Health Assessment Exam 1 Study Guide ACTUAL UPDATED QUESTIONS AND
CORRECT ANSWERS
characteristics of a health assessment - systematically collecting and recording data
- starting point for the nursing process
- continuous/ongoing process
2 parts of a health assessment interview (collecting subjective data) and physical examination (collecting
objective data)
database collection of subjective data, objective data, patient's record, and labs
how is the database used by the nurse? allows the nurse to make a clinical judgement or diagnosis about the pt's health
state
[key = organization]
subjective data symptoms; reported by the patient/family, cannot be verified by examiner
objective data signs; observable/measurable, can be verified by examiner
, nursing process ADPIE
1. assessment
2. diagnosis
3. planning (outcome identification and goal setting)
4. implementation
5. evaluation
diagnostic reasoning process of analyzing health data and drawing conclusions to identify diagnoses
(cluster data that is correlated and identify cues)
cue important piece of information that can be used in diagnostic reasoning
nursing process: assessment systematic, holistic, dynamic process by which the nurse (through interaction with
the pt, S/Os, and health care providers) collects and analyzes data about the pt
3 bases of evidence-based practice (EBP) research evidence (science), clinical expertise (practitioner's input), patient
preference/values (consent)
nursing process: essential data components physiological, psychological, sociocultural, developmental, and spiritual client
data
complete database describes current and past health state and forms baseline to measure all future
changes
occurs:
- when establishing a PCP
- during admission to a hospital or long-term care facility
episodic/problem-centered database mini database, smaller scope and more focused than complete database
occurs:
- in all settings
- to assess new/localized/short-term problem
follow-up database used in all settings to evaluate and note changes that have occurred
emergency database urgent and rapid, used in an emergency center to collect crucial info along with
lifesaving measures
first-level priority emergent, life-threatening, and immediate ABCs
CORRECT ANSWERS
characteristics of a health assessment - systematically collecting and recording data
- starting point for the nursing process
- continuous/ongoing process
2 parts of a health assessment interview (collecting subjective data) and physical examination (collecting
objective data)
database collection of subjective data, objective data, patient's record, and labs
how is the database used by the nurse? allows the nurse to make a clinical judgement or diagnosis about the pt's health
state
[key = organization]
subjective data symptoms; reported by the patient/family, cannot be verified by examiner
objective data signs; observable/measurable, can be verified by examiner
, nursing process ADPIE
1. assessment
2. diagnosis
3. planning (outcome identification and goal setting)
4. implementation
5. evaluation
diagnostic reasoning process of analyzing health data and drawing conclusions to identify diagnoses
(cluster data that is correlated and identify cues)
cue important piece of information that can be used in diagnostic reasoning
nursing process: assessment systematic, holistic, dynamic process by which the nurse (through interaction with
the pt, S/Os, and health care providers) collects and analyzes data about the pt
3 bases of evidence-based practice (EBP) research evidence (science), clinical expertise (practitioner's input), patient
preference/values (consent)
nursing process: essential data components physiological, psychological, sociocultural, developmental, and spiritual client
data
complete database describes current and past health state and forms baseline to measure all future
changes
occurs:
- when establishing a PCP
- during admission to a hospital or long-term care facility
episodic/problem-centered database mini database, smaller scope and more focused than complete database
occurs:
- in all settings
- to assess new/localized/short-term problem
follow-up database used in all settings to evaluate and note changes that have occurred
emergency database urgent and rapid, used in an emergency center to collect crucial info along with
lifesaving measures
first-level priority emergent, life-threatening, and immediate ABCs
