Pearson - Assessment Module
4 types of assessments used when collecting data about a client - ANS-1. ongoing assessment
2. system-specific assessment
3. emergency assessment
4 baseline assessment
ongoing assessment - ANS-done in a homecare setting to compare against an initial
assessment conducted earlier
system specific assessment - ANS-done on an ongoing basis and integrated with current
nursing care to determine status of a specific problem problem identified earlier
emergency assessment - ANS-performed during a physical or psychological crisis;
baseline assessment - ANS-initial assessment to identify problems from data gathered soon
after admission to a healthcare agency
example of an initial or baseline assessment - ANS-nursing admission assessment
example of a problem-focused (or system specific) assessment - ANS-hourly assessment of
fluid intake and urinary output in an ICU
example of emergency assessment - ANS-evaluation of airway, breathing and circulation during
cardiac arrest or suicidal assessment
example of ongoing assessment - ANS-reassessment of functional health problems in a home
care setting
subjective data (also referred to as symptoms or covert data) - ANS-can only be described or
verified by the client
examples of subjective data - ANS-sensations like itching; feelings; values; beliefs; attitudes;
and perceptions
, objective data (also called signs or overt data) - ANS-detectable by an observer or can be
measured or tested against an accepted standard. Can be seen, heard, felt or smelled and they
are obtained by observation or physical examination
examples of objective data - ANS-blood pressure reading or skin discoloration
primary data - ANS-obtained directly from the client unless the client is too ill, young or
confused to communicate clearly
secondary data (sometimes referred to as indirect data) - ANS-obtained from family other
healthcare professionals, records and reports, laboratory and diagnostic analyses and relevant
literature; all data from this source should be validated when possible
Principle methods used to collect data are - ANS-1. observing
2. interviewing
3 examining
2 aspects of observation are - ANS-1. noticing the data
2. selecting, organizing and interpreting the data
problem focused or system specific assessment is - ANS-performedas an ongoing process that
is integrated with nursing care to determine the status of a specific problem identified earlier
initial or baseline assessment is - ANS-performed soon after admission to a healthcare agentcy
ongoing assessment is - ANS-a comparison performed several months after the initial
assessment
emergency assessment is - ANS-performed during a physical or psychological crisis
subjective data - ANS-can only be described or verified by the client
Which of these are the 3 stages of aninterview? - ANS-opening, body, closing
The nondirective or rapport building approach allows the client to control thepurpose, subject
matter, and pacing. This approach can be helpful when interviewing a client with a high level of
anxiety. The directive interview is highly structured and controlled by the nurse. Closed
questions are those that elicit a'yes' or'no' answer and are not likely to elicit much information
or help build rapport with the client. Comfort is a consideration in preparing the room prior to the
interview. - ANS-
When teaching a client how to perform a breastself-examination, the nurse palpates a small
nodule. Based on thisfinding, which assessment strategy is most appropriate to determine the
detail of themass?
4 types of assessments used when collecting data about a client - ANS-1. ongoing assessment
2. system-specific assessment
3. emergency assessment
4 baseline assessment
ongoing assessment - ANS-done in a homecare setting to compare against an initial
assessment conducted earlier
system specific assessment - ANS-done on an ongoing basis and integrated with current
nursing care to determine status of a specific problem problem identified earlier
emergency assessment - ANS-performed during a physical or psychological crisis;
baseline assessment - ANS-initial assessment to identify problems from data gathered soon
after admission to a healthcare agency
example of an initial or baseline assessment - ANS-nursing admission assessment
example of a problem-focused (or system specific) assessment - ANS-hourly assessment of
fluid intake and urinary output in an ICU
example of emergency assessment - ANS-evaluation of airway, breathing and circulation during
cardiac arrest or suicidal assessment
example of ongoing assessment - ANS-reassessment of functional health problems in a home
care setting
subjective data (also referred to as symptoms or covert data) - ANS-can only be described or
verified by the client
examples of subjective data - ANS-sensations like itching; feelings; values; beliefs; attitudes;
and perceptions
, objective data (also called signs or overt data) - ANS-detectable by an observer or can be
measured or tested against an accepted standard. Can be seen, heard, felt or smelled and they
are obtained by observation or physical examination
examples of objective data - ANS-blood pressure reading or skin discoloration
primary data - ANS-obtained directly from the client unless the client is too ill, young or
confused to communicate clearly
secondary data (sometimes referred to as indirect data) - ANS-obtained from family other
healthcare professionals, records and reports, laboratory and diagnostic analyses and relevant
literature; all data from this source should be validated when possible
Principle methods used to collect data are - ANS-1. observing
2. interviewing
3 examining
2 aspects of observation are - ANS-1. noticing the data
2. selecting, organizing and interpreting the data
problem focused or system specific assessment is - ANS-performedas an ongoing process that
is integrated with nursing care to determine the status of a specific problem identified earlier
initial or baseline assessment is - ANS-performed soon after admission to a healthcare agentcy
ongoing assessment is - ANS-a comparison performed several months after the initial
assessment
emergency assessment is - ANS-performed during a physical or psychological crisis
subjective data - ANS-can only be described or verified by the client
Which of these are the 3 stages of aninterview? - ANS-opening, body, closing
The nondirective or rapport building approach allows the client to control thepurpose, subject
matter, and pacing. This approach can be helpful when interviewing a client with a high level of
anxiety. The directive interview is highly structured and controlled by the nurse. Closed
questions are those that elicit a'yes' or'no' answer and are not likely to elicit much information
or help build rapport with the client. Comfort is a consideration in preparing the room prior to the
interview. - ANS-
When teaching a client how to perform a breastself-examination, the nurse palpates a small
nodule. Based on thisfinding, which assessment strategy is most appropriate to determine the
detail of themass?
