NURS 1861: Exam 1: Nursing Process
assessing the systematic and continuous collection, analysis, validation, and communication
of patient data
data information
cue significant information that is helpful in making decisions
database all the pertinent patient information that enables a comprehensive and effective
plan of care to be designed and implemented
emergency assessment rapid focused assessment conducted to determine potentially fatal
situations
focused assessment assessment conducted to assess a specific problem; focuses on pertinent
history and body regions
inference the judgement reached about a cue
initial assessment comprehensive nursing assessment resulting in baseline data that enables
the nurse to make a judgement about a patient's health status, ability to manage one's own health
care
interview planned communication for a specific purpose (e.g. data collection)
minimum data set a standard established by health care institutions that specifies the
information that must be collected from every patient
nursing history assessment of the patient by interview to identify the patient's health
status, strengths, health problems, health risks, and need for nursing care
objective data information perceptible to the senses; may be verified by another person - SIGNS
observation conscious and deliberate use of the five senses to gather data
physical assessment systematic examination of the patient for objective data to better define the
patient's condition and to help the nurse in planning care, usually performed in a head-to-toe
format; a collection of objective data about changes in the patient's body systems
review of systems (ROS) physical examination of all body systems in a systematic manner
as part of the nursing assessment
subjective datainformation perceived only by the affected person - SYMPTOMS
time-lapsed assessment an assessment that is scheduled to compare a patient's current
status to baseline data obtained earlier
validation act of confirming or verifying
What are the methods of data collection? Observation, interviews with clients and families,
medical history, a comprehensive or focused physical examination, diagnostic and laboratory
reports, and collaboration.
, What does subjective data include? The clients' feelings, perceptions, and descriptions of health
status.
Nurses observe and measure __________ ______ during a physical examination. They may feel,
see, hear, and smell to obtain it. objective data
The client tells the nurse, "My shoulder is really sore." Is this subjective or objective data?
Subjective data - came directly from client
The client's mother tells the nurse, "She told me that her shoulder is sore every morning." Is this
subjective or objective data? Subjective data - because it is based on information that the client
has told her
A physical therapy note in client's chart indicates client has decreased range of motion of left
shoulder. Is this subjective or objective data? Objective data - it is part of client's medical
history/ documentation
During which step of the nursing process does the nurse validate, interpret, and cluster data?
Assessment
What are the four types of nursing assessments? 1) Initial comprehensive: find baseline (e.g.
head-to-toe)
2) Focused: one-system assessment (e.g. respiratory assessment for asthma)
3) Emergency: for life-threatening matters; use Maslow's Hierarchy
4) Time lapsed: now vs. past; is patient's condition getting better or worse?
Tell whether the following statement is true or false.
A nursing assessment duplicates a medical assessment by focusing on the patient's responses to
the health problem. False.
A medical assessment targets data pointing to pathologic conditions.
Which one of the following assessments would be performed on a patient to gather data about his
previously diagnosed liver cancer?
A. Initial comprehensive assessment
B. Focused assessment
C. Emergency assessment
D. Time-lapsed assessment B. Focused assessment
Tell whether the following statement is true or false.
A patient rates his pain as a "7" on a pain rating scale. This rating is considered to be objective
data. False.
This is subjective data because it is what the patient perceives his pain to be.
Tell whether the following statement is true or false.
Most health care institutions establish a minimum data set that specifies the information that
must be collected from every patient and uses a structured assessment form to organize or cluster
these data. True.
Name some skills of nursing observation. - Determines patient's current responses (physical
ad emotional).
- Determines patient's current ability to manage care.
- Determines immediate environment and its safety.
- Determines larger environment (hospital or community)
What are the four phases of a nursing interview? 1) Preparatory phase: (e.g. read chart)
2) Introduction: sets the tone-tell patient who you are and what you're collecting
3) Working phase: gathering data
assessing the systematic and continuous collection, analysis, validation, and communication
of patient data
data information
cue significant information that is helpful in making decisions
database all the pertinent patient information that enables a comprehensive and effective
plan of care to be designed and implemented
emergency assessment rapid focused assessment conducted to determine potentially fatal
situations
focused assessment assessment conducted to assess a specific problem; focuses on pertinent
history and body regions
inference the judgement reached about a cue
initial assessment comprehensive nursing assessment resulting in baseline data that enables
the nurse to make a judgement about a patient's health status, ability to manage one's own health
care
interview planned communication for a specific purpose (e.g. data collection)
minimum data set a standard established by health care institutions that specifies the
information that must be collected from every patient
nursing history assessment of the patient by interview to identify the patient's health
status, strengths, health problems, health risks, and need for nursing care
objective data information perceptible to the senses; may be verified by another person - SIGNS
observation conscious and deliberate use of the five senses to gather data
physical assessment systematic examination of the patient for objective data to better define the
patient's condition and to help the nurse in planning care, usually performed in a head-to-toe
format; a collection of objective data about changes in the patient's body systems
review of systems (ROS) physical examination of all body systems in a systematic manner
as part of the nursing assessment
subjective datainformation perceived only by the affected person - SYMPTOMS
time-lapsed assessment an assessment that is scheduled to compare a patient's current
status to baseline data obtained earlier
validation act of confirming or verifying
What are the methods of data collection? Observation, interviews with clients and families,
medical history, a comprehensive or focused physical examination, diagnostic and laboratory
reports, and collaboration.
, What does subjective data include? The clients' feelings, perceptions, and descriptions of health
status.
Nurses observe and measure __________ ______ during a physical examination. They may feel,
see, hear, and smell to obtain it. objective data
The client tells the nurse, "My shoulder is really sore." Is this subjective or objective data?
Subjective data - came directly from client
The client's mother tells the nurse, "She told me that her shoulder is sore every morning." Is this
subjective or objective data? Subjective data - because it is based on information that the client
has told her
A physical therapy note in client's chart indicates client has decreased range of motion of left
shoulder. Is this subjective or objective data? Objective data - it is part of client's medical
history/ documentation
During which step of the nursing process does the nurse validate, interpret, and cluster data?
Assessment
What are the four types of nursing assessments? 1) Initial comprehensive: find baseline (e.g.
head-to-toe)
2) Focused: one-system assessment (e.g. respiratory assessment for asthma)
3) Emergency: for life-threatening matters; use Maslow's Hierarchy
4) Time lapsed: now vs. past; is patient's condition getting better or worse?
Tell whether the following statement is true or false.
A nursing assessment duplicates a medical assessment by focusing on the patient's responses to
the health problem. False.
A medical assessment targets data pointing to pathologic conditions.
Which one of the following assessments would be performed on a patient to gather data about his
previously diagnosed liver cancer?
A. Initial comprehensive assessment
B. Focused assessment
C. Emergency assessment
D. Time-lapsed assessment B. Focused assessment
Tell whether the following statement is true or false.
A patient rates his pain as a "7" on a pain rating scale. This rating is considered to be objective
data. False.
This is subjective data because it is what the patient perceives his pain to be.
Tell whether the following statement is true or false.
Most health care institutions establish a minimum data set that specifies the information that
must be collected from every patient and uses a structured assessment form to organize or cluster
these data. True.
Name some skills of nursing observation. - Determines patient's current responses (physical
ad emotional).
- Determines patient's current ability to manage care.
- Determines immediate environment and its safety.
- Determines larger environment (hospital or community)
What are the four phases of a nursing interview? 1) Preparatory phase: (e.g. read chart)
2) Introduction: sets the tone-tell patient who you are and what you're collecting
3) Working phase: gathering data
