Assessment
What is the primary purpose of assessment (data collection) in nursing?
To gather information about the patient’s health status to plan and deliver appropriate care.
👉 What are the two main modes of communication used by nurses?
📝 Verbal and nonverbal communication.
👉 Why is accurate documentation important in nursing?
📝 It serves as a legal record, supports continuity of care, and ensures patient safety.
👉 What is the goal of therapeutic communication?
📝 To promote understanding, build trust, and help patients express their feelings.
👉 Which step of the nursing process involves data collection?
📝 The Assessment step.
👉 Name the three basic methods used to gather a patient database.
📝 Interview, physical examination, and review of diagnostic/laboratory data
👉 List two examples of verbal communication in nursing practice.
📝 Examples: Patient interviews, providing education, explaining procedures, charting.
👉 Name twn.o types of health records used in documentation.
📝 Examples: Electronic Health Record (EHR), paper charts, flow sheets, narrative notes.
👉 Name one therapeutic communication technique.
📝 Examples: Active listening, open-ended questions, reflecting, clarifying, summarizing.
👉 Why is active listening important in both assessment and communication?
Answer:
📝 It helps gather accurate information, builds trust, and improves patient outcomes.
👉 Differentiate between subjective and objective data
📝 Subjective data = patient’s reported symptoms (e.g., “I feel dizzy”).
Objective data = measurable/observable signs (e.g., BP, HR, rash).
👉 List two factors that can influence communication between the nurse and patient.
📝 Culture, language, emotions, environment, pain, developmental level
👉 What is one legal guideline nurses must follow when documenting care?
📝 Documentation must be accurate, timely, objective, and signed by the nurse.
👉 Name one nontherapeutic communication technique that should be avoided.
📝 Examples: Giving false reassurance, interrupting, judging, and minimizing patient concerns.
👉 Which type of data would the nurse collect during a physical examination?
📝 Objective data
👉 What type of assessment is performed shortly after the patient arrives to establish a baseline for future comparisons?
📝 Initial (admission) assessment.
Explain the difference between therapeutic and nontherapeutic communication techniques
📝 Therapeutic techniques build trust, encourage expression, and promote understanding.
Nontherapeutic techniques block communication or shut down the conversation.
👉 What should you do if you make an error in documentation?
📝 Draw a single line through the error, write “error,” initial, date, and correct it—never erase or use white-out
👉 A patient says, “I’m scared about my surgery tomorrow.” What is the best therapeutic response?
📝 “Tell me more about what scares you” (using reflection and open-ended questioning).
👉 A nurse observes a patient avoiding eye contact and responding briefly. Which communication influencer might be at play?
📝 Cultural or emotional factors affecting communication.
👉 Describe at least two techniques used during a physical examination.
📝 Examples: Inspection, palpation, percussion, auscultation (any two accepted).
👉 A patient becomes defensive when you ask about their medication use. What communication technique could help de-escalate this situation
📝 Using active listening, empathy, and open-ended questions to reduce defensiveness and build trust.
👉 Why is the phrase “If it wasn’t documented, it wasn’t done” important in nursing practice?
📝 Because undocumented care cannot be legally or professionally verified and may be considered not provided.
👉 List three principles of therapeutic communication.
📝 Acceptance, empathy, active listening, respect, genuineness, and clear boundaries (any three accepted).
👉 Explain how accurate documentation supports both communication and patient safety.
📝 It ensures continuity of care, provides legal protection, and allows the healthcare team to make informed decisions.