NUR 211 - Health Assess - Ch 1-4 & 7
Review Questions and Correct Answers
Assessment is a "doing" process. The four techniques of physical assessment are: ✅1.
Inspection, looking
2. Percussion, tapping different areas of the body to assess underlying structures.
3. Palpation, using your hands to feel surface characteristics
4. Auscultation, listening for sounds
Critical Thinking ✅Essential during the assessment process.
Performing an assessment requires the nurse to be able to think, recall knowledge, and
recognize the difference or deviations between normal and abnormal assessment
findings.
Critical thinking is an active, purposeful, and organized cognitive process involving
creativity, reflection, problem-solving, both rational and intuitive judgment, an attitude of
inquiry, and a philosophical orientation toward thinking about how a nurse thinks
Critical thinking is a unique problem-solving, reflective process that uses:
■ a combination of reasoned thinking, openness to alternatives, an ability to reflect, and
a desire to seek truth
■ a process of purposeful and creative thinking about resolving problems
■ a multidimensional thinking process
■ reflective thinking
■ thinking "outside of the box"
■ questioning, interpreting information, and analyzing the situation and then
synthesizing the information
■ development of alternative solutions to a problem.
Clinical Reasoning ✅uses an individual's history, physical signs, symptoms, laboratory
data, and diagnostic imaging to arrive at a diagnosis and assess and formulate a
treatment plan. Nurses collect these data to identify normal and abnormal findings, risk
factors, health promotion, and prevention behaviors. Physical assessment findings are
used to problem solve and develop the appropriate plan of care.
Clinical Judgment ✅is defined as "an interpretation or conclusion about a patient's
needs, concerns, or health problems and/or the decision to take action (or not), use or
modify standard approaches, or improvise new ones as deemed appropriate by the
patient's response"
,Nursing Process ✅1. Assessment is the first, essential step requiring the nurse to
collect and analyze information about the whole individual. This information includes
physiological, psychological, psychosocial, spiritual, and cultural practices and beliefs.
2. Diagnosis involves analyzing a potential or actual health problem with a patient.
Nursing diagnosis reflects the individual's actual or potential health risks or problems;
the nurse uses clinical judgement and critical thinking to analyze all the information
about the individual, synthesize and cluster the information, and hypothesize about the
individual's health status (Wilkinson et al., 2015).
3. Planning/Outcomes involves working with the individual as a copartner in care to
meet the needs or short- and long-term goals of the individual. The goals must be
measurable and achievable.
4. Implementation of interventions includes the nursing and individual actions and plan
of care to meet the individual's goals.
5. Evaluation is the ongoing process that assesses whether the short- and long-term
goals have been met; this phase of the nursing process involves clinical judgment about
whether the goals have been met or are unmet.
Significance of Evidence-Based Practice ✅It has international importance.
There are large, regional variations in use of evidence-based practices.
There is rapid development of research but slow adoption of evidence-based practices.
Only about half of all patients in the United States receive recommended care.
There is a 28 percent improvement rate in patient outcomes when nurses use
intervention based on research versus standard care.
"Pay-for-performance" requires that evidence-based practices are used.
"Know-do gap" keeps patients from receiving the best care.
Levels of Prevention: Primary ✅is the prevention of disease and disability and focuses
on improving an individual's overall health and well-being (e.g., immunizations and
health education).
Levels of Prevention: Secondary ✅encompasses early screenings and detection of
disease and treatment of diseases (e.g., colonoscopy to screen for colon cancer and
medications to treat a curable illness).
Levels of Prevention: Tertiary ✅encompasses the restoration of health after illness or
disease has occurred (e.g., rehabilitation program for stroke patients).
Therapeutic communication encompasses the following dimensions for a patient-
centered assessment: ✅■ Empathy and compassion are a deep awareness of and
insight into the feelings, emotions, and behavior of another person and their meaning
and significance, and identifies a patient's feelings and concerns.
, ■ Unconditional regard means respecting and accepting a patient as a unique
individual.
■ Genuineness is being honest with the patient. A nurse needs to be truthful and
understanding with every patient encounter. Listen to the patient with an open heart and
compassion.
■ Respect is a moral value. It demonstrates that you have a positive feeling for every
patient and accept each patient as a person who has unique qualities. As a nurse, you
acknowledge that each patient is important and of value.
■ Caring is the essence of nursing and connotes responsiveness between the nurse
and the patient.
Holistic Communication: Be CLEAR ✅Center yourself
• Pause for a moment.
• Breathe deeply.
• Connect with a feeling of love and compassion.
• Create a silent intention that thoughts, words, and actions will be for the greater good.
Listen wholeheartedly
• Set aside your own thoughts, emotions, and feelings.
• Focus on the person's agenda.
• Do not judge or analyze.
• Open your heart to what is being communicated.
Empathize
• Come from a place of genuine concern.
• Have the ability to feel with a person, not be sorry for them.
• Empathy involves an understanding that comes from sensing into the being of another.
Attention: be fully present
• Be aware of what you are feeling and sensing. Stay present with yourself.
• Be the fullness of yourself to every moment—emotionally, mentally, physically, and
spiritually.
Respect
• Respect all that is.
• Respect yourself and set boundaries, if needed.
• Respect the patient—ho
Preparation ✅■ Reading the patient's record before seeing the patient will help you to
prepare.
■ The patient should stay dressed until you are ready to perform the actual physical
assessment.
■ Arrange for the interview to take place in a private environment that is free from
distractions and noise, has good lighting, and has a comfortable temperature.
■ Allow sufficient time to complete the interview and health history. Have a clock
available to keep track of time but only glance occasionally at the clock.
