nurses collect data about a pa ent in a _____________________, ongoing process -correct
answerssystema c
Sensa ons or symptoms, feelings, percep ons, desires, preferences, beliefs, ideas, values, and
personal informa on that are reported BY THE PATIENT and verified by the pa ent -correct
answersSubjec ve data
Data directly and indirectly observed through measurement
Sources include physical assessment, the pa ents record, measurements, and the results of
tes ng -correct answersObjec ve data
Steps of Health Assessment -correct answersCollec on of subjec ve data
collec on of objec ve data
valida on of data
documenta on data
Steps may overlap; not in any par cular order
Phases of the Interview -correct answersPreintroductory
Introductory
Working
,Summary/closing
Looking at the medical records prior to mee ng the pa ent -correct answersPreintroductory
phase
Introduce yourself to the pa ent and why you are there -correct answersIntroductory phase
Collec on of data, medical or family history, review of systems, history of present illness,
observa on, and thinking cri cally -correct answersWorking phase of interview process
Physician orders, discussing goals, how to resolve, and any concerns or ques ons. -correct
answersSummary/closing phase of interview process
Communica on to _____________
Nonverbal:
Excessive or insufficient eye contact
Distrac on and distance
Standing
Verbal:
Biased or leading ques ons
Rushing
Reading the ques ons -correct answersAvoid
Provides founda on for iden fying problems
Provides focus for physical exam -correct answersComplete health history
, Eight sec ons for the complete health history -correct answersBiological data
Reason for seeking care
History of present illness (HPI)
Personal health history
Family health history
Review of systems for current health problems (ROS)
Lifestyle and health prac ces
Developmental level
_____________ is the primary source of informa on- all other sources (family, medical records,
other healthcare prac oners) are secondary sources -correct answersClient
what is used to collect data ?
1
2
3
4 -correct answerspa ent
pa ents family
other hc providers
environment
nurses synthesize the data collectected to iden fy _____________ and ________________ -
correct answerspa erns
problems
subjec ve data about the clients percep on of illness, past history, family history, lifestyle and
health prac ces