Health Assessment Fall 2017
Exam 1 Study Guide
Chapter 1
Compare and contrast subjective and objective data.
Subjective data is what the person says about himself or herself during history taking while
objective data is what we, as the health professionals observe by inspecting, percussing,
palpating, and auscultating during the physical examination. (pg. 2)
Define “nursing process.”
The nursing process is the six phases (assessment, diagnosis, outcome identification, planning,
implementation, and evaluation) that nurses go through when in contact with a patient and their
problem. (pg. 3)
State the steps of nursing process.
1. Assessment
a. Collect data
b. Document relevant data
2. Diagnosis
a. Compare clinical findings with normal and abnormal variation and developmental
events
b. Interpret data
c. Validate diagnoses
d. Document diagnoses
3. Outcome Identification
a. Identify expected outcomes
b. Individualize to the person
c. Culturally appropriate
d. Realistic and measureable
e. Timeline
4. Planning
a. Establish priorities
b. Develop outcomes
c. Interventions
d. Document plan of care
5. Implementation
a. Implement in a safe and timely manner
b. Evidence-based interventions
c. Collaborate with colleagues
6. Evaluation
a. Progress toward outcomes
b. Use ongoing assessment to revise diagnoses, outcomes, and plan
Define “nursing diagnosis” and describe different types of nursing diagnoses (e.g.
actual, risk, wellness).
,PART I: Chose the label for your problem (nursing diagnosis).
PART II: Identify factors “related to” (the cause or etiology of the problem).
PART III: Statement that contains a list of evidence that supports the nurses claim that the
diagnosis is accurate (as evidenced by). Risk diagnoses will only have two parts – diagnosis
label and “related to”.
Describe prioritization and know what to do when there is more than one diagnosis (e.g.
first-level, second-level, and third-level problems).
Prioritization is setting an order of what is more important to access first. When there is more
than one diagnosis, look at the steps below to prioritize the problems.
1. Assign high priority to first-level priority problems (immediate priorities): Remember the “ABCs
plus V”:
• Airway problems
• Breathing problems
• Cardiac/circulation problems
• Vital sign concerns (e.g., high fever)
2. Next attend to second-level priority problems:
• Mental status change (e.g., confusion, decreased alertness)
• Untreated medical problems requiring immediate attention (e.g., a person with diabetes who
has not had insulin)
• Acute pain
• Acute urinary elimination problems
• Abnormal laboratory values
• Risks of infection, safety, or security (for the patient or for others)
3. Address third-level priority problems (later priorities):
• Health problems that do not fit into the previous categories (e.g., problems with lack of
knowledge, activity, rest, family coping)
Define and explain the terms “health promotion” and “disease prevention.”
Disease prevention can be achieved through counseling from primary care providers designed
to change people's unhealthy behaviors related to smoking, alcohol and other drug use, lack of
exercise, poor nutrition, injuries, and sexually transmitted infections. Health promotion is a set of
positive acts that we can take.
Chapter 2 Cultural Competence/ Cultural Care
Define the term “culture”
One definition is that culture is a pattern of shared attitudes, beliefs, self-definitions, norms,
roles, and values that can occur among those who speak a particular language or live in a
defined geographic region. Culture is a complex whole in which each part is related to every
other part. It is also a web of communication, and much of culture is transmitted nonverbally
through socialization or enculturation.
Describe what influences one’s cultural development
This indicates the level of acculturation and assimilation. (Acculturation - the process of
adapting to and acquiring another culture. Assimilation – the process by which a person
, develops a new cultural identity and becomes like the members of the dominant culture.
Biculturalism – dual pattern of identification and often of divided loyalty. Culture shock – the
state of disorientation or inability to respond to the behavior of a different cultural group because
of its sudden strangeness, unfamiliarity, and incompatibility to the newcomer’s perceptions and
expectations.)
Explain why a patient’s culture is important
You need to determine what the person believes has caused the illness before determining
whether cultural practices are helpful, harmful, or neutral for the proposed treatment plan.
NOTE: reflecting on your own culture and spiritual beliefs will allow you to be more effective in
your assessment of your patients’ needs
Explain the term “disease causation.”
Theories of causation have been formulated on the basis of ethnic identity, religious beliefs,
social class, philosophic perspectives, and level of knowledge
Compare and contrast the biomedical, naturalistic, and magico religious perspectives of
disease causation.
The first, called the biomedical or scientific theory of illness causation, assumes that all events
in life have a cause and effect, that the human body functions more or less mechanically (i.e.,
the functioning of the human body is analogous to the functioning of an automobile), that all life
can be reduced or divided into smaller parts (e.g., the reduction of the human person into body,
mind, and spirit), and that all of reality can be observed and measured
The naturalistic or holistic perspective, found most frequently among American Indians,
Asians, and others who believe that human life is only one aspect of nature and a part of the
general order of the cosmos. These people believe that the forces of nature must be kept in
natural balance or harmony.
A basic premise of the magico religious perspective is that the world is an arena in which
supernatural forces dominate. The fate of the world and those in it depends on the action of
supernatural forces for good or evil.
Define the term “cultural taboo” and give examples.
Cultural taboo is going against someone’s religious views by using a medical practice.
Examples could be receiving or giving blood from another patient, or even some surgeries.
Chapter 3 The Interview
Describe the purpose of the interview.
The interview is the first point of contact with a client* and the most important part of data
collection. During the interview you collect subjective data. Although the purpose of the
interview isn't to collect objective data, you will collect some objective data as you note the
person's posture, physical appearance, ability to carry on a conversation, and overall demeanor.
The interview is the best chance a person has to tell you what he or she perceives the health
state to be.
List important external factors in preparing the interview setting.
