NUR 310 Health Assessment Exam 1 Information, Health
Assessment Test 1
What are the different parts of The Nursing Process? ✅Assessment, Diagnosis/Analysis, Planning,
Implementation, and Evaluation
What happens in the "Assessment" portion of The Nursing Process? (This is the first step) ✅Nurse
collects data, and health assessment data is characterized as either subjective or objective
What is subjective data? ✅Data that includes interpretations and information provided by an individual
about himself or herself
- typically gathered from health history; pt. presents this information to you (ex: "I feel nauseous")
What is objective data? ✅Data that is measurable and observable
- typically obtained through physical examination or lab/diagnostic tests
- can be observed by someone else
**ALWAYS verify information from the patient!!
What is a health database? ✅The patient's laboratory and diagnostic studies, and objective and
subjective data collected by the nurse
What happens during the "Diagnosis/Analysis" portion of The Nursing Process? (this is the second step)
✅the nurse analyzes the data collected during the assessment using clinical judgement; nursing
diagnosis is formed here; nurse collaborates with patient to develop the plan of care and will identify
both actual and potential problems
What happens during the "Planning" step of The Nursing Process? (third step) ✅The nurse establishes
priorities based on the patient outcomes and starts to identify interventions that will allow those
outcomes to be met within a timeframe
- identifies priorities: 1st, 2nd, 3rd level
,First level priority problems ✅emergent, life-threatening, and immediate, such as establishing an airway
or supporting breathing
Second-level priority problems ✅those that are next in urgency requiring your prompt intervention to
prevent further deterioration. (mental status change, acute pain, acute urinary elimination problem,
untreated medical problems, abnormal lab test results
Third-level priority problems ✅those that are important to the patient's health but can be addressed
after more urgent health problems are addressed. (Knowledge deficit, altered family processes, and low
self esteem)
What happens during the "Implementation" stage of The Nursing Process? (fourth step) ✅the nurse will
DO something
- implement evidence-based interventions in a safe and timely manner using collaboration and
delegation
What happens during the "Evaluation" stage of The Nursing Process? (fourth and final step) ✅The nurse
will refer to established outcomes to:
1) evaluation individual's condition and progress toward outcomes
2) identify reasons for failure to achieve expected outcomes
3) take corrective action to modify plan of care
4) Document evaluation in plan of care
medical diagnosis ✅has an actual pathophysiology; (ex: broken arm, depression); the basis on which a
nursing diagnosis can be made
nursing diagnosis ✅NOT medical; decisions nurses make in response to a medical diagnosis
Nonmaleficence ✅Duty to do no harm
Beneficence ✅The "doing of good" ; return to health is the goal for the patient!
,Autonomy ✅Individuals have the right to determine their own actions and freedom to make their own
decisions
Justice ✅treat everyone fairly, regardless of their ability to pay for treatment, social status, etc
Confidentiality ✅respecting the rights of the pt. to maintain privacy
What are the ethical principles of nursing care? ✅Nonmaleficence, Beneficence, Autonomy, Justice,
Confidentiality
What does the CDC recommend as the first line of defense to decrease nosocomial infections and
prevent transmission of microorganisms? ✅hand washing
Alcohol based hand rub ✅kill more organisms more quickly, less damaging to skin
- use mechanical soap-and-water washing when hands are visibly soiled
Standard precautions ✅consider all waste and contact as potentially infectious; they also ensure that all
health care providers treat all patients equally
What is the intent of standard precautions? ✅prevent disease transmission during contact with non-
intact skin, mucous membranes, body substances, and blood-borne contacts
What can a latex allergy result from? ✅repeated exposure to proteins found in natural rubber latex
through skin contact or inhalation
- reaction can occur within minutes or hours
Why should gloves be worn, according to the CDC? ✅1) to reduce the risk of acquiring infections from
patients
2) to prevent the transmission of flora from health care workers to patients
, 3) to reduce transient contamination of the hands of personnel by flora that can be transmitted from
one patient to another
**Gloves should NOT be worn from room out into the hallway
What are the different aspects of The Process of Communication? ✅Sending (nurse conscious of
messages sent), Receiving (receiver uses his or her own interpretations to process sent messages),
Internal Factors (nurse maintains respect, empathy, listening factors, self-awareness), External factors
(nurse should make sure the physical setting is comfortable)
What should be done to prepare for the physical assessment? ✅1) organize the examination
2) prepare the environment
3) prepare the patient
What are the four assessment techniques in order? ✅Inspection, Palpation, Percussion, Auscultation
What is the assessment order for the abdomen? ✅Inspection, Auscultation, Percussion, Palpation
What should be done during the "inspection" portion of the physical assessment? ✅look carefully and
thoroughly at the patient; this offers an overall impression of the patient and severity of the situation
- most revealing and provides a LOT of info
- note symmetry b/w right and left side, skin characteristics, shape of chest, facial features, patient
mood
what should be done during the "Palpation" portion of the physical assessment? ✅touch to assess for
findings such as texture, temperature, moisture, tenderness, and edema
what are the finger pads used to palpate for? ✅- pulses, lymph nodes, small lumps, skin texture, edema
what are the palmar surfaces of the fingers and finger joints used to palpate for? ✅firmness, contour,
position size, paint and tenderness
