Chapter 3: Nursing Process: Assessment – Flashcards
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Ch 3: What are the four features common to all definitions of assessment?
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Assessment is the systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community. Assessment involves data collection, use of a systematic and ongoing process, categorizing of data, and recording of data.
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Ch 3: How is a nursing assessment similar to a medical assessment?
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Both collect data that you use to identify problems and plan care. Both collect data about physical problems and disease symptoms.
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Ch 3: How is a nursing assessment different from a medical assessment?
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A nursing assessment is holistic and focuses on client responses to disease, pathology, and other stressors. A medical assessment focuses on disease and pathology.
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Ch 3: Maslow's Hierarchy of Needs
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Physiological Safety and security Love and belonging Esteem and Self Esteem Cognitive Aesthetic Self Actualization
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Ch 3: Erickson's 8 stages
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Oral - sensory Muscular - Anal Locomotor Latency Adolescence Young Adulthood Middle Adulthood Maturity
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Ch 3: Nursing Theoretical Frameworks
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Watson Orem Leininger King Newman Rogers Nightingale
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Ch 3: During Sami's appointment at the women's clinic, she has a Pap smear, breast exam, and blood work. She also informs the nurse practitioner that her menstrual flow is very heavy and that she experiences severe abdominal cramping. All of these data are added to the database as reference for future visits. Sami's Pap smear results and breast exam are normal, but she is moderately anemic (she has a low hemoglobin level). When the nurse practitioner sees the lab results, she suspects that the heavy flow may be causing Sami's anemia. According to clinic protocol, she prescribes birth control pills for Sami to control her heavy, painful periods and provide contraception. Ongoing assessment will include visits every 6 months to manage her birth control pills and monitor the anemia. State whether the following data are primary or secondary, subjective or objective: You see in the chart that Sami's breast exam was normal.
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Objective data (Someone other than Sami made the observation; it was not from Sami's perspective.)
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Ch 3: During Sami's appointment at the women's clinic, she has a Pap smear, breast exam, and blood work. She also informs the nurse practitioner that her menstrual flow is very heavy and that she experiences severe abdominal cramping. All of these data are added to the database as reference for future visits. Sami's Pap smear results and breast exam are normal, but she is moderately anemic (she has a low hemoglobin level). When the nurse practitioner sees the lab results, she suspects that the heavy flow may be causing Sami's anemia. According to clinic protocol, she prescribes birth control pills for Sami to control her heavy, painful periods and provide contraception. Ongoing assessment will include visits every 6 months to manage her birth control pills and monitor the anemia. State whether the following data are primary or secondary, subjective or objective: Sami tells the nurse practitioner that she experiences cramping with her menstrual cycle. For the nurse practitioner, is this primary or secondary, subjective or objective data?
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- Primary data (The nurse practitioner obtained the information from Sami.) - Subjective data (Sami's perspective, told directly to the nurse practitioner by Sami)
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Ch 3: During Sami's appointment at the women's clinic, she has a Pap smear, breast exam, and blood work. She also informs the nurse practitioner that her menstrual flow is very heavy and that she experiences severe abdominal cramping. All of these data are added to the database as reference for future visits. Sami's Pap smear results and breast exam are normal, but she is moderately anemic (she has a low hemoglobin level). When the nurse practitioner sees the lab results, she suspects that the heavy flow may be causing Sami's anemia. According to clinic protocol, she prescribes birth control pills for Sami to control her heavy, painful periods and provide contraception. Ongoing assessment will include visits every 6 months to manage her birth control pills and monitor the anemia. State whether the following data are primary or secondary, subjective or objective: The nurse practitioner tells you that Sami is anemic.
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- Objective data (Observed by someone other than the patient; not told to you by the patient. It isn't the verbal reporting of data that makes them "subjective"; it is the verbal reporting by the patient.) - Secondary data for you (You did not get the data from Sami.) Actually, anemia is a diagnostic conclusion made by the nurse practitioner, not data. But when you receive the information, it is, for you, data.
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Ch 3: During Sami's appointment at the women's clinic, she has a Pap smear, breast exam, and blood work. She also informs the nurse practitioner that her menstrual flow is very heavy and that she experiences severe abdominal cramping. All of these data are added to the database as reference for future visits. Sami's Pap smear results and breast exam are normal, but she is moderately anemic (she has a low hemoglobin level). When the nurse practitioner sees the lab results, she suspects that the heavy flow may be causing Sami's anemia. According to clinic protocol, she prescribes birth control pills for Sami to control her heavy, painful periods and provide contraception. Ongoing assessment will include visits every 6 months to manage her birth control pills and monitor the anemia. State whether the following data are primary or secondary, subjective or objective: You check the results of the Pap smear on the computer and see that it is normal.