- Insure privacy
- Refuse interruptions
Exam 1 Study Guide
Chapter 1
Compare and contrast subjective and objective data.
Subjective data is what the person says about himself or herself during history taking while
objective data is what we, as the health professionals observe by inspecting, percussing,
palpating, and auscultating during the physical examination. (pg. 2)
Define “nursing process.”
The nursing process is the six phases (assessment, diagnosis, outcome identification, planning,
implementation, and evaluation) that nurses go through when in contact with a patient and their
problem. (pg. 3)
State the steps of nursing process.
1. Assessment
a. Collect data
b. Document relevant data
2. Diagnosis
a. Compare clinical findings with normal and abnormal variation and developmental
events
b. Interpret data
c. Validate diagnoses
d. Document diagnoses
3. Outcome Identification
a. Identify expected outcomes
b. Individualize to the person
c. Culturally appropriate
d. Realistic and measureable
e. Timeline
4. Planning
a. Establish priorities
b. Develop outcomes
c. Interventions
d. Document plan of care
5. Implementation
a. Implement in a safe and timely manner
b. Evidence-based interventions
c. Collaborate with colleagues
6. Evaluation
a. Progress toward outcomes
b. Use ongoing assessment to revise diagnoses, outcomes, and plan
Define “nursing diagnosis” and describe different types of nursing diagnoses (e.g.
actual, risk, wellness).
,PART I: Chose the label for your problem (nursing diagnosis).
PART II: Identify factors “related to” (the cause or etiology of the problem).
PART III: Statement that contains a list of evidence that supports the nurses claim that the
diagnosis is accurate (as evidenced by). Risk diagnoses will only have two parts – diagnosis
label and “related to”.
Describe prioritization and know what to do when there is more than one diagnosis (e.g.
first-level, second-level, and third-level problems).
Prioritization is setting an order of what is more important to access first. When there is more
than one diagnosis, look at the steps below to prioritize the problems.
1. Assign high priority to first-level priority problems (immediate priorities): Remember the “ABCs
plus V”:
• Airway problems
• Breathing problems
• Cardiac/circulation problems
• Vital sign concerns (e.g., high fever)
2. Next attend to second-level priority problems:
• Mental status change (e.g., confusion, decreased alertness)
• Untreated medical problems requiring immediate attention (e.g., a person with diabetes who
has not had insulin)
• Acute pain
• Acute urinary elimination problems
• Abnormal laboratory values
• Risks of infection, safety, or security (for the patient or for others)
3. Address third-level priority problems (later priorities):
• Health problems that do not fit into the previous categories (e.g., problems with lack of
knowledge, activity, rest, family coping)
Define and explain the terms “health promotion” and “disease prevention.”
Disease prevention can be achieved through counseling from primary care providers designed
to change people's unhealthy behaviors related to smoking, alcohol and other drug use, lack of
exercise, poor nutrition, injuries, and sexually transmitted infections. Health promotion is a set of
positive acts that we can take.
Chapter 2 Cultural Competence/ Cultural Care
Define the term “culture”
One definition is that culture is a pattern of shared attitudes, beliefs, self-definitions, norms,
roles, and values that can occur among those who speak a particular language or live in a
defined geographic region. Culture is a complex whole in which each part is related to every
other part. It is also a web of communication, and much of culture is transmitted nonverbally
through socialization or enculturation.
Describe what influences one’s cultural development
This indicates the level of acculturation and assimilation. (Acculturation - the process of
adapting to and acquiring another culture. Assimilation – the process by which a person
, develops a new cultural identity and becomes like the members of the dominant culture.
Biculturalism – dual pattern of identification and often of divided loyalty. Culture shock – the
state of disorientation or inability to respond to the behavior of a different cultural group because
of its sudden strangeness, unfamiliarity, and incompatibility to the newcomer’s perceptions and
expectations.)
Explain why a patient’s culture is important
You need to determine what the person believes has caused the illness before determining
whether cultural practices are helpful, harmful, or neutral for the proposed treatment plan.
NOTE: reflecting on your own culture and spiritual beliefs will allow you to be more effective in
your assessment of your patients’ needs
Explain the term “disease causation.”
Theories of causation have been formulated on the basis of ethnic identity, religious beliefs,
social class, philosophic perspectives, and level of knowledge
Compare and contrast the biomedical, naturalistic, and magico religious perspectives of
disease causation.
The first, called the biomedical or scientific theory of illness causation, assumes that all events
in life have a cause and effect, that the human body functions more or less mechanically (i.e.,
the functioning of the human body is analogous to the functioning of an automobile), that all life
can be reduced or divided into smaller parts (e.g., the reduction of the human person into body,
mind, and spirit), and that all of reality can be observed and measured
The naturalistic or holistic perspective, found most frequently among American Indians,
Asians, and others who believe that human life is only one aspect of nature and a part of the
general order of the cosmos. These people believe that the forces of nature must be kept in
natural balance or harmony.
A basic premise of the magico religious perspective is that the world is an arena in which
supernatural forces dominate. The fate of the world and those in it depends on the action of
supernatural forces for good or evil.
Define the term “cultural taboo” and give examples.
Cultural taboo is going against someone’s religious views by using a medical practice.
Examples could be receiving or giving blood from another patient, or even some surgeries.
Chapter 3 The Interview
Describe the purpose of the interview.
The interview is the first point of contact with a client* and the most important part of data
collection. During the interview you collect subjective data. Although the purpose of the
interview isn't to collect objective data, you will collect some objective data as you note the
person's posture, physical appearance, ability to carry on a conversation, and overall demeanor.
The interview is the best chance a person has to tell you what he or she perceives the health
state to be.
List important external factors in preparing the interview setting.
- Insure privacy
- Refuse interruptions
