2026 Fundamentals: Chapter
16, Nursing Assessment
Nursing process-CORRECT ANSWER--A critical thinking process that professional
nurses use to apply the best available evidence to caregiving and promoting human
functions and responses to health and illness.
Nursing Process Five Steps-CORRECT ANSWER--Def. Fundamental blueprint for
how to care for a patient. "Standard of Practice"
1. Assessment - Collection, verification, and analysis of data.
2. Diagnose - identify the patient's problems
3. Plan- Set goals of care and desired outcomes and id appropriate nursing actions
4. Implement- perform the nursing actions id in planning
5. Evaluate- determine if goals and expected outcomes are achieved
Assessment-CORRECT ANSWER--Def. The deliberate and systematic collection of
information about a patient to determine his or her current and past health and
functional status and his or her present and past coping patterns.
Nursing Assessment includes two steps:
1. Collection of information from a primary source (the patient) and secondary
sources (e.g. family members, health professionals, and medical record)
2. The interpretation and validation of data to ensure a complete database.
Database-CORRECT ANSWER--The purpose of assessment is to establish a
database about the patient's perceived needs, health problems, and responses to
these problems. In addition, the data reveal related experiences, health practices,
goals, values, and expectations about the health care system.
Data Collection-CORRECT ANSWER--Gather information (assessment) to make an
accurate judgment about a patient's current condition.
Your information comes from:
1. The patient, through interview, observations, and physical examinations
2. Family members or significant others' reports and response to interview
3. Other members of healthcare team
4. Medical records (patient history, labs, x-ray)
5. Scientific Literature (evidence about assessment techniques and standards)
, Cue-CORRECT ANSWER--Information that a nurse obtain through the use of the
senses (hearing, visual observations, touch, and smell).
Inference-CORRECT ANSWER--Your judgment or interpretation of the cues
Example: A patient crying is a cue that possibly implies fear or sadness
Observational overview using cues and forming inferences.-CORRECT
ANSWER--Male patient in bed, looks uncomfortable. Patient presents with
discomfort in surgical area.
Cues
- Lies still with arms along sides; tense
- States has not turned for some time
- Reports pain a 7 on a scale of 0 to 10
Inferences
- Pain is severe
- Pain limits patient's ability to move and reposition self
11 Functional health patterns-CORRECT ANSWER--An example of a structured
database format, one approach to perform a comprehensive assessment. Gordon's
functional health patterns model offers a holistic framework for assessment of any
health problem. Health perception-health management pattern, Nutritional-metabolic
patten, Elimination pattern, Activity-exercise pattern, sleep-rest pattern,
cognitive-perceptual pattern, Self-perception-self-concept pattern, role-relationship
pattern, Sexuality-reproductive pattern, Coping-stress tolerance pattern, and
Value-belief pattern
Health perception-health management pattern-CORRECT ANSWER--Describes
patient's self-report of health and well-being; how patient manages health. Example:
frequency of health care provider visits, adherence to therapies at home; knowledge
of preventative health practices
Nutritional-metabolic pattern-CORRECT ANSWER--Describes patient's daily/weekly
pattern of food and fluid intake. Example: food preferences or restrictions, special
diet, appetite; actual weight, weight loss or gain
Elimination pattern-CORRECT ANSWER--Describes pattern of excretory function.
Example: bowel, bladder, and skin
Activity-exercise pattern-CORRECT ANSWER--Describes patterns of exercise,
activity, leisure, and recreation; ability to perform activities of daily living
Sleep-rest pattern-CORRECT ANSWER--Describes patterns of sleep, rest, and
relaxation.
16, Nursing Assessment
Nursing process-CORRECT ANSWER--A critical thinking process that professional
nurses use to apply the best available evidence to caregiving and promoting human
functions and responses to health and illness.
Nursing Process Five Steps-CORRECT ANSWER--Def. Fundamental blueprint for
how to care for a patient. "Standard of Practice"
1. Assessment - Collection, verification, and analysis of data.
2. Diagnose - identify the patient's problems
3. Plan- Set goals of care and desired outcomes and id appropriate nursing actions
4. Implement- perform the nursing actions id in planning
5. Evaluate- determine if goals and expected outcomes are achieved
Assessment-CORRECT ANSWER--Def. The deliberate and systematic collection of
information about a patient to determine his or her current and past health and
functional status and his or her present and past coping patterns.
Nursing Assessment includes two steps:
1. Collection of information from a primary source (the patient) and secondary
sources (e.g. family members, health professionals, and medical record)
2. The interpretation and validation of data to ensure a complete database.
Database-CORRECT ANSWER--The purpose of assessment is to establish a
database about the patient's perceived needs, health problems, and responses to
these problems. In addition, the data reveal related experiences, health practices,
goals, values, and expectations about the health care system.
Data Collection-CORRECT ANSWER--Gather information (assessment) to make an
accurate judgment about a patient's current condition.
Your information comes from:
1. The patient, through interview, observations, and physical examinations
2. Family members or significant others' reports and response to interview
3. Other members of healthcare team
4. Medical records (patient history, labs, x-ray)
5. Scientific Literature (evidence about assessment techniques and standards)
, Cue-CORRECT ANSWER--Information that a nurse obtain through the use of the
senses (hearing, visual observations, touch, and smell).
Inference-CORRECT ANSWER--Your judgment or interpretation of the cues
Example: A patient crying is a cue that possibly implies fear or sadness
Observational overview using cues and forming inferences.-CORRECT
ANSWER--Male patient in bed, looks uncomfortable. Patient presents with
discomfort in surgical area.
Cues
- Lies still with arms along sides; tense
- States has not turned for some time
- Reports pain a 7 on a scale of 0 to 10
Inferences
- Pain is severe
- Pain limits patient's ability to move and reposition self
11 Functional health patterns-CORRECT ANSWER--An example of a structured
database format, one approach to perform a comprehensive assessment. Gordon's
functional health patterns model offers a holistic framework for assessment of any
health problem. Health perception-health management pattern, Nutritional-metabolic
patten, Elimination pattern, Activity-exercise pattern, sleep-rest pattern,
cognitive-perceptual pattern, Self-perception-self-concept pattern, role-relationship
pattern, Sexuality-reproductive pattern, Coping-stress tolerance pattern, and
Value-belief pattern
Health perception-health management pattern-CORRECT ANSWER--Describes
patient's self-report of health and well-being; how patient manages health. Example:
frequency of health care provider visits, adherence to therapies at home; knowledge
of preventative health practices
Nutritional-metabolic pattern-CORRECT ANSWER--Describes patient's daily/weekly
pattern of food and fluid intake. Example: food preferences or restrictions, special
diet, appetite; actual weight, weight loss or gain
Elimination pattern-CORRECT ANSWER--Describes pattern of excretory function.
Example: bowel, bladder, and skin
Activity-exercise pattern-CORRECT ANSWER--Describes patterns of exercise,
activity, leisure, and recreation; ability to perform activities of daily living
Sleep-rest pattern-CORRECT ANSWER--Describes patterns of sleep, rest, and
relaxation.