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- Objective data (Observed by someone other than the patient) - Secondary data (You did not get the information directly from the patient. It would be primary data for the pathologist.)
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Ch 3: The American Nurses Association's Code of Ethics for Nursing—Provisions (2001) states, "The nurse determines the appropriate ______________ of tasks consistent with the nurse's obligation to provide optimum ___________."
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Delegation, patient care
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Ch 3: Delegation of nursing care is regulated legally by which of the following? A. ANA B. Hospital policy C. The Joint Commission D. State practice acts
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D. State practice acts State practice acts legally define the scope and practice of nursing within the state, and this is what you are accountable for. Hospital policy, ANA, and The Joint Commission all provide standards, guidelines, or positions for nurses to refer to for clarification as to the nurse's role or responsibility in the nursing process.
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Ch 3: Taylor, a 7-year-old boy, is brought to the Urgent Care Center by his father. He is bleeding from a wound on the back of his head. You inspect the wound visually and assess that you will need to clean the wound area to determine the length, depth, and severity. What additional component of physical assessment will you perform while cleansing the wound? A. Auscultation B. Percussion C. Palpation D. Developmental
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C. Palpation With palpation, you will feel the skin around the wound to determine if there is swelling or any foreign objects such as dirt or gravel, twigs, etc. in or around the wound. You will also be able to evaluate pain, if elicited. The other responses are incorrect. Auscultation, is listening for changes such as decreased breath sounds and heart rate. Percussion is using the fingers and hand to tap on areas of the body to assess for changes. Developmental assessment, is important when working with children, but to gather data you will need to talk to the patient to assess verbal skills and comprehension.
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Ch 3: You are preparing to perform an initial nursing assessment for 89-year-old Lucy J. She is petite, thin, and is seated in a wheelchair in her assigned room. As you enter the room, you observe her sobbing into a tissue. Your initial intervention to help her prepare for the interview is which of the following? A. Ask her if she would like you to call a family member for her. B. Ask her if she would like to talk about what is upsetting her. C. Walk over to Lucy, take her hand, and reassure her that things will be okay. D. Walk over to Lucy and introduce yourself by name, position, and role.
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D. Walk over to Lucy and introduce yourself by name, position, and role. Before beginning any nursing care with a new patient, introduce yourself by name and position (RN), and tell the patient what aspects of care you will be responsible for. None of the other responses is the first thing to do. Asking about calling a family member assumes information about her support system that may not be accurate; she may live in another state or be estranged from her family. Asking if she'd like to talk about what is upsetting her can be supportive, but this does not take into consideration any cultural barriers that may inhibit her from being comfortable talking to you about her personal feelings. Offering her reassurance is not an appropriate response; you have not collected enough data to determine what she is upset about.
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Ch 3: Vital signs, level of consciousness, and skin color that you observe are which type of data? A. Secondary data B. Objective data C. Subjective data D. Focused data
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B. Objective data Objective data are observations and information collected about the patient's condition (e.g., vital signs). The other responses are incorrect. Secondary data are data that are obtained from any source other than the patient. Subjective data are patient statements and information supplied on the intake form. Focused data are in-depth information about abnormal cues or identifies problems with a body part or function.
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Ch 3: Medication assessment is part of the initial assessment. Patients are asked if they take vitamins or supplements in order to gather which of the following? A. Information about the patient's culture and ethnicity B. Data about the patient's health concerns, such as osteoporosis C. Information about the value the patient places on health D. Data that might reveal an interaction with prescribed medications
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D. Data that might reveal an interaction with prescribed medications Many vitamins and supplements interfere or interact with prescription medications. Patients may take specific supplements as part of their cultural practices, to address health concerns, or because they want to maintain a certain level of health; but safety is the primary reason for gathering this information. Medication data would not necessarily provide any information about the patient's culture, osteoporosis, or the value the person places on health.
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Ch 3: Of the following, which is an example of an open-ended question? A. Do you live alone or with family? B. What problems have you had since your injury? C. Did you injure your hand at work? D. Where did the accident occur?
