Health assessment: Unit 1 Study guide
1. What are the elements of a database?
a. Patients record
b. Subjective data (i.e., what the person says during history taking)
c. Objective data (i.e., what you the health professional observe by inspecting, percussing,
palpating, and auscultating during the physical examination)
d. Laboratory studies
2. What are the actions nurses do in diagnostic reasoning “How do nurses think?”?
a. Nurses use diagnostic reasoning as a form of data collection to correctly and accurately
perform their assessment, by recognizing cues, analyzing data, making hypotheses,
setting priorities, and evaluating their outcomes
3. What do nurses do if they are not sure about what is going on with the patient?
4. How do nurses identify priorities?
a. First level
i. Emergencies-life threatening
ii. Immediate concerns
iii. ABC’s
b. Second level
i. Urgent issues-needs attention soon
ii. Mental status changes
iii. Acute pain
iv. Abnormal lab values
v. Acute urinary problems
c. Third level
i. Important needs for the patient’s health but not urgent
ii. Patient Education
iii. Coping
iv. Mobility problems
5. What is evidence-based assessment and why is it important?
a. Evidence-based practice is concrete data and putting it into practice
b. It led to the conviction that all patients deserve to be treated with the most current and
best-practice techniques
6. What are the different types of data and when do we collect each?
2023SUQ Dr. Kiss
, a. Complete (Total health) database includes a complete health history and a full physical
examination. It describes the current and past health state and forms a baseline against
which all future changes can be measured. Often performed in a primary care setting
b. Focused or Problem-based database: limited or short-term problem, it’s more targeted
than the complete database. Concerns are mainly one problem, one cue, and one body
system. Used in all settings: hospital, primary care, long-term care
c. Follow-up database: is the status of the acute problem (if not resolved it jumps back to a
problem-based assessment)
d. Emergency database: an urgent, rapid collection of crucial information that is often
compiled concurrently with lifesaving measures. The priority questions related to the
issue will be mainly focused on. Questions are typically asked as care is being provided
7. Which patient would be most likely to not hear you or misinterpret what you are saying?
a. Patients who are in pain
b. On medication
c. Patients with personal issues
8. What are some of the internal and external factors affecting communication?
Internal factors- specific to the examiner External factors- physical setting
Liking others- respecting their choices Ensure privacy
Empathy-ability to understand Avoid interruptions
Listening- complete and focused attention Comfortable room temp
Active listening- ask follow-up questions Lighting
Do not interrupt Reduce noise
Self-awareness- understand personal biases Equal status sitting (4-5) feet / Note taking
9. What are the phases of the interview? What do nurses do in each phase?
a. Introduction of the Interview
i. Introduce yourself
ii. Establish rapport
iii. Establish interview contract
b. Working Phase
i. Gathering data
ii. Open and closed-ended questions
iii. Maintain appropriate eye contact
iv. Listen attentively
c. Closing the interview
i. Discuss positive health aspects
ii. Provide a plan of action
iii. Explain subsequent physical exam
iv. Thank the patient for their time
2023SUQ Dr. Kiss
1. What are the elements of a database?
a. Patients record
b. Subjective data (i.e., what the person says during history taking)
c. Objective data (i.e., what you the health professional observe by inspecting, percussing,
palpating, and auscultating during the physical examination)
d. Laboratory studies
2. What are the actions nurses do in diagnostic reasoning “How do nurses think?”?
a. Nurses use diagnostic reasoning as a form of data collection to correctly and accurately
perform their assessment, by recognizing cues, analyzing data, making hypotheses,
setting priorities, and evaluating their outcomes
3. What do nurses do if they are not sure about what is going on with the patient?
4. How do nurses identify priorities?
a. First level
i. Emergencies-life threatening
ii. Immediate concerns
iii. ABC’s
b. Second level
i. Urgent issues-needs attention soon
ii. Mental status changes
iii. Acute pain
iv. Abnormal lab values
v. Acute urinary problems
c. Third level
i. Important needs for the patient’s health but not urgent
ii. Patient Education
iii. Coping
iv. Mobility problems
5. What is evidence-based assessment and why is it important?
a. Evidence-based practice is concrete data and putting it into practice
b. It led to the conviction that all patients deserve to be treated with the most current and
best-practice techniques
6. What are the different types of data and when do we collect each?
2023SUQ Dr. Kiss
, a. Complete (Total health) database includes a complete health history and a full physical
examination. It describes the current and past health state and forms a baseline against
which all future changes can be measured. Often performed in a primary care setting
b. Focused or Problem-based database: limited or short-term problem, it’s more targeted
than the complete database. Concerns are mainly one problem, one cue, and one body
system. Used in all settings: hospital, primary care, long-term care
c. Follow-up database: is the status of the acute problem (if not resolved it jumps back to a
problem-based assessment)
d. Emergency database: an urgent, rapid collection of crucial information that is often
compiled concurrently with lifesaving measures. The priority questions related to the
issue will be mainly focused on. Questions are typically asked as care is being provided
7. Which patient would be most likely to not hear you or misinterpret what you are saying?
a. Patients who are in pain
b. On medication
c. Patients with personal issues
8. What are some of the internal and external factors affecting communication?
Internal factors- specific to the examiner External factors- physical setting
Liking others- respecting their choices Ensure privacy
Empathy-ability to understand Avoid interruptions
Listening- complete and focused attention Comfortable room temp
Active listening- ask follow-up questions Lighting
Do not interrupt Reduce noise
Self-awareness- understand personal biases Equal status sitting (4-5) feet / Note taking
9. What are the phases of the interview? What do nurses do in each phase?
a. Introduction of the Interview
i. Introduce yourself
ii. Establish rapport
iii. Establish interview contract
b. Working Phase
i. Gathering data
ii. Open and closed-ended questions
iii. Maintain appropriate eye contact
iv. Listen attentively
c. Closing the interview
i. Discuss positive health aspects
ii. Provide a plan of action
iii. Explain subsequent physical exam
iv. Thank the patient for their time
2023SUQ Dr. Kiss
