Nursing Assessment Exam 1 (1-9) Questions And Answers Already Passed Graded A+.

What are the 6 steps of the nursing process? if asking for 5 remove (outcome identification) - correct answer ADOPIE Assessment Diagnosis Outcome Identification Planning Implementation Evaluation What are the types of Health Assessment? - correct answer 1) Comprehensive assessment 2)Problem-based/Focused assessment 3) Emergency assessment What are the 3 primary components of Health Assessment? - correct answer History (subjective data) Physical examination (objective data) Documentation of data Why do we document all of our data? - correct answer Improves plan of care It is a legal document of patient's health Draws a baseline for future evaluations It must be accurate, concise, and without bias T/F If it is not documented you did not do it. - correct answer True What is context of care? - correct answer it refers to circumstance or situation related to health care delivery. 1) may be related to setting or environment 2) may be related to physical, psychological, or SES circumstances involving the pt. What is a comprehensive assessment? - correct answer A detailed H&P exam performed at the onset of care in a primary care setting or on admission to a hospital or long-term facility. What is a Problem-based/focused assessment? - correct answer the problem-based or focused assessment involves a history and examination that are limited to a specific problem or complaint. This type of assessment is most commonly used in a walk-in clinic or emergency department, but it may also be applied in other outpatient setting. What is emergency assessment? - correct answer life-threatening situation What is a screening assessment? - correct answer a short examination focused on disease detection. usually conducted in health fairs. What is Health promotion? - correct answer Behavior motivated by desire to increase well-being and actualize health potential. What is Health protection? - correct answer Behavior motivated by desire to avoid illness, detect illnesses early, and maintain functioning when ill. What are the 3 levels of health promotion? - correct answer Primary= preventing disease from developing through promoting a healthy lifestyle. Secondary= Screening efforts to promote early detection of disease. Tertiary= minimizing disability from acute or cronic illness or injury and allowing for most productive life within lilmitations. What are examples for the 3 levels of health promotion? - correct answer Primary= Immunizations Secondary= Mammogram Tertiary = The disease is already present: Hypertension management. A mother of three is being seen for a screening assessment. While planning the initial part of the visit with this patient, the nurse needs to ensure that: a)The patient receives a refill for her thyroid medication. b)The patient is instructed on preventive measures for hypertension. C)Other family members are present during the interview. D)Information about the patient's lifestyle habits is gathered. - correct answer Correct Answer: D Rationale: There are multiple types of health assessments. If a patient receives a refill, this is an episodic or follow-up assessment. If a patient is instructed in preventive measures, this is more along the lines of a comprehensive assessment. A screening assessment would require the nurse to have data about lifestyle habits. The medical-surgical nurse is reviewing the practice related to a patient who acquired pneumonia while recovering from a hip replacement. The unit documents this event as failure to rescue and would like the nurse to develop a personal professional action plan. This plan will most likely include: A)Reflection on action B)Tertiary prevention of health care-associated infections C)Reasoning patterns - correct answer Correct Answer: A Rationale: Reflection on action represents the contribution of an experience to a nurse's collective experiences. Reflection in action specifically relates to evaluating outcomes of interventions. The nurse needs to look at his practice to identify whether something can change. A nurse is assessing a female teenager. The nurse asks the young woman to bend over and touch her toes. The nurse assesses the curvature of the spine as a means of detecting scoliosis. Assessing the curvature of the spine is an example of: A)Health education B)Primary prevention C)Secondary prevention D)Tertiary prevention - correct answer Correct Answer: C Rationale: Primary prevention is preventing the disease before it begins. Secondary prevention means that the nurse is trying to detect disease as early as possible to improve outcomes. What are the two primary components of health assessment? - correct answer Health history Physical examination Is a health history subjective or objective data? - correct answer Subjective Single-most important factor for successful interviewing is the ______ skill of the nurse. - correct answer communication What are some factors that affect a nurses therapeutic communication? - correct answer Physical setting, nurse behaviors, type of questions asked, how questions are asked. Behavior of pt. How the pt. feels during the interview, nature of information being discussed or problem being confronted Begin interviews with what type of questions? - correct answer open-ended. encourage a free-flowing open response. If want more precise data from your patients what type of question should you ask? - correct answer Close-ended What do directive questions do? - correct answer lead patient to focus on one set of thoughts. Most often used in reviewing systems and evaluation functional status. Use _____ to help concentrate on pt. responses and subtleties. - correct answer listening