WITH SOLUTIONS GRADED A+
✔✔What does the assessment phase of the nursing process include? - ✔✔Nursing
health history
Physical assessment
Reviewing client records
Reviewing literature
Talking to people in the client's support system
Organizing, validating and documenting data
✔✔Are the client's vital signs subjective or objective data? - ✔✔Objective data, signs,
which can be measured or tested.
✔✔What is subjective data in an assessment? - ✔✔Symptoms that the client feels or
experiences.
✔✔What is the difference between primary and secondary data? - ✔✔Primary comes
from the client. Secondary comes from family, lab values, other professionals, etc.
✔✔What are the four types of nursing assessments? - ✔✔Problem-focused
Emergency
Time-lapsed
Initial
✔✔Which type of assessment is the most important? - ✔✔The one that is most
appropriate for the situation is most important. If a patient comes into the emergency
department bleeding profusely, then an emergency assessment is most important at
that time.
✔✔Once the baseline data has been collected, is the assessment phase complete? -
✔✔No, assessment will continue to monitor for changes.
✔✔What is the "chief complaint"? - ✔✔The chief complaint is the main reason the client
is coming for care. History of Present Illness
✔✔The client says, "I feel sick." Is this enough information for the History of Present
Illness? What other questions would you ask? - ✔✔No, this not enough. The nurse will
need to ask, "when did you start getting sick? What kind of symptoms have you had?
Did is start quickly or gradually?" etc.
✔✔When collecting data for the client's history, what type of information is the nurse
collecting? - ✔✔Past illnesses
Immunizations
Allergies
, Accidents and Injuries
Hospitalizations
Medications
✔✔What are the components of a Nursing Health History? - ✔✔Biographic data
Chief Complaint
Past History
Family History of Illness
Lifestyle
Social data
Psychological data
Patterns of healthcare
✔✔How does a nurse collect data? - ✔✔Observing by listening, seeing, smelling,
touching
Interviewing
Examining
✔✔Which question is an example of an open ended question?
Tell me about any heart conditions you may have?
Do you have any heart conditions? - ✔✔Open ended questions allow for the client to
share more information and can not be answered with a "yes" or "no." "Tell me about..."
is an open ended question.
✔✔What are the stages of an interview? - ✔✔The opening: sets tone, establishes
rapport
The body: the nurse askes the client questions to elicit the information
The closing: finishing the interview.
✔✔What is the nurse analyzing in the second phase of the nursing process? - ✔✔Is the
information complete? What are the problems? What are the risks? What are the
strengths?
Previously developed nursing diagnoses, now call "Client problems."
✔✔In the planning phase of the nursing process, what happens? - ✔✔Goals/Outcomes
are established
Problems prioritized
Developing nursing care plan with evidence based interventions.
✔✔The nurse monitors the patient's vital signs every 4 hours. What phase of the
nursing process is this? - ✔✔Implementing: actually doing the care and documenting it.
✔✔In the evaluation phase what does the nurse evaluate?
a. If the interventions were done correctly.
b. If the client did better.