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B. What problems have you had since your injury? This question offers the patient the opportunity to express concerns or discuss changes in functioning that have occurred since the injury; it provides opportunity for further exploration. The other questions allow the patient to answer in brief or one-word responses, which limits the data obtained.
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Ch 3: Mr. Long has had surgical repair of an abdominal hernia. He will be discharged tomorrow. You are assigned as his nurse for the evening shift. To identify his discharge planning needs, you will perform a ______________ assessment. A. Special needs B. Psychosocial C. Focused D. Comprehensive
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C. Focused A focused assessment is performed to obtain data about an actual, potential, or possible problem that has been identified. It focuses on a particular topic, body part, or functional ability rather than on overall health status. A psychosocial assessment gathers information about lifestyle, normal coping patterns, understanding of the current illness, personality style, previous psychiatric disorders, recent stressors, major issues related to the illness, and mental status. A special needs assessment is a type of focused assessment. It provides in-depth information about a particular area of client functioning and often involves using a specially designed form (e.g., nutrition and pain). A comprehensive assessment (also called a global assessment, patient database, or nursing database) provides holistic information about the client's overall health status.
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Ch 3: You were assigned to the care of Sally Combs on the 11 p.m. to 7 a.m. shift yesterday. You had talked with her extensively about her home and any problems she anticipated upon discharge. You documented her concerns about her limited mobility and reach, but today you recall that you forgot to document her concerns about her ability to pay her bills. You should do which of the following? A. Document it in today's progress note, identifying data and time collected. B. Leave a note for the social worker explaining the patient's concerns C. Add information to original database. D. A & B E. A & C
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D. A & B You obtained this information on a previous shift, and it should be documented validly and reliably. Because this information is important to the patient's discharge planning, it needs to get conveyed to the social worker to be incorporated into the discharge plan. As this is discharge assessment data, it is inappropriate to add it to the original database, and information cannot be added to previous documentation.
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Ch 3: Marti, a 30-year-old woman, has come for a scheduled gynecology visit. She is concerned about her irregular menstrual cycle, which ranges from 21 to 45 days. Marti is about 5'7" tall, weighs 125 lb, and reports that she runs between 5 and 7 miles each day. Marti and her husband would like to have a baby within the next year and a half. The following statements are elicited during your assessment. Identify whether the statement is a cue or inference. A. Marti states, "I don't know if I'll be able to get pregnant with my irregular cycle." B. Marti describes her menstrual cycle as "lasting about 3 days but very unpredictable." C. Marti's exercise regime and weight are contributing to her irregular menses. D. Marti states her sister had a great deal of difficulty conceiving her first child. She says she is concerned she will have the same difficulty. E. Marti is anxious and preoccupied with her irregular menses.
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A. Cue B. Cue C. Inference D. Cue E. Inference Cues are what the client says and what you observe. Inferences are judgments and interpretations about what the cues mean.
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Ch 3: This qualitative study explored the everyday work of hospital nurses. It examined the initial assessment of patients being admitted to the hospital to compare what the nursing literature says about assessment with the assessments the researcher observed in practice. The literature clearly states that assessments should be patient centered and that they are the important first step to a therapeutic nurse-patient relationship. The researcher concluded that the actual nursing admission assessments were at odds with recommendations in the literature. The nurses used a routinized, bureaucratic approach to assessment as a means of doing the work faster. Which of the following inferences can you make? State whether the study summary provides good, some, or no evidence to support each inference. 1. These results occurred because the nurses used a standardized form designed by the hospital.
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No evidence. Because most hospitals use a standardized form for admission assessments, you could presume the nurses documented assessment data on the form. However, there is no information in the summary to suggest that this is so.
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Ch 3: This qualitative study explored the everyday work of hospital nurses. It examined the initial assessment of patients being admitted to the hospital to compare what the nursing literature says about assessment with the assessments the researcher observed in practice. The literature clearly states that assessments should be patient centered and that they are the important first step to a therapeutic nurse-patient relationship. The researcher concluded that the actual nursing admission assessments were at odds with recommendations in the literature. The nurses used a routinized, bureaucratic approach to assessment as a means of doing the work faster. Which of the following inferences can you make? State whether the study summary provides good, some, or no evidence to support each inference. 2. The nurses did not care about their patients.
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No evidence. There may be many reasons the nurses hurried their assessments. In fact, the summary suggests that it was because they wanted to do their work faster, not because they didn't care about their patients.
