lp7
The purpose of a Physical Assessment is to primarily do what?
Examine the patient for objective data to define their condition and plan care.
Information perceived only by the affected person; these data cannot be perceived or verified by another person.
Subjective Data
An assessment scheduled to compare a patient's current status to the baseline data obtained earlier.
Time-Lapsed Assessment
What is the overall goal of the 'Assessing' step in nursing care?
To systematically collect, analyze, validate, and communicate patient data.
A nurse measures a patient's blood pressure as 140/90 mmHg. This measurement is an example of what type of data?
Objective Data
What structured assessment form is used to organize data collected from every patient as specified by the Minimum Data Set?
A structured assessment form to organize or cluster this data.
Which method is described as the conscious and deliberate use of the five senses to gather data?
Observation
Which component of the patient assessment process helps to verify data gathered during the nursing history or yield new data?
Physical assessment
A patient reports feeling dizzy and nauseous. This information is an example of what type of data?
Subjective Data
Conscious and deliberate use of the five senses to gather data.
Observation
A subjective or objective piece of information identified by the nurse, such as 'the patient does not respond when I speak to him on his left side.'
Cue
Short, focused, prioritized assessments performed to gain the most important information first.
Quick Priority Assessment (QPAs)
The 'Database' for a patient includes information gathered by whom?
Nurses and other healthcare professionals.
The act of confirming or verifying information.
Validation
A set that specifies the information that must be collected from every patient and uses a structured assessment form.
Minimum Data Set
An assessment performed shortly after the patient is admitted to a health care facility or service.
Initial Assessment
Systematic and continuous collection, analysis, validation, and communication of patient data.
Assessing
What is the primary patient right concerning their information during assessment and data storage?
The right to expect privacy and confidentiality of their health data.
A judgment reached about a cue, for example, 'the patient's hearing may be impaired on his left side.'
Inference
Which type of assessment is short, focused, and prioritized to gather essential information quickly?
Quick Priority Assessment (QPAs)
Which of the following describes a 'cue'?
Identified patient data, either subjective or objective.
A nurse forms a judgment that 'the patient's anxiety may be causing their rapid breathing.' This is an example of what?
Inference
When discussing patient privacy, what must be ensured if a family member is in the room?
Make sure it is acceptable to the patient to speak about HIPAA in front of others.
A patient states, 'I feel a sharp pain in my chest.' This statement is an example of a:
Cue
When is an Emergency Assessment typically performed?
When there is a need to identify immediate life-threatening problems.
A planned communication designed to establish a successful and strong working partnership with the patient is known as a(n):
Interview
What type of assessment is specifically designed to use social determinants of health to evaluate patient complexity?
Patient-Centered Assessment Method (PCAM)
Which action is crucial for obtaining a comprehensive nursing history?
Using effective interviewing techniques to establish a database.
What is the primary purpose of a Time-Lapsed Assessment?
To compare a patient's current status with baseline data obtained earlier.
Observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them.
Objective Data
A patient's nursing history primarily helps to identify what?
Health status, strengths, actual and potential problems, risks, and nursing care needs.
The process by which professionals screen patients to determine the extent and severity of their problems and recommend follow-up.
Triage
A nurse observes a patient grimacing and guarding their abdomen. This is an example of:
Objective Data
An assessment primarily focused on identifying life-threatening problems.
Emergency Assessment
An examination of the patient for objective data that may better define the patient's condition and help plan care.
Physical Assessment
Which assessment typically involves a head-to-toe format for examining all body systems systematically?
Review of Systems (ROS)
When does data primarily need to be validated?
When it lacks objectivity or there is suspicion about its accuracy.
What distinguishes Subjective Data from Objective Data?
Subjective data is perceived by the patient, while objective data is observable by others.
When a patient expresses suicidal remarks, what is the most important immediate action regarding data reporting?
Communicate this immediately to the health care team to ensure precautions.
A physical assessment involving the systematic examination of all body systems, often using a head-to-toe format.
Review of Systems (ROS)
The record that identifies the patient's health status, strengths, actual and potential health problems, health risks, and need for nursing care.
Nursing history
An assessment where the nurse gathers data about a specific problem that has already been identified.
Focused Assessment
A broad term referring to pieces of information.
Data
A planned communication used to gather information from a patient.
Interview
What is the primary purpose of an Initial Assessment?
To establish a comprehensive baseline of patient data upon admission.
The process of screening patients to determine the severity of their problems and recommend follow-up is known as:
Triage
A tool health care practitioners can use to assess patient complexity using the social determinants of health.
Patient-Centered Assessment Method (PCAM)
When gathering patient data, what quality of information is paramount for planning patient assessments effectively?
Purposeful, prioritized, complete, systematic, accurate, and relevant.
What is the main goal of a Focused Assessment?
To gather specific data related to a problem already identified.
All pertinent patient information collected by the nurse and other health care professionals.
Database