health threats</p> Signup and view all the answers

During which step of the nursing process do nurses and patients collaborate to set goals?

<p>Planning (B)</p> Signup and view all the answers

Health history interviews serve to establish a trusting relationship with the patient.

<p>True (A)</p> Signup and view all the answers

What are the ABCs when conducting an emergency history?

<p>Airway, Breathing, Circulation</p> Signup and view all the answers

What type of data consists of observable and measurable information?

<p>Objective data (D)</p> Signup and view all the answers

Subjective data includes information obtained through observations and laboratory testing.

<p>False (B)</p> Signup and view all the answers

What does HPI stand for in a medical history context?

<p>History of Present Illness</p> Signup and view all the answers

The acronym OLD CART helps to remember the seven attributes of a symptom: Onset, Location, Duration, ________, Associated Manifestations, Relieving/Exacerbating Factors, and Treatment.

<p>Characteristic Symptoms</p> Signup and view all the answers

Which of the following is NOT typically included in the Past History section of a medical history?

<p>Current lifestyle habits (C)</p> Signup and view all the answers

Match the following components of medical history with their descriptions:

<p>Allergies = Reactions to medications or environmental factors Medications = Name, dose, route, and frequency of use Childhood illnesses = Previous significant diseases during childhood Adult illnesses = Medical conditions or surgeries occurring after childhood</p> Signup and view all the answers

The Risk factors are part of the key elements of the History of the Present Illness.

<p>True (A)</p> Signup and view all the answers

Name one chronic childhood illness that should be included in the Past History.

<p>Asthma</p> Signup and view all the answers

Which immunization is NOT typically included in health maintenance assessments?

<p>Plague (A)</p> Signup and view all the answers

Screening tests should include results and dates of tests performed.

<p>True (A)</p> Signup and view all the answers

What are some examples of environmental hazards that should be inquired about?

<p>Mold, asbestos, chemicals, or pollutants in the home or work environment</p> Signup and view all the answers

The recommended two types of tobacco usage questions should inquire about use and _____.

<p>age of initiation</p> Signup and view all the answers

Match the following screening tests with their purpose:

<p>Tuberculin tests = Detect tuberculosis Cholesterol tests = Assess cholesterol levels Pap smears = Screen for cervical cancer Mammograms = Screen for breast cancer</p> Signup and view all the answers

What is a common symptom to ask about in a head-to-toe review of systems?

<p>Cough (B)</p> Signup and view all the answers

Cultural constructs of mental illness are universally recognized and accepted.

<p>False (B)</p> Signup and view all the answers

Ask open-ended questions initially to encourage _____ from the patient.

<p>discussion</p> Signup and view all the answers

What is the primary purpose of a physical examination?

<p>To obtain objective data and promote healthy lifestyles (B)</p> Signup and view all the answers

It is appropriate to interpret your findings during a physical examination.

<p>False (B)</p> Signup and view all the answers

List two steps you should take to make the patient comfortable during an examination.

<p>Close nearby doors and draw the curtains; Wash your hands.</p> Signup and view all the answers

Before beginning the physical examination, you should ensure that you have checked your ______.

<p>equipment</p> Signup and view all the answers

Which of the following should be adjusted to create a comfortable environment for a physical examination?

<p>The lighting and surroundings (B)</p> Signup and view all the answers

Match the following actions with their purposes during a physical examination:

<p>Washing hands = Prevent infection Draping the patient = Maintain privacy Checking vital signs = Monitor health status Adjusting lighting = Improve visibility</p> Signup and view all the answers

Why is it important to inform the patient about their vital signs during the examination?

<p>To keep the patient informed and reduce anxiety.</p> Signup and view all the answers

Most patients view a physical examination with some anxiety.

<p>True (A)</p> Signup and view all the answers

Flashcards

Health Definition

A relative state where a person can live to their full potential, considering seven key dimensions: physical, emotional, social, cultural, spiritual, environmental, and developmental.

Nursing Health Assessment

A comprehensive evaluation of a person's health, including a detailed history and physical examination.

Health History

The first part of a health assessment, focusing on gathering information about a patient's past medical history, lifestyle, and social factors.

Physical Examination

The second part of a health assessment, involving a systematic physical examination of the body, from head to toe.

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Emotional Health

A person's ability to cope with emotions, have a positive outlook, and express emotions in a healthy way.

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Social Well-being

The quality of a person's relationships with family, friends, and community.

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Cultural Influence

The influence of a person's cultural background on their health beliefs and practices.

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Spiritual Influence

A person's spiritual beliefs, values, and practices that impact their health and well-being.

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Nursing Process

The systematic approach nurses use to identify patient problems, develop care plans, implement interventions, and evaluate outcomes.

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Assessment

The initial step of the nursing process that involves gathering subjective and objective information about the patient's health status.

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Nursing Diagnosis

The process of analyzing assessment data and identifying actual or potential health problems or responses to health problems.

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Planning

The stage of the nursing process where the nurse develops individualized interventions and goals to address the identified nursing diagnoses.

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Implementation

The phase of the nursing process involving carrying out the planned interventions, such as medication administration, patient education, or providing emotional support.

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Evaluation

The final phase of the nursing process where the nurse evaluates the effectiveness of the interventions and the progress towards the set goals.

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Comprehensive Health Assessment

A comprehensive health assessment conducted upon a patient's admission to a healthcare facility, covering all aspects of their health.

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Focused/Problem-Oriented Assessment

A focused assessment on a specific problem or concern, often used as a follow-up or for emergency situations.

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Pre-Interview Phase

A stage of the interview process where you prepare yourself and the environment for a successful conversation with the patient.

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Self-Reflection

A key part of the pre-interview phase where you reflect on your own skills, knowledge, and biases to ensure objective patient care.

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Introduction Phase

Establishing a connection with the patient by greeting them warmly, ensuring comfort, and clearly outlining the purpose of the interview.

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Working Phase

The main part of the interview where you gather information from the patient, actively listen, and understand their perspective.

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Invite the Patient's Story

A technique used in the working phase to encourage the patient to share their story in their own words.

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FIFE (Feelings, Ideas, Function, Expectations)

A tool for understanding the patient's experience by considering their feelings, ideas, impact on their life, and expectations.

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Termination Phase

The concluding stage of the interview where you summarize key points, discuss the care plan, and address any remaining questions.

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Review Patient Record

A crucial step in patient care, involving reviewing and clarifying patient information to ensure accuracy and completeness.

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Reflect on your approach

The act of presenting oneself as a confident and calm nursing student to reduce patient anxiety during the physical examination.

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Adjust the Lighting and Environment

Adjusting the environment and lighting for optimal visibility and a comfortable patient experience.

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Make the Patient Comfortable

Creating a comfortable atmosphere for the patient by respecting privacy, modesty, and informing them about each step of the examination.

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Ensure the Patient's Privacy

Ensuring the patient's privacy and modesty by closing doors and drawing curtains before examination begins.

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Wash Your Hands

Washing hands before the examination to maintain proper hygiene and prevent infection.

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Patient Draping

Using a drape to expose only the area being examined, while maintaining the patient's modesty and comfort.

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Communicate Results and Expectations

Communicating examination findings, general impressions, and expected next steps to the patient.

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Subjective Data

Data based on the patient's own feelings, perceptions, and concerns. This information is gathered through interviews and conversations.

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Objective Data

Measurable and observable data obtained through physical examinations, observations, and laboratory tests. This data is collected through objective means like vital signs and lab results.

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History of Present Illness (HPI)

A detailed chronological account of the patient's current health issues that led them to seek medical attention. It includes the onset of the problem, its evolution, symptoms, treatments, and impact on daily life.

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Seven Attributes of a Symptom

Seven key attributes of each symptom a patient describes. These are 'Onset', 'Location', 'Duration', 'Characteristics', 'Associated Manifestations', 'Relieving/Exacerbating Factors', and 'Treatment'.

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Medications in Past History

A record of all medications, both prescribed and over-the-counter, including vitamins, herbal supplements, and even borrowed medications. It also includes details about dosage, frequency, and route of administration.

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Childhood and Adult Illnesses in Past History

Includes a record of childhood illnesses like measles, mumps, rubella, and chronic conditions like asthma. This section also documents any adult illnesses like diabetes, hypertension, or HIV.

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Surgical History in Past History

This section documents all surgeries performed on the patient, including dates, reasons, and types of procedures.

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Allergies in Past History

A detailed record of any allergies the patient has, including reactions to medications, foods, insects, or environmental factors.

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What is a Health History?

A systematic approach to gathering data about a patient's health, encompassing past medical events, lifestyle factors, and social influences. Often the first step in a comprehensive health assessment.

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What is a Review of Systems?

A series of questions asked to systematically assess different body systems. It helps identify potential health concerns and areas for further investigation during a physical examination.

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What is a Genogram?

A graphic representation of a family's health history, often used to track genetic conditions and identify potential risks. It includes information about family members' health status and causes of death.

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What is a Mental Health History?

Gathering information about a patient's mental health, including past experiences with mental illness, current symptoms, and treatment history. It aims to understand the patient's emotional well-being and identify potential needs.

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What is Accident and Illness History?

A critical component of health history taking where the nurse inquires about a patient's history of accidents, illnesses, and injuries, including details of the events, dates, treatments received, and any remaining disabilities.

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What is Immunization History?

Asking patients about their vaccination status, including the type of vaccines received, dates of administration, and booster doses. It helps assess their immune protection and identify potential vaccination needs.

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What are Screening Tests in a Health History?

Gathering information about various screening tests that the patient has undergone, including the types of tests, dates performed, and results obtained. Screening tests are used to detect potential health problems early.

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What are Risk Factors in a Health History?

A section of the health history that explores a patient's lifestyle habits, including tobacco use, environmental hazards, substance abuse, and alcohol consumption. This information helps identify potential risk factors for health problems.

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Study Notes

Module 1: Definition of Health

  • Health is a relative state, enabling a person to live to their full potential, encompassing seven facets.
  • Physical health: how the body functions and adapts.
  • Emotional health: positive outlook and healthy emotional expression.
  • Social well-being: supportive relationships with family and friends.
  • Cultural influence: favorable connections promoting health.
  • Spiritual influence: peaceful, moral, and ethical living.
  • Environmental influence: favorable conditions promoting health.
  • Developmental level: cognitive abilities, problem-solving, and decision-making.
  • Health isn't just the absence of disease but a combination of these factors.

Module 1: Health Assessment

  • Nursing health assessment involves a comprehensive history and physical examination.
  • The assessment gathers data from the patient and/or family, using past medical records if necessary.
  • The assessment considers physical, psychological, social, cultural, and spiritual factors to understand their overall health status.
  • A structured head-to-toe physical examination is part of the assessment to detect changes or abnormalities.
  • Results assist in developing a patient care plan.

Module 1: Nursing Process

  • Nurses use the nursing process (a problem-solving approach) to systematically address patient needs.
  • This process involves assessing problems, setting goals, developing action plans, implementing the plan, and evaluating outcomes.
  • Steps include: Assessment, Diagnosis, Planning, Implementation, and Evaluation.
  • The nurse uses data collected to make diagnoses, formulate goals, and develop plans to address patient concerns.
  • The process is documented in patients' medical records.

Module 2: Interviewing and Communication

  • A health history interview involves building rapport, gathering information, and providing information.
  • The goal is to create a trusting and supportive relationship while providing pertinent information.
  • A health history format structures information into past, present, and family history categories.
  • The format facilitates easy communication among healthcare providers.
  • Information is gathered in a manner that allows a focused or problem-oriented approach, or a follow-up history.
  • Emergency histories focus on priority needs (ABCs).

Module 2: Phases of Interview

  • The interview process has pre-interview, working, and termination stages.
  • In the pre-interview, the setting is prepared, and self-reflection assists professional development.
  • During the working stage there is reflection, patient's story gathering, clarification of emotional clues, testing diagnostic hypotheses, agreeing on a plan for evaluation, treatment, counseling, and self-management.
  • The termination phase reviews major points covered in the conversation, plans of care, and follow-up instructions.

Module 2: Seven Attributes of a Symptom

  • Onset: when the symptom began.
  • Location: specific area of the body where the symptom manifests.
  • Duration: how long the symptom lasts each occurrence.
  • Characteristics: details describing the symptom (severity, pain scale, etc.).
  • Relieving/Exacerbating factors: factors that ease, worsen, or trigger symptoms.
  • Explore the patient's feelings, their understanding of the problem, its impact on their life, and their expectations for care.

Module 3: Physical Examination

  • Physical examinations use objective data to further assess a patient's health.
  • Steps include appropriate attire, environmental adjustments that create comfort for the patient.
  • Visual inspection, palpation, and auscultation are used to assess body systems.
  • Observation of patient behavior and general appearance are critical parts of the examination.
  • Use standard precautions in a professional manner.
  • Focus on patient's comfort and privacy.

Types of Data

  • Objective data includes observable and measurable information from observations, physical exams, and laboratory tests.
  • Subjective data comes from the client's perspective, and includes feelings, perceptions, and concerns expressed through interviews.

History of Present Illness (HPI)

  • A chronological account of the problems causing a patient to seek care.
  • Covers the onset of the issue, where and how it developed, symptoms, and responses to treatment.

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