Physical Assessment EXAM 1 Test
Questions and Answers | Comprehensive
Exam Review | Verified Answers [2026]
C
Terms in this set (312)
is the collection of data about the individual's health
Assessment state.
is a phase of the nursing process.
Assessment
is to make a judgment or diagnosis.
The purpose of an
assessment
is the starting point of diagnostic reasoning.
An organized
assessment
What patient says about himself or herself during history
Subjective data taking
Observed when inspecting, percussing, palpating, and
Objective data
auscultating patient during physical examination
, Formed from these elements, plus patient's record and
Data base
laboratory studies
reasoning-the process of analyzing health data and
Diagnostic reasoning
drawing conclusions to identify diagnos
includes six phases: assessment, diagnosis, outcome
Nursing Process
identification, planning, implementation, and
evaluation
is required for sound diagnostic reasoning and clinical
Critical Thinking
judgement
piece of information, sign, symptom, or piece of
Cue laboratory data
tentative explanation for cues used as a basis for
Hypothesis
further investigation
1.Attend to initially available cues
Diagnostic Reasoning
2. Formulate diagnostic hypotheses
3. Gather data relative to tentative hypotheses
4. Evaluate each hypothesis with new data collected to
arrive at final diagnosis
1. Collect Data
Assessment
-review of the clinical record
-Health History
- Physical Examination
- Functional Assessment
- Risk assessment
- Review of the literature
2. Use evidence-based assessment techniques
3. Document relevant data
1. compare clinical findings with normal and abnormal
Diagnosis
variation and developmental events
2. Interpret data
- Identify clusters of cues
- make hypotheses
- test hypotheses
- derive diagnoses
3. validate diagnosis
4. document diagnoses
, 1. identify expected outcomes
Outcome identification
2. individualize to the person
3. culturally appropriate
4. realistic and measurable
5. include a timeline
1. establish priorities
Planning
2. Develop outcomes
3. set timelines for outcomes
4. identify interventions
5. integrate evidence-based trends and research
6. document plan of care
1. implement in a safe and timely manner
Implementation
2. used evidence-based interventions
3. collaborate with colleagues
4. coordinate care delivery
5. provide health teaching and health promotion
6. document implementation and any modification
1. progress toward outcomes
Evaluation
2. conduct systematic, ongoing, criterion-based evaluation
3. include patient and significant others
4. use ongoing assessment to revise diagnosis, outcomes,
plan
6. disseminate results to patient and family
applying the best available research results (evidence)
Evidence-based practice
when making decisions about health care.
Examples-corticosteroid use in pre-term babies to
Evidence-based practice
facilitate lung development; use of normal saline
flushes to maintain IV patency
1. Includes complete health history and full
Complete total health
physical examination
data base
2. Describes current and past health state and forms
baseline to measure all future changes
3. Yields first diagnoses
A. Four types
How many types of data
-Complete
do you collect - Focused or problem centered
- Follow-up
- Emergency
, 1. For limited or short-term problems
Episodic or
problem-centered 2. Collect "mini" data base, smaller scope and more
focused than complete data base
data base
3. Concerns mainly one problem, one cue complex,
or one body system
4. History and examination follow direction of
presenting concern
- Acute or chronic onset, associated with fever, local or
generalized
1. Status of all identified problems should be
Follow-up data base
evaluated at regular and appropriate intervals
2. Note changes that have occurred
3. Evaluate whether problem is getting better or worse
4. Identify coping strategies being used
1. Rapid collection of data, often compiled
Emergency data base
concurrently with lifesaving measures
2. Diagnosis must be swift and sure
-Person is questioned simultaneously while his or her
airway, breathing, circulation, level of consciousness,
and disability are being assessed
Interval of assessment varies with illness and wellness
FREQUENCY OF needs
ASSESSMENT
1. Ill people seek care because of pain or abnormal
Interval of
signs and symptoms
assessment varies
2. This prompts an assessment: gathering complete,
with illness and episodic, or emergency data base
wellness needs
-Screening history for dietary intake, physical activity,
tobacco/alcohol/drug use, and sexual practices
-Counseling for injury prevention, substance use, sexual
behavior, diet and exercise, and dental health
Questions and Answers | Comprehensive
Exam Review | Verified Answers [2026]
C
Terms in this set (312)
is the collection of data about the individual's health
Assessment state.
is a phase of the nursing process.
