COMPLETE QUESTIONS AND SOLUTIONS
GRADED A+
◉Why do you want to interview before assess?. Answer: To know
health history, risk factors, medications etc
◉Why do you want to interview before assess?. Answer: To know
what to focus on or assess
◉"Are you healthy?" is a good question for assessment (T/F).
Answer: F
◉How do you assess systematically? and comprehensively?. Answer:
Head-to-toe
Knowing where to start and where to go
◉When assessing you should start with the most pressing issue
(T/F). Answer: T
,◉What is health?. Answer: A relative state in which a person is able
to live to his/her potential and includes the 7 facets
◉Health is the _____________. Answer: sum of 7 facets
◉What are the 7 facets?. Answer: Physical, Emotional, Social,
Culture, spiritual, environmental, developmental
◉What is health history?. Answer: the write up that follows the
interview and the nurses use this data to develop a problem list, and
the interview is the actual communication process.
◉What is the goal of health assessment?. Answer: development of
an individualized plan of care
◉Why does a nurse use nursing process?. Answer: to identify
patient problems; set a goal and develop an action plan; implement
plan; and evaluate the outcome
◉What are the nursing process steps?. Answer: ADPIE
Assessment
Diagnosis
Planning
Implementation
,Evaluation
◉Assessment. Answer: collects info and synthesize info about pt and
situation
subjective and objective data during health assessment
◉Diagnosis. Answer: what is most important? Identify the issue,
utilize clinical reasoning
◉Planning. Answer: the patient and nurse create short/long term
goals to alleviate the problem
◉Implementation (Clinical reasoning). Answer: Identify abnormal
or positive findings
Cluster the findings
Interpret the findings
Intervention to initiate goals, this is where modifications can be
made
Develop a plan agreeable to the patient
◉Evaluate. Answer: Did it work?
Continuing process to determine if the goals have been attained and
if not, intervene again and reevaluate
, ◉What is subjective data?. Answer: What you are told, pain,
symptoms, cannot verify
◉What is objective data?. Answer: What you observe
Signs
◉What is the clinical reasoning process?. Answer: A nurse interacts
with a patient, collects information, identifies abnormal findings,
clusters findings, interprets findings, generates and tests
hypotheses, and determines optimal diagnosis and treatment based
on the information obtained while making sure the patient agrees.
◉OLD CAARTS. Answer: onset
location
duration
characteristics
aggravating factors