What does the term "assessment" mean in terms of the nursing process? - Answer-A
systematic method of collecting and analyzing data for the purpose of planning patient-
centered care
/.Data collected during a health assessment is compared to ideal state of health based
on..... - Answer-age
gender
culture
ethnicity
physical status
psychological status
socioeconomic status
/.What is one approach developed by the
ANA to develop a plan of care? - Answer-ANA standards of practice
/.What does ADPIE stand for in the nursing process? - Answer-A - Assessment
D - Diagnosis
P - Planning
I - Implementation
E - Evaluation
/.Assessment? (standards of practice) - Answer-Collecting pertinent data and info
relative to patient's health/situation
/.Diagnosis? (standards of practice) - Answer-Analyzing assessment data to determines
actual or potential diagnosis, problems, or issues
/.Planning? (standards of practice) - Answer-RN develops a plan that prescribes
strategies to attain expected/measurable outcomes
/.Implementation? (standards of practice) - Answer-Identified plan is implemented
/.Evaluation? (standards of practice) - Answer-reassess or evaluate to ensure the
desired outcome has been met
/.What are the components of a health assessment? - Answer-Health History, Physical
Examination, Documentation of Data
/.What does the info collected during a health history & the extent of examination
depend on? - Answer-The setting, situation, patient needs, and nurse experience
,/.Health history? - Answer-consists of data collected during an interview which includes
information obtained by the health history assessment about the patient's history
relevent to the patient's visit
/.What are components of a health history? - Answer-biographic data, reason for
seeking care, history of present illness, present health status, current medication, past
health history as well as surgeries, family history, personal and psychosocial history,
review of systems
/.What is biographic data? - Answer-name, gender, address, telephone, email, birth
date, birthplace, race/ethnicity, religion, marital status, occupation, contact person,
source of data
/.Can biographic data change? - Answer-Yes, it remains updated as data changes and
with patient visits
/.Signs versus symptoms? - Answer-Signs are objective evidence observed, felt, heard,
or measured; such as any result from clinical tests
Symptoms are subjective pieces of data taken from the patient; such as pain
/.What does subjective data mean? - Answer-Subjective data is the primary source of
data because it comes from the patient
/.What is secondary source data? - Answer-Data given by another individual such as a
family member/ guardian
/.Signs are objective or subjective data? - Answer-objective data
/.What is clinical manifestation? - Answer-Describes the presenting of signs and
symptoms experienceed by the patient
/.How many steps are in the nursing process? - Answer-6
/.ANA stands for? - Answer-American Nurses Association
/.Is patient history subjective or objective data? - Answer-Subjective
/.Is examination data from the patient assessment subjective or objective? - Answer-
objective
/.Data = ____________ and _____________ - Answer-signs and symptoms
/.Every interaction is part of the ________________ _______________ - Answer-
nursing process
, /.What are the types of assessments? - Answer-60 second assessment
Comprehensive assessment
Focused assessment
Episodic assessment
Screening assessment
/.What is the purpose of a health assessment? - Answer-To obtain info about client's
perception of their health, their health status, risks, health promotion activities; and to
differentiate expected and unexpected findings using critical thinking
/.What is critical thinking? - Answer-Ability to sort through data to make a sound
judgement
/.What is a physical examination? - Answer-An examination that is carried out by the
nurse to collect objective data
/.What does OLD CARTS stand for? - Answer-Onset
Location
Duration
Characteristics
Aggravating factors
Related symptoms
Treatment
Severity
/.Onset (OLDCART) - Answer-onset of symptoms; when they begun, what were you
doing when they began, sudden or over period of time
/.location (OLDCART) - Answer-where at, vague or generalized, does it radiate
/.duration (OLDCART) - Answer-how long does it last, intermittent or constant
/.Characteristics (OLDCART) - Answer-how does symptoms feel or look, describe the
sensation; does it smell
/.aggravating factors (OLDCART) - Answer-What makes it worse, activity or other
factors such as environment that makes it worse
/.related symptoms (OLDCART) - Answer-related symptoms, any other symptoms
occuring that may be related
/.treatment (OLDCART) - Answer-what relieves it, position changes, home remedies,
any other treatment
/.severity - Answer-describe size, 0-10 rate symptoms, does it affect work, sleep, etc.
