Nursing Process and Assessment Types

10 Questions

What is the key difference between directive and nondirective interviews?

The nurse controls the purpose and subject matter in a directive interview, while the client controls these aspects in a nondirective interview.

Which type of question specifies a broad topic to discuss and invites longer answers?

Open-ended question

At what stage of an interview does the nurse establish rapport with the client?

During the opening stage

Which data-collection method uses observation, inspection, auscultation, palpation, and percussion in a systematic way?

Examining

What does documenting data in a factual manner without stating interpretations refer to?

Documenting

Which phase of the nursing process involves the continuous collection, organization, validation, and documentation of data?

Assessing

Which type of assessment is performed during any psychological or physiological crisis of a client?

Emergency assessment

What should be performed and documented within 24 hours of a client's admission?

Initial nursing assessment

Which data type is apparent only to the person affected and cannot be observed by others?

Subjective data

Which source of data is important to ensure continuity of care when clients are transferred to and from home and health care agencies?

Health care professionals

Study Notes

Directing an Interview

Nurse establishes purpose and controls the interview in a directive interview
In a nondirective interview, the client controls the purpose, subject matter, and pacing

Building Rapport

Rapport is an understanding between two or more people
Established through creating goodwill and trust in the opening stage of an interview

Types of Interview Questions

Closed questions: restrictive, require a "yes" or "no" answer, and require less effort and information from the client
Open-ended questions: specify a broad topic to discuss, invite longer answers, and get more information from the client
Neutral questions: do not lead the client towards a particular answer
Leading questions: tend to suggest a particular answer or response

Stages of an Interview

The Opening: establish rapport, create goodwill, and explain the purpose of the interview
The Body: the client communicates, and the nurse asks questions
The Closing: the nurse ends the interview when necessary information is collected

Physical Examination

Cephalocaudal approach: a head-to-toe progression used in the examination
Screening examination: a review of systems used to identify potential health problems

Conceptual Models/Frameworks

Gordon's functional health pattern framework: a model used to guide nursing practice
Orem's self-care model: a model focused on promoting self-care
Roy's adaptation model: a model that views the person as an adaptive system
Wellness models: assist clients to identify and explore lifestyle habits and health behaviors, beliefs, values, and attitudes
Non-nursing models: body systems model and Maslow's Hierarchy of Needs

Collecting and Recording Data

Validation: the act of "double-checking" to verify the accuracy of data
Cues: subjective and objective data that can be directly observed by the nurse
Inference: the nurse's interpretation based on cues
Documenting data: recording client data in a factual manner without stating interpretations

Diagnosing

NANDA International: defines, refines, and promotes a taxonomy of nursing diagnostic terminology
Taxonomy: a classification system or set of categories arranged based on a principle
Diagnosing: the reasoning process used to identify a problem
Diagnosis: a statement or conclusion regarding the nature of a health problem

Nursing Process

Systematic, rational method of planning and providing individualized nursing care
Assessing: systematic and continuous collection, organization, validation, and documentation of data
Four types of assessment: initial, problem-focused, emergency, and time-lapsed reassessment

Collecting Data

History: collecting information about a client's past and current health status
Physical examination: performed and documented within 24 hours of admission
Types of data: subjective (symptoms) and objective (signs)
Client: the best source of data, unless too ill, young, or confused to communicate clearly
Secondary sources: family members, significant others, healthcare professionals, and literature