Holistic Assessment: The Nurse's Role in Health Assessment,
The Nursing Process, Collecting Subjective and Objective
Data
Apnea
Bradypnea
Tachypnea
Eupnea
Dyspnea Correct Answer - absence of breath
- slower respirations
- faster respirations
- state of stable normal breathing
- difficulty breathing
Assessment is _____ and ______ throughout all phases of the
nursing process Correct Answer ongoing and continous
Before measuring the blood pressure, what behavioral and
environmental conditions can affect a reading Correct Answer
1. room temperature- too hold/cold
2. recent exercise
3. alcohol intake
4. nicotine use
5. muscle tension
6. bladder distension
7. background noise
8. talking (either client or nurse)
9. arm position
bell and diaphragm of stethoscope Correct Answer Bell: low
pitched sounds (vascular or murmur)
,Diaphragm: high pitched sounds
(breath sounds, bowel sounds)
blunt percussion Correct Answer used to detect tenderness over
organs by placing one hand flat on the body surface and using
the fist of the other hand to strike the back of the hand flat on the
body surface
Collecting Data: Subjective v. Objective Correct Answer
Objective
Overt
Measurable
Something you can see and measure, its objective
Subjective
Covert
Not measurable
Pt. will tell you, its subjective
Define health assessment Correct Answer Analyzing data and
make judgements and plan of care and see how those
interventions helped
direct percussion Correct Answer involves striking a finger or
hand directly against the patient's body
Examples of a secondary preventative care Correct Answer -
Early detection, prompt intervention and health maintenance for
those with health problems
-Pre-diabetic checked through blood test (hemoglobin A1C
checks avg. blood sugar over the last 90 days)
-Pap Smear, cancer screenings
, Examples of a tertiary preventative care Correct Answer
Rehabilitative or extended care
Chronic illness and monitoring them long term
((CHF (fluid overload) low salt and water diet and weighing
themselves frequently))
Examples of primary preventative care Correct Answer Health
promotion and prevention
Immunizations, health fairs, nutrition, physical activity, access
to safe sex
Give examples of collective data Correct Answer physical
characteristics, body functions, appearance, behavior,
measurements, results of lab tests, medical records
Give examples of subjective data Correct Answer family
history, health history, lifestyle practices, review of systems,
history of present health concerns, biographical information**
on notes**
sensations and symptoms
feelings
perceptions
desires
preferences
beliefs
ideas
values
personal info
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