systematic method of collecting and analyzing data for the purpose of planning patient-
centered care
/.Data collected during a health assessment is compared to ideal state of health based
on..... - Answer-age
gender
culture
ethnicity
physical status
psychological status
socioeconomic status
/.What is one approach developed by the
ANA to develop a plan of care? - Answer-ANA standards of practice
/.What does ADPIE stand for in the nursing process? - Answer-A - Assessment
D - Diagnosis
P - Planning
I - Implementation
E - Evaluation
/.Assessment? (standards of practice) - Answer-Collecting pertinent data and info
relative to patient's health/situation
/.Diagnosis? (standards of practice) - Answer-Analyzing assessment data to determines
actual or potential diagnosis, problems, or issues
/.Planning? (standards of practice) - Answer-RN develops a plan that prescribes
strategies to attain expected/measurable outcomes
/.Implementation? (standards of practice) - Answer-Identified plan is implemented
/.Evaluation? (standards of practice) - Answer-reassess or evaluate to ensure the
desired outcome has been met
/.What are the components of a health assessment? - Answer-Health History, Physical
Examination, Documentation of Data
/.What does the info collected during a health history & the extent of examination
depend on? - Answer-The setting, situation, patient needs, and nurse experience
,/.Health history? - Answer-consists of data collected during an interview which includes
information obtained by the health history assessment about the patient's history
relevent to the patient's visit
/.What are components of a health history? - Answer-biographic data, reason for
seeking care, history of present illness, present health status, current medication, past
health history as well as surgeries, family history, personal and psychosocial history,
review of systems
/.What is biographic data? - Answer-name, gender, address, telephone, email, birth
date, birthplace, race/ethnicity, religion, marital status, occupation, contact person,
source of data
/.Can biographic data change? - Answer-Yes, it remains updated as data changes and
with patient visits
/.Signs versus symptoms? - Answer-Signs are objective evidence observed, felt, heard,
or measured; such as any result from clinical tests
Symptoms are subjective pieces of data taken from the patient; such as pain
/.What does subjective data mean? - Answer-Subjective data is the primary source of
data because it comes from the patient
/.What is secondary source data? - Answer-Data given by another individual such as a
family member/ guardian
/.Signs are objective or subjective data? - Answer-objective data
/.What is clinical manifestation? - Answer-Describes the presenting of signs and
symptoms experienceed by the patient
/.How many steps are in the nursing process? - Answer-6
/.ANA stands for? - Answer-American Nurses Association
/.Is patient history subjective or objective data? - Answer-Subjective
/.Is examination data from the patient assessment subjective or objective? - Answer-
objective
/.Data = ____________ and _____________ - Answer-signs and symptoms
/.Every interaction is part of the ________________ _______________ - Answer-
nursing process
, /.What are the types of assessments? - Answer-60 second assessment
Comprehensive assessment
Focused assessment
Episodic assessment
Screening assessment
/.What is the purpose of a health assessment? - Answer-To obtain info about client's
perception of their health, their health status, risks, health promotion activities; and to
differentiate expected and unexpected findings using critical thinking
/.What is critical thinking? - Answer-Ability to sort through data to make a sound
judgement
/.What is a physical examination? - Answer-An examination that is carried out by the
nurse to collect objective data
/.What does OLD CARTS stand for? - Answer-Onset
Location
Duration
Characteristics
Aggravating factors
Related symptoms
Treatment
Severity
/.Onset (OLDCART) - Answer-onset of symptoms; when they begun, what were you
doing when they began, sudden or over period of time
/.location (OLDCART) - Answer-where at, vague or generalized, does it radiate
/.duration (OLDCART) - Answer-how long does it last, intermittent or constant
/.Characteristics (OLDCART) - Answer-how does symptoms feel or look, describe the
sensation; does it smell
/.aggravating factors (OLDCART) - Answer-What makes it worse, activity or other
factors such as environment that makes it worse
/.related symptoms (OLDCART) - Answer-related symptoms, any other symptoms
occuring that may be related
/.treatment (OLDCART) - Answer-what relieves it, position changes, home remedies,
any other treatment
/.severity - Answer-describe size, 0-10 rate symptoms, does it affect work, sleep, etc.
