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Terms in this set (21)
Systematic collection of information about body systems through use of observation, inspection, auscultation, palpation, and percussion
Gordon's Functional Health Patterns Model is helpful for gathering and organizing both physical and psychosocial data
-Nurse collects data from multiple sources: primary (client) and secondary (family members, support persons, healthcare professionals, and records)
Consultation with individuals who can contribute to client's database is helpful in obtaining the most complete and accurate information about a client
Supplemental information from secondary sources (any source other than client) can help verify information, provide information for a client who cannot do so, and convey information about client's status prior to admission
Review of literature
A professional nurse engages in continued education to maintain knowledge of current information related to healthcare and nursing practice
Format for Physical Assessment
• General head-to-toe assessment
• Integumentary system
• Head, ears, eyes, nose, throat
• Breast and axillae
• Thorax and lungs
• Cardiovascular system
• Nervous system
• Abdomen and gastrointestinal system
• Anus and rectum
• Genitourinary system •
• Musculoskeletal system
Gordon's Functional Health Problems
• Health perception-health management
• Activity-exercise •
• Coping-stress tolerance
Which type of question would be best for the nurse to use on trying to determine the extent of a patient's knowledge concerning a disease process
A) Open ended
C) Close ended
A) Open ended questions are best utilize to elicit a narrative response
Direct focused or closed ended questions are used to obtain demographic or specific information rather than a depth of data
Which statement by the nurse best describes health history asssessent
Collection of health history information is ongoing throughout patient interaction
Which statement best illustrates appropriate documentation on palpation
Abdomen soft and tender, non tender without distention
Percussion deals with ____
Auscultation deals with _____
Which assessment is most appropriate for a patient newly admitted to the hospital for intermittent loss of vision in the left eye?
Compete: examination of the cranial nerves is necessary upon admission to the acute care setting
______ assessment will follow throughout the patients hospitalization and at follow up outpatient visits
Alll patients assessment findings are related to neurological functioning which should be organized under the area of ______ and _______
Cognition and perception
Concerns regarding identity of body image will be documented under the health patterns of _____ -____ and _____-____
Stress tolerance and support system information would be recorded in the _____ & ____ management area
Coping and stress
Assessment findings related to cardiac respiratory musculoskeletal systems are documented as part of the ______ and ______ function health pattern
Exercise and activity
1. Which actions does the nurse take during the termination phase of the patient interview? (Select all that apply.)
a. Express appreciation for the patient's participation.
b. Review key assessment findings that were noted.
c. Validate information covered with the patient.
d. Allow the patient to add additional insights.
e. Agrees on the next time to meet.
ANS: A, B, C, D
There would not be another meeting after the termination phase.
the most important source in data collection is/are:
a. nursing literature.
b. the patient.
c. medical records.
d. family members.
b: the patient
Patients from which generation would be most comfortable with the nurse using electronic resources for health screening?
a. Baby boomers
b. Generation X
Millennials are typically very computer literate or technology natives. Of the generations listed, millennials would be the most comfortable with accessing electronic resources for health screening.
Which closed-ended questions would the nurse use when interviewing a patient? Select all that apply.
Do you have pain now?"
"Tell me more about your pain."
"Is the pain cramping in nature?"
"Do you think the medication is helping you?"
"How do you feel about using pain medications?"
Closed-ended questions are used to identify specific problem areas.
These questions are usually answered in one or two words.
Therefore the nurse should ask if the patient has pain or not, if the pain is cramping or not, and if the medication is helping.
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