Examination and History Taking all 20
Chapters Covered
Objective Data - answerHealth professional's observations during physical examination
Subjective Data - answerInformation provided by the person during history taking
Data Base - answerCombination of patient's record, laboratory studies, objective, and
subjective data
Validation of Data - answerEnsuring accuracy by confirming uncertain information
Novice Nurses - answerNew graduate nurses lacking experience, rely on structured rules
Intuition - answerExpert nurses act based on pattern recognition without conscious labeling
Evidence-Based Practice (EBP) - answerSystematic approach using best evidence, clinician's
experience, patient preferences
First-Level Priority Problem - answerExample: Patient with postoperative pain
Diagnostic Reasoning - answerExpert nurses' ability to analyze assessment data patterns
1
, Clinical Knowledge - answerExpert nurses' ability to act based on assessment data without
conscious labeling
First-level priority problems - answerEmergent, life-threatening, immediate issues (e.g.,
establishing an airway)
Second-level priority problems - answerRequire prompt intervention to prevent deterioration
(e.g., mental status change)
Clustering related cues - answerCritical thinking skill to see relationships among data
Nursing diagnosis - answerBasis for selecting nursing interventions
Nursing process - answerSequential problem-solving method: assessment, diagnosis, outcome
identification, planning, implementation, evaluation
Diagnostic reasoning - answerFormulating a diagnostic hypothesis
Barriers to EBP - answerInclude lack of research skills, isolation from knowledgeable colleagues,
and time constraints
Assessment step - answerData collection via health history, physical exam, and interview
Committee Formation - answerCreating a group to conduct research studies for evidence-based
practice.
Bulletin Board Posting - answerDisplaying published research studies for easy access and
2