Nursing 230 Final Exam Study Guide UPDATED ACTUAL
Questions and CORRECT Answers
Four types of health assessments 1. Initial comprehensive assessment
2. Ongoing or partial assessment
3. Focused or problem-oriented
4. Emergency assessment
What is ADPIE? 1. Assessment
2. Diagnose
3. Planning
4. Implementation
5. Evaluation
Initial Comprehensive assessment - Collection of subjective data involving health history, family history, and lifestyle
practices
- Collection of objective data gathered by a step-by-step thorough exam
When is a comprehensive assessment done? - When a patient first enters a health care system
- After baseline data against which future health status changes can be measured
and compared
- The frequency also depends on the patient's age, risk factors, health status,
health promotion practices, and lifestyle
Ongoing or Partial assessment - After the comprehensive database is established
- Mini overview of body systems and holistic health patterns as a follow up on
health status
- Any problems initially detected will be reassessed to determine changes from
baseline data
- Brief reassessment of body systems and health patterns to detect any new
problems
Focused or Problem-oriented assessment - DOES NOT replace comprehensive health assessment
- Performed when a comprehensive database exists for the client
- A thorough assessment of a particular problem and does not address areas not
related to the problem
Emergency Assessment - A very rapid assessment performed in life-threatening situations
- Situations like choking, cardiac arrest, drowning
- Such as the evaluation of the ABCs (airway, breathing, and circulation)
- The major and only concern during this type of assessment is to determine the
status of the client's life-sustaining physical functions
Steps of Health Assessment - Collecting subjective data
- Collecting objective data
- Validation of data
- Documentation of data
, What should be done when preparing for a health - The nurse should review the client's medical record if available
assessment? - Know the patients basic biographical data
- Do not assume all info is correct it can alter your ability to collect accurate data
- Obtain and organize materials needed for the assessment
Collecting Subjective Data - Biographical information (name, age, religion, occupation, etc.)
- History of present health concern: physical symptoms related to each body part
or system (e.g. eyes and ears, abdomen)
- Personal health History
- Family History
- Health and lifestyle practices (e.g., health practices that put the client at risk,
nutrition, activity, relationships, cultural beliefs or practices, family structure and
function, community environment)
- Review of systems
Collecting Objective Data - Physical characteristics (skin color, posture)
- Body functions (heart rate, respiratory rate)
- Appearance (dress, hygiene)
- Behavior (mood, affect)
- Measurements (blood pressure, temperature, height, weight)
- Results of laboratory testing (platelet count, x-ray findings)
Evidence-Based Practice clinical decision-making that integrates the best available research with clinical
expertise and patient characteristics and preferences
Documenting data - Forms the database for the entire nursing process and provides data for all other
members of the health care team
- Thorough and accurate documentation is vital to ensure that valid conclusions
are made when data is analyzed
Process of data analysis 1. Identify abnormal cues and supportive cues
2. Cluster cues
3. Draw inferences and identify and prioritize client concerns
4. Propose possible collaborative problems to notify primary care provider
5. Identify need for referral to primary care provider
6. Document conclusions
Phases of nursing interview 1. Preintroductory phase
2. Introductory phase
3. Working phase
4. Summary and closing phase
Preintroductory Phase Review the medical record before meeting with the client
Introductory Phase - Explains the purpose of the interview
- Discusses the types of questions that will be asked
- Explains the reason for taking notes
- Assures the client that confidential information will remain confidential
Questions and CORRECT Answers
Four types of health assessments 1. Initial comprehensive assessment
2. Ongoing or partial assessment
3. Focused or problem-oriented
4. Emergency assessment
What is ADPIE? 1. Assessment
2. Diagnose
3. Planning
4. Implementation
5. Evaluation
Initial Comprehensive assessment - Collection of subjective data involving health history, family history, and lifestyle
practices
- Collection of objective data gathered by a step-by-step thorough exam
When is a comprehensive assessment done? - When a patient first enters a health care system
- After baseline data against which future health status changes can be measured
and compared
- The frequency also depends on the patient's age, risk factors, health status,
health promotion practices, and lifestyle
Ongoing or Partial assessment - After the comprehensive database is established
- Mini overview of body systems and holistic health patterns as a follow up on
health status
- Any problems initially detected will be reassessed to determine changes from
baseline data
- Brief reassessment of body systems and health patterns to detect any new
problems
Focused or Problem-oriented assessment - DOES NOT replace comprehensive health assessment
- Performed when a comprehensive database exists for the client
- A thorough assessment of a particular problem and does not address areas not
related to the problem
Emergency Assessment - A very rapid assessment performed in life-threatening situations
- Situations like choking, cardiac arrest, drowning
- Such as the evaluation of the ABCs (airway, breathing, and circulation)
- The major and only concern during this type of assessment is to determine the
status of the client's life-sustaining physical functions
Steps of Health Assessment - Collecting subjective data
- Collecting objective data
- Validation of data
- Documentation of data
, What should be done when preparing for a health - The nurse should review the client's medical record if available
assessment? - Know the patients basic biographical data
- Do not assume all info is correct it can alter your ability to collect accurate data
- Obtain and organize materials needed for the assessment
Collecting Subjective Data - Biographical information (name, age, religion, occupation, etc.)
- History of present health concern: physical symptoms related to each body part
or system (e.g. eyes and ears, abdomen)
- Personal health History
- Family History
- Health and lifestyle practices (e.g., health practices that put the client at risk,
nutrition, activity, relationships, cultural beliefs or practices, family structure and
function, community environment)
- Review of systems
Collecting Objective Data - Physical characteristics (skin color, posture)
- Body functions (heart rate, respiratory rate)
- Appearance (dress, hygiene)
- Behavior (mood, affect)
- Measurements (blood pressure, temperature, height, weight)
- Results of laboratory testing (platelet count, x-ray findings)
Evidence-Based Practice clinical decision-making that integrates the best available research with clinical
expertise and patient characteristics and preferences
Documenting data - Forms the database for the entire nursing process and provides data for all other
members of the health care team
- Thorough and accurate documentation is vital to ensure that valid conclusions
are made when data is analyzed
Process of data analysis 1. Identify abnormal cues and supportive cues
2. Cluster cues
3. Draw inferences and identify and prioritize client concerns
4. Propose possible collaborative problems to notify primary care provider
5. Identify need for referral to primary care provider
6. Document conclusions
Phases of nursing interview 1. Preintroductory phase
2. Introductory phase
3. Working phase
4. Summary and closing phase
Preintroductory Phase Review the medical record before meeting with the client
Introductory Phase - Explains the purpose of the interview
- Discusses the types of questions that will be asked
- Explains the reason for taking notes
- Assures the client that confidential information will remain confidential
