Fundamentals of Assessment
This is the first step of the nursing process.
What is Assessment?
This assessment is performed at the beginning of care and is very detailed.
What is a Comprehensive assessment?
This is another name for the chief complaint.
What is the Reason for seeking care?
This type of question encourages patients to elaborate.
What are Open-ended questions?
This technique involves careful observation using the senses.
What is Inspection?
These are the two main types of data collected during assessment.
What are Subjective and Objective data?
This type focuses on a specific problem or complaint.
What is a Focused assessment?
This part of the history includes a detailed analysis of symptoms (location, duration, severity).
What is the History of Present Illness (HPI)?
The nurse says, “Tell me more about your pain.” This demonstrates what technique?
What is Facilitation/encouraging elaboration?
This technique uses touch to assess temperature and tenderness.
What is Palpation?
This is considered a legal, permanent record of patient data.
What is Documentation?
This assessment is done every shift to detect changes from baseline.
What is a Shift assessment?
The nurse asks about tobacco, alcohol, and drug use. This is part of which section?
What is Personal and psychosocial history?
The nurse repeats the patient’s words to confirm understanding.
What is Restatement?
This technique evaluates the size and density of organs using tapping.
What is Percussion?
This organization establishes standards of nursing practice, including assessment.
What is the American Nurses Association (ANA)?
This type of assessment is used to detect disease in asymptomatic patients.
What is a Screening assessment?
This component reviews each body system for current and past symptoms.
What is the Review of Systems (ROS)?
Which communication behavior should the nurse avoid because it can seem judgmental?
What is asking “why” questions?
Name two types of palpation.
What are Light palpation and Deep palpation?
Name the four primary components of a health assessment.
What are Health history, Physical exam, Documentation, and Clinical reasoning/judgment?
This assessment follows up on previously identified problems.
What is an Episodic or follow-up assessment?
The nurse traces diseases through three generations. What is being completed?
What is a Family history/genogram?
A patient becomes silent and tearful. What is the BEST nursing response?
What is Allow silence and provide emotional support?
Why must auscultation be performed before palpation when assessing the abdomen?
What is palpation, and how can it alter bowel sounds and lead to inaccurate findings?