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Ch 3: This qualitative study explored the everyday work of hospital nurses. It examined the initial assessment of patients being admitted to the hospital to compare what the nursing literature says about assessment with the assessments the researcher observed in practice. The literature clearly states that assessments should be patient centered and that they are the important first step to a therapeutic nurse-patient relationship. The researcher concluded that the actual nursing admission assessments were at odds with recommendations in the literature. The nurses used a routinized, bureaucratic approach to assessment as a means of doing the work faster. Which of the following inferences can you make? State whether the study summary provides good, some, or no evidence to support each inference. 3. The nurses were feeling pressured by their workload.
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Good evidence. The summary actually says they used their approach "as a means of doing the work faster." This doesn't necessarily mean they felt pressured because of workload. As an extreme example, they might have felt pressured because they wanted to go to lunch with a friend, or because they were racing to see who could finish first. However, knowing what we know about nurses' work, the evidence is good enough to risk making this inference.
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Ch 3: This qualitative study explored the everyday work of hospital nurses. It examined the initial assessment of patients being admitted to the hospital to compare what the nursing literature says about assessment with the assessments the researcher observed in practice. The literature clearly states that assessments should be patient centered and that they are the important first step to a therapeutic nurse-patient relationship. The researcher concluded that the actual nursing admission assessments were at odds with recommendations in the literature. The nurses used a routinized, bureaucratic approach to assessment as a means of doing the work faster. Which of the following inferences can you make? State whether the study summary provides good, some, or no evidence to support each inference. 4. The nurses did not know how important the initial assessment is.
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No evidence. You might make the case that there is some evidence. Certainly one cannot assume that all nurses know the importance of the initial assessment, and they did behave as though it was not so important. However, there is really nothing in the summary to suggest what they knew or didn't know. The researcher knew the importance of initial assessment; that is clear from the summary.
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Ch 3: This qualitative study explored the everyday work of hospital nurses. It examined the initial assessment of patients being admitted to the hospital to compare what the nursing literature says about assessment with the assessments the researcher observed in practice. The literature clearly states that assessments should be patient centered and that they are the important first step to a therapeutic nurse-patient relationship. The researcher concluded that the actual nursing admission assessments were at odds with recommendations in the literature. The nurses used a routinized, bureaucratic approach to assessment as a means of doing the work faster. Which of the following inferences can you make? State whether the study summary provides good, some, or no evidence to support each inference. 5. Nursing practice is not always done according to the literature.
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Good evidence. The summary clearly gives this one instance of not practicing according to the literature. Even one instance means that it is not "always" done.
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Ch 3: Which organization's standards require that all patients be assessed specifically for pain? 1) American Nurses Association (ANA) 2) State nurse practice acts 3) National Council of State Boards of Nursing (NCSBN) 4) The Joint Commission
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4) The Joint Commission Rationale: The Joint Commission has developed assessment standards, including that all clients be assessed for pain. The ANA has developed standards for clinical practice, including those for assessment, but not specifically for pain. State nurse practice acts regulate nursing practice in individual states. The NCSBN asserts that the scope of nursing includes a comprehensive assessment but does not specifically include pain.
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Ch 3: Match the correct example to the correct letter for the mnemonic from Volume 1 of your text: H E L P. _________ Help Examples A. Is the oxygen running? B. Who else is in the room with the patient? C. Take a through look at the patient D. Is the patient in pain? E. Are there any spills? F. Does the client have any issues?
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D Rationale: H: (Help): Look for signs of patient distress E: (Equipment and Environment): Check for safety hazards and equipment operation. L: (Look more closely): Look more closely at the patient for cues that care may need to be given. P: (People): Who else is in the room?
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Ch 3: Match the correct example to the correct letter for the mnemonic from Volume 1 of your text: H E L P. _________ Look Examples A. Is the oxygen running? B. Who else is in the room with the patient? C. Take a through look at the patient D. Is the patient in pain? E. Are there any spills? F. Does the client have any issues?
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C Rationale: H: (Help): Look for signs of patient distress E: (Equipment and Environment): Check for safety hazards and equipment operation. L: (Look more closely): Look more closely at the patient for cues that care may need to be given. P: (People): Who else is in the room?
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Ch 3: Match the correct example to the correct letter for the mnemonic from Volume 1 of your text: H E L P. _________ People Examples A. Is the oxygen running? B. Who else is in the room with the patient? C. Take a through look at the patient D. Is the patient in pain? E. Are there any spills? F. Does the client have any issues?
