Test Bank For Health Assessment in Nursing 7th Edition by
Janet R. Weber; Jane H. Kelley
COLDSPA - ANSWER: c-characteristics: describe the symptoms
o- on-sent: when did it start
L- location: where is it, does if radiate, occur anywhere else
D-duration: how long does the pain last
S- severity- pain (use scale 1-10 if able)
P- pattern: what makes it better or worse
A- associated factors: what else is going on
nursing is defined as - ANSWER: -protection
-promotion
-optimization of : health and abilities
- prevention of illness and injury
- alleviation of suffering
-advocacy in care of : individuals, families, communities, and populations
the health promotion model - ANSWER: focuses on the individual and unique
characteristics and experiences; behavior specific cognitions and affect; behavioral
outcomes
subjective data consists of - ANSWER: - sensations of symptoms
- feelings
- perceptions
- desires
- preferences
- beliefs
- ideas
- values
- personal info
phases of the interview - ANSWER: -pre-introductory
-introductory
-working
-summary and closing
pre-introductory phase (interview phases) - ANSWER: review the medical record
before meeting with the patient
introductory phase (interview phases) - ANSWER: explain the purpose of the
interview, discusses the types of questions that will be asked, explains the reason for
taking notes, and assures the client that confidential information will remain
confidential
,working phase (interview phases) - ANSWER: the nurse elicits the clients comments
about major biographical data, reasons for seeking care, history of present health
concern, past health history, family history, review of body systems for current
health problems, lifestyle and health practices, and developmental level
summary and closing phase (interview phases) - ANSWER: the nurse summarizes
information obtained during the working phase and validates problems and goals
with the client; also identify and discuss possible plans to resolve the problem with
client
four assessment techniques (nclex) - ANSWER: inspection, palpation, percussion, and
auscultation
to become proficient with physical assessment skills, the nurse must have basic
knowledge in three areas: - ANSWER: - types and operation of equipment needed for
the particular examination
- preparation of the setting, oneself, and the client for the physical assessment
- performance of the four assessment techniques: inspect, percuss, palpate,
auscultate
three different parts of the hand used during palpation - ANSWER: fingerpads,
ulnar/palmer surface, and dorsal surface
purpose of documentation - ANSWER: promote effective communication among
multidisciplinary health team members to facilitate safe and effective client care
methods of validation - ANSWER: - recheck your own data through repeat
assessment
- clarify data with the client by asking additional questions
- verify the data with another health care professional
- compare your objective findings with your subjective findings to uncover
discrepancies
the use of EHRs - ANSWER: improved diagnostic and clinical outcomes, reduced
errors, and improved patient safety
SBAR - ANSWER: situation, background, assessment, recommendation; done when
you do a report off to another caregiver
actual diagnoses - ANSWER: nursing diagnoses (from NANDA) related to etiology
(cause) as evidenced by defining characteristics (what you see or observe)
wellness diagnoses or health promotion diagnosis - ANSWER: readiness for enhanced
(nursing diagnosis) related to (statement of desire to improve etiology)
, risk diagnosis (hasn't happened yet) - ANSWER: risk for (NANDA diagnosis) related to
(etiology(cause))
definition of health - ANSWER: as defined by WHO is a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity
factors affecting mental health - ANSWER: -economic and social factors
-unhealthy life choices-substance abuse
-exposure to violence
-personality factors
-spiritual factors
-cultural
-change or impairment in neurologic system
-psychosocial development level
Erikson theory - ANSWER: a psychosocial theory, with psychosocial being defined as
the intrapersonal and interpersonal responses
Erikson's Eight stages of psychosocial development - ANSWER:
Jean Piaget's stages of cognitive development - ANSWER:
assimilation - ANSWER: interpreting one's new experience in terms of one's existing
schemas
accommodation - ANSWER: adapting our current understandings (schemas) to
incorporate new information; modification
Lawrence Kohlberg Moral development theory - ANSWER:
Freud theory of psychosexual development - ANSWER:
pain - ANSWER: an unpleasant sensory and emotional experience, which we
primarily associate with tissue damage or describe in terms of such damage
myelinated afferent fibers (a fibers) - ANSWER: -fatty covering over nerve
-carries pain impulses quickly up the afferent pathways
-responsible for acute pain
-identify the painful area
unmyelinated afferent fibers (C fibers) - ANSWER: -no fatty covering over the nerve
-carries pain impulses slowly up the afferent pathway
-responsible for chronic pain
FLACC scale - ANSWER:
Numeric pain scale - ANSWER:
Janet R. Weber; Jane H. Kelley
COLDSPA - ANSWER: c-characteristics: describe the symptoms
o- on-sent: when did it start
L- location: where is it, does if radiate, occur anywhere else
D-duration: how long does the pain last
S- severity- pain (use scale 1-10 if able)
P- pattern: what makes it better or worse
A- associated factors: what else is going on
nursing is defined as - ANSWER: -protection
-promotion
-optimization of : health and abilities
- prevention of illness and injury
- alleviation of suffering
-advocacy in care of : individuals, families, communities, and populations
the health promotion model - ANSWER: focuses on the individual and unique
characteristics and experiences; behavior specific cognitions and affect; behavioral
outcomes
subjective data consists of - ANSWER: - sensations of symptoms
- feelings
- perceptions
- desires
- preferences
- beliefs
- ideas
- values
- personal info
phases of the interview - ANSWER: -pre-introductory
-introductory
-working
-summary and closing
pre-introductory phase (interview phases) - ANSWER: review the medical record
before meeting with the patient
introductory phase (interview phases) - ANSWER: explain the purpose of the
interview, discusses the types of questions that will be asked, explains the reason for
taking notes, and assures the client that confidential information will remain
confidential
,working phase (interview phases) - ANSWER: the nurse elicits the clients comments
about major biographical data, reasons for seeking care, history of present health
concern, past health history, family history, review of body systems for current
health problems, lifestyle and health practices, and developmental level
summary and closing phase (interview phases) - ANSWER: the nurse summarizes
information obtained during the working phase and validates problems and goals
with the client; also identify and discuss possible plans to resolve the problem with
client
four assessment techniques (nclex) - ANSWER: inspection, palpation, percussion, and
auscultation
to become proficient with physical assessment skills, the nurse must have basic
knowledge in three areas: - ANSWER: - types and operation of equipment needed for
the particular examination
- preparation of the setting, oneself, and the client for the physical assessment
- performance of the four assessment techniques: inspect, percuss, palpate,
auscultate
three different parts of the hand used during palpation - ANSWER: fingerpads,
ulnar/palmer surface, and dorsal surface
purpose of documentation - ANSWER: promote effective communication among
multidisciplinary health team members to facilitate safe and effective client care
methods of validation - ANSWER: - recheck your own data through repeat
assessment
- clarify data with the client by asking additional questions
- verify the data with another health care professional
- compare your objective findings with your subjective findings to uncover
discrepancies
the use of EHRs - ANSWER: improved diagnostic and clinical outcomes, reduced
errors, and improved patient safety
SBAR - ANSWER: situation, background, assessment, recommendation; done when
you do a report off to another caregiver
actual diagnoses - ANSWER: nursing diagnoses (from NANDA) related to etiology
(cause) as evidenced by defining characteristics (what you see or observe)
wellness diagnoses or health promotion diagnosis - ANSWER: readiness for enhanced
(nursing diagnosis) related to (statement of desire to improve etiology)
, risk diagnosis (hasn't happened yet) - ANSWER: risk for (NANDA diagnosis) related to
(etiology(cause))
definition of health - ANSWER: as defined by WHO is a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity
factors affecting mental health - ANSWER: -economic and social factors
-unhealthy life choices-substance abuse
-exposure to violence
-personality factors
-spiritual factors
-cultural
-change or impairment in neurologic system
-psychosocial development level
Erikson theory - ANSWER: a psychosocial theory, with psychosocial being defined as
the intrapersonal and interpersonal responses
Erikson's Eight stages of psychosocial development - ANSWER:
Jean Piaget's stages of cognitive development - ANSWER:
assimilation - ANSWER: interpreting one's new experience in terms of one's existing
schemas
accommodation - ANSWER: adapting our current understandings (schemas) to
incorporate new information; modification
Lawrence Kohlberg Moral development theory - ANSWER:
Freud theory of psychosexual development - ANSWER:
pain - ANSWER: an unpleasant sensory and emotional experience, which we
primarily associate with tissue damage or describe in terms of such damage
myelinated afferent fibers (a fibers) - ANSWER: -fatty covering over nerve
-carries pain impulses quickly up the afferent pathways
-responsible for acute pain
-identify the painful area
unmyelinated afferent fibers (C fibers) - ANSWER: -no fatty covering over the nerve
-carries pain impulses slowly up the afferent pathway
-responsible for chronic pain
FLACC scale - ANSWER:
Numeric pain scale - ANSWER:
