Health Assessment In Nursing
Assessment ✔✔Collection of subjective and objective data
Diagnoses ✔✔Analysis of subjective and objective data to make a professional nursing
judgement
Planning ✔✔Developing a plan of nursing care and outcome criteria
Implementation ✔✔Carrying out the plan of care
Evaluation ✔✔Assessing whether outcome criteria have been met and revising the plan of care
if necessary
Nursing Diagnosis ✔✔Clinical judgement about individual, family or community responses to
actual or potential health problems and life processes
Subjective Data ✔✔Sensations or symptoms that can be verified only by the client (ex. pain)
Objective Data ✔✔Findings directly observed or indirectly observed through measurements
(ex. body temperature)
Collaborative Problem ✔✔Physiologic complications that nurses monitor to detect their onset
or changes in status
Referral Problem ✔✔Problem that requires the attention or assistance of other health care
professionals
A medical examination differs from a comprehensive nursing examination in that the medical
examination focuses primarily on the client's ✔✔Physiologic status
The result of a nursing assessment is the ✔✔Formulation of nursing diagnoses
Although the assessment phase of the nursing process precedes the other phases, the
assessment phase is ✔✔Continuous
When a client first enters the hospital for an elective surgical procedure, the nurse should
perform an assessment termed ✔✔Comprehensive
, An ongoing or partial assessment of a client ✔✔Includes a brief reassessment of the client's
normal body system
The purpose of the comprehensive health assessment is to ✔✔Arrive at conclusions about the
client's health
The use of this type of question can keep a client interview from going off track ✔✔Closed-
ended
A nurse can clarify a client's statements by ✔✔Rephrasing the client's statements
During what phase of the interview between a nurse and client do you collaborate to identify
problems and goals ✔✔Working phase
When dealing with a manipulative client it is important for the nurse to ✔✔Provide structure
and set limits
The primary purpose of the health history is to ✔✔Identify risk factors to the client and his or
her significant others
Define the "COLDSPAA" accronym ✔✔Character, Onset, Location, Duration, Severity, Pattern,
Associated factors, how it Affects the client
Sim's position ✔✔Side-lying position used during the rectal examination
Sitting Position ✔✔Position used during much of the physical examination including
examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper
extremities
Supine Position ✔✔Back-lying position used for examination of the abdomen (with one small
pillow under the head and another under the knees); this position also allows easy access for
palpation of peripheral pulses
Standing Position ✔✔Position used to examine male genitalia and to assess gait, posture, and
balance
Prone Position ✔✔Client lies on abdomen with head turned to the side; may be used to assess
back and mobility of hip joint
Assessment ✔✔Collection of subjective and objective data
Diagnoses ✔✔Analysis of subjective and objective data to make a professional nursing
judgement
Planning ✔✔Developing a plan of nursing care and outcome criteria
Implementation ✔✔Carrying out the plan of care
Evaluation ✔✔Assessing whether outcome criteria have been met and revising the plan of care
if necessary
Nursing Diagnosis ✔✔Clinical judgement about individual, family or community responses to
actual or potential health problems and life processes
Subjective Data ✔✔Sensations or symptoms that can be verified only by the client (ex. pain)
Objective Data ✔✔Findings directly observed or indirectly observed through measurements
(ex. body temperature)
Collaborative Problem ✔✔Physiologic complications that nurses monitor to detect their onset
or changes in status
Referral Problem ✔✔Problem that requires the attention or assistance of other health care
professionals
A medical examination differs from a comprehensive nursing examination in that the medical
examination focuses primarily on the client's ✔✔Physiologic status
The result of a nursing assessment is the ✔✔Formulation of nursing diagnoses
Although the assessment phase of the nursing process precedes the other phases, the
assessment phase is ✔✔Continuous
When a client first enters the hospital for an elective surgical procedure, the nurse should
perform an assessment termed ✔✔Comprehensive
, An ongoing or partial assessment of a client ✔✔Includes a brief reassessment of the client's
normal body system
The purpose of the comprehensive health assessment is to ✔✔Arrive at conclusions about the
client's health
The use of this type of question can keep a client interview from going off track ✔✔Closed-
ended
A nurse can clarify a client's statements by ✔✔Rephrasing the client's statements
During what phase of the interview between a nurse and client do you collaborate to identify
problems and goals ✔✔Working phase
When dealing with a manipulative client it is important for the nurse to ✔✔Provide structure
and set limits
The primary purpose of the health history is to ✔✔Identify risk factors to the client and his or
her significant others
Define the "COLDSPAA" accronym ✔✔Character, Onset, Location, Duration, Severity, Pattern,
Associated factors, how it Affects the client
Sim's position ✔✔Side-lying position used during the rectal examination
Sitting Position ✔✔Position used during much of the physical examination including
examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper
extremities
Supine Position ✔✔Back-lying position used for examination of the abdomen (with one small
pillow under the head and another under the knees); this position also allows easy access for
palpation of peripheral pulses
Standing Position ✔✔Position used to examine male genitalia and to assess gait, posture, and
balance
Prone Position ✔✔Client lies on abdomen with head turned to the side; may be used to assess
back and mobility of hip joint