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B Rationale: H: (Help): Look for signs of patient distress E: (Equipment and Environment): Check for safety hazards and equipment operation. L: (Look more closely): Look more closely at the patient for cues that care may need to be given. P: (People): Who else is in the room?
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Ch 3: Match the correct example to the correct letter for the mnemonic from Volume 1 of your text: H E L P. _________ Equipment & Environment Examples A. Is the oxygen running? B. Who else is in the room with the patient? C. Take a through look at the patient D. Is the patient in pain? E. Are there any spills? F. Does the client have any issues?
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A Rationale: H: (Help): Look for signs of patient distress E: (Equipment and Environment): Check for safety hazards and equipment operation. L: (Look more closely): Look more closely at the patient for cues that care may need to be given. P: (People): Who else is in the room?
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Ch 3: Which of the following is an example of data that should be validated? 1) The urinalysis report indicates there are white blood cells in the urine. 2) The client states she feels feverish; you measure the oral temperature at 98°F. 3) The client has clear breath sounds; you count a respiratory rate of 18. 4) The chest x-ray report indicates the client has pneumonia in the right lower lobe.
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2) The client states she feels feverish; you measure the oral temperature at 98°F. Rationale: Validation should be done when subjective and objective data do not make sense. For instance, it is inconsistent data when the patient feels feverish and you obtain a normal temperature. The other distractors do not offer conflicting data. Validation is not usually necessary for laboratory test results.
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Ch 3: Which of the following is an example of appropriate behavior when conducting a client interview? 1) Recording all the information on the agency-approved form during the interview 2) Asking the client, "Why did you think it was necessary to seek health care at this time?" 3) Using precise medical terminology when asking the client questions 4) Sitting, facing the client in a chair at the client's bedside, using active listening
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4) Sitting, facing the client in a chair at the client's bedside, using active listening Rationale: Active listening should be used during an interview. The nurse should face the patient, have relaxed posture, and keep eye contact. Asking "why" may make the client defensive. Note-taking interferes with eye contact. The client may not understand medical terminology or health care jargon.
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Ch 3: The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to (select all that apply): 1) A body systems model 2) A head-to-toe framework 3) Maslow's hierarchy of needs 4) Gordon's functional health patterns
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1) A body systems model 3) Maslow's hierarchy of needs Rationale: Nursing models produce a holistic database that is useful in identifying nursing rather than medical diagnoses. Body systems and head-to-toe are not nursing models, and they are not holistic; they focus on identifying physiological needs or disease. Maslow's hierarchy is not a nursing model, but it is holistic, so it is acceptable for identifying nursing diagnoses. Gordon's functional health patterns are a nursing model.
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Ch 3: The nurse is recording assessment data. She writes, "The patient seems worried about his surgery. Other than that, he had a good night." Which errors did the nurse make? Select all that apply. 1) Used a vague generality 2) Did not use the patient's exact words 3) Used a "waffle" word (e.g., appears) 4) Recorded an inference rather than a cue
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1) Used a vague generality 3) Used a "waffle" word (e.g., appears) Rationale: The nurse recorded a vague generality: "he has had a good night." The nurse did not use the patient's exact words, but she did not quote the patient at all, so that is not one of her errors. The nurse used the "waffle" word, "seems" worried instead of documenting what the patient said or did to lead her to that conclusion. The nurse recorded these inferences: worried and had a good night.
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Ch 3: The nurse is completing a head-to-toe assessment on her client at the beginning of the shift for the hospital unit. This would be considered a/an a. Focused assessment b. Initial assessment c. Ongoing assessment d. Special needs assessment
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c. Ongoing assessment This type of assessment can be completed at any time after the initial assessment. Gathering data at the beginning of a shift will enable the nurse to more effectively evaluate how to proceed with the plan of care for the shift.
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Ch 3: When gathering admission assessment data the nurse obtains a weight of 200 pounds. The client states, "I've never weighed that much!" The nurse should a. Explain to the client how weight gain occurs b. Check the calibration and re-weigh the client c. Document the weight as 200 pounds d. Instruct the UAP to re-weigh the client in 2 hours
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b. Check the calibration and re-weigh the client It is important to FIRST validate data when there is a mismatch between what the client states as history and the data obtained. Validating data often includes ensuring that equipment is functioning properly first.