Assessment
is to make a judgment or diagnosis.
The purpose of an
assessment
is the starting point of diagnostic reasoning.
An organized
assessment
What patient says about himself or herself during history
Subjective data taking
Observed when inspecting, percussing, palpating, and
Objective data
auscultating patient during physical examination
, Formed from these elements, plus patient's record and
Data base
laboratory studies
reasoning-the process of analyzing health data and
Diagnostic reasoning
drawing conclusions to identify diagnos
includes six phases: assessment, diagnosis, outcome
Nursing Process
identification, planning, implementation, and
evaluation
is required for sound diagnostic reasoning and clinical
Critical Thinking
judgement
piece of information, sign, symptom, or piece of
Cue laboratory data
tentative explanation for cues used as a basis for
Hypothesis
further investigation
1.Attend to initially available cues
Diagnostic Reasoning
2. Formulate diagnostic hypotheses
3. Gather data relative to tentative hypotheses
4. Evaluate each hypothesis with new data collected to
arrive at final diagnosis
1. Collect Data
Assessment
-review of the clinical record
-Health History
- Physical Examination
- Functional Assessment
- Risk assessment
- Review of the literature
2. Use evidence-based assessment techniques
3. Document relevant data
1. compare clinical findings with normal and abnormal
Diagnosis
variation and developmental events
2. Interpret data
- Identify clusters of cues
- make hypotheses
- test hypotheses
- derive diagnoses
3. validate diagnosis
4. document diagnoses
, 1. identify expected outcomes
Outcome identification
2. individualize to the person
3. culturally appropriate
4. realistic and measurable
5. include a timeline
1. establish priorities
Planning
2. Develop outcomes
3. set timelines for outcomes
4. identify interventions
5. integrate evidence-based trends and research
6. document plan of care
1. implement in a safe and timely manner
Implementation
2. used evidence-based interventions
3. collaborate with colleagues
4. coordinate care delivery
5. provide health teaching and health promotion
6. document implementation and any modification
1. progress toward outcomes
Evaluation
2. conduct systematic, ongoing, criterion-based evaluation
3. include patient and significant others
4. use ongoing assessment to revise diagnosis, outcomes,
plan
6. disseminate results to patient and family
applying the best available research results (evidence)
Evidence-based practice
when making decisions about health care.
Examples-corticosteroid use in pre-term babies to
Evidence-based practice
facilitate lung development; use of normal saline
flushes to maintain IV patency
1. Includes complete health history and full
Complete total health
physical examination
data base
2. Describes current and past health state and forms
baseline to measure all future changes
3. Yields first diagnoses
A. Four types
How many types of data
-Complete
do you collect - Focused or problem centered
- Follow-up
- Emergency
, 1. For limited or short-term problems
Episodic or
problem-centered 2. Collect "mini" data base, smaller scope and more
focused than complete data base
data base
3. Concerns mainly one problem, one cue complex,
or one body system
4. History and examination follow direction of
presenting concern
- Acute or chronic onset, associated with fever, local or
generalized
1. Status of all identified problems should be
Follow-up data base
evaluated at regular and appropriate intervals
2. Note changes that have occurred
3. Evaluate whether problem is getting better or worse
4. Identify coping strategies being used
1. Rapid collection of data, often compiled
Emergency data base
concurrently with lifesaving measures
2. Diagnosis must be swift and sure
-Person is questioned simultaneously while his or her
airway, breathing, circulation, level of consciousness,
and disability are being assessed
Interval of assessment varies with illness and wellness
FREQUENCY OF needs
ASSESSMENT
1. Ill people seek care because of pain or abnormal
Interval of
signs and symptoms
assessment varies
2. This prompts an assessment: gathering complete,
with illness and episodic, or emergency data base
wellness needs
-Screening history for dietary intake, physical activity,
tobacco/alcohol/drug use, and sexual practices
-Counseling for injury prevention, substance use, sexual
behavior, diet and exercise, and dental health
