ANS: D
Nội dung chính
- Which type of question is used when starting the assessment of a patient?
- What are the 4 general components of a nursing assessment?
- What is the preparatory phase of the nursing interview?
- What should a clinical interview ideally focus on?
Components of a nursing health history include physical examination findings, patient expectations, environmental history, and diagnostic data. Current treatment orders are located under the Orders section in the patients chart and are not a part of the nursing health history. Patient concerns, not nurses concerns, are included in the database. Goals that are mutually established, not nurses goals, are part of the nursing care plan.
PQRST
p- provokes: What causes symptom? What makes it better or worse? Are there activities (e.g., exercise) that affect it?
q- quality: What does the symptom feel like? If patient cannot describe, offer probes such as "Is it sharp? Dull? Burning?"
R—Radiate: Where is the symptom located? Is it in one place? Does it go anywhere else? Have patient be as precise as possible.
S—Severity: Ask a patient to rate the severity of a symptom on a scale of 0 to 10. This gives you a baseline with which to
compare in follow-up assessments.
T—Time: Assesses onset and duration of symptom. When did
it start? Does it come and go? If so, how often and for how long?
What time of day or day of the week?
B. Dependence-independence pattern
The nurse can use two approaches for comprehensive assessment. They include using a structured database format and a problem-oriented approach. Gordon's model is an example of a structured database format. It has 11 functional health patterns that are assessed: the health perception-health management pattern, nutritional-metabolic pattern, elimination pattern, activity-exercise pattern, sleep-rest pattern, cognitive-perceptual pattern, self-perception-self-concept pattern, role-relationship pattern, sexuality-reproductive pattern, coping-stress tolerance pattern, and the value-belief pattern.
A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the last month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. Thank you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?"
A. 4, 2, 1, 3, 5
B. 2, 4, 3, 1, 5
C. 4, 2, 5, 1, 3
D. 2, 4, 1, 5, 3
a nurse is conducting a patient centered interview. place the statements from the interview in the correct order, beginning with the first statement a nurse would ask
1. "you say you've lost weight. tell me how much weight you've lost in the last month"
2. "my name is Todd, i'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history"
3. "i have no further questions. thank you for your patience"
4. "tell me what brought you to the hospital"
5. "so, to summarize, you've lost about 6 lbs in the
last month, and your appetite has been poor, correct?"
A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask.
1. "You say you've lost weight. Tell me how much weight you've lost in the last month."
2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history."
3. "I have no further
questions. Thank you for your patience."
4. "Tell me what brought you to the hospital."
5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?"
4, 2, 1, 3, 5
2, 4, 3, 1, 5
4, 2, 5, 1, 3
2, 4, 1, 5, 3
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Terms in this set (15)
A nurse assess a patient who comes to the pulmonary clinic. I see that it's been over 6 months since you've been here but your appointment was for every 2 months. Tell me about that. Also i see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan? the nurse's assessment covers which of Gordon's functional health patterns?
Health perception - health managment pattern
The nurse's assessment covers the health perception--health management pattern which is a patient's self report of how they manage their health and their knowledge of preventive health practices.
The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the info gained to suspect that the patient has a mobility problem. This conclusions is an example of:
Clinical inference
An inference is your judgment or interpretation of cues such as the shuffling gait and reduced leg strength. Any info gathered through your senses is a cue.
A 72 year old male patient comes to the health clinic for an annual follow up. The nurse enters the patient's room and notices him to be diaphoretic holing his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, " tell me where your pain is." Which of the following assessment approaches does this scenario describe?
Problem oriented approach
The nurse focuses on assessing 1 body system to determine the nature of the patient's pain and other presenting symptoms
The nurse asks a patient, "describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep?" This series of questions would likely occur during which phase of a patient centered interview?
Working phase
The gathering of info
A nurse is assigned to a 42 year old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems?
You have 4 children, do you have any concerns about going home and caring for them?
This is the only assessment approach that is not biased or does not show judgement about the patient's weight or occupational status.
Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care?
Open ended
The best interview question for initially determining why a patient is seeking health care is by asking an open ended question that allows the patient to tell their story.
A nurse is checking a patient's iv line and while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing:
Patient's level of function
Observing a patient perform activities physical, socially, psychologically, and developmentally assess their level of function. In the case of this question the nurse assesses physical functional level.
A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tell the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, how do you see yourself now? On the basis of Gordon's functional health patterns, which pattern does the nurse assess?
Self perception--self concept pattern
Assessment of patient's feelings about his worth and body image
A nurse is conducting a patient centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask:
My name is Jess, I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history.
Tell me what brought you to the hospital
You say you've lost weight. Tell me how much weight you've lost in the last month
So to summarize you've lost about 6 lbs in the last month, and your
appetite has been poor -- correct?
I have no further question. Thank you for your patience
During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing?
Tell me what makes your headaches begin
An open ended question that probes such as tells me what makes your headaches begin encourages a fuller description of situation.
Which of the following examples are steps of nursing assessment?
Collection of info about patient's family members
Recognition that further observations are needed to clarify info
Comparison of data with another source to determine data accuracy
When a nurse conducts an assessment data about the patient often comes from which of the following sources?
An observation of
how a patient turns and moves in bed
The care recommendations of PT
The results of diagnostic x-ray film
A nurse gathers the following assessment data. Which of the following cues together forms a pattern suggesting a problem?
The skin around the wound is tender to touch
Patient has drainage from surgical wound
Body temp is 38.3 C (101 F)
A nurse makes the following statements during a change of shift report to another nurse, "i assessed Mr. Diaz, my 61 year old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment finding s when she rounds on the patient?
The nurse asks the patient to rate their pain on scale of 0 to 10
The
nurse asses the patient's lower limb strength
The nurse compares data reported by the previous nurse with data collected directly with the patient, including assessing pain on the rating scale and assessing the patient's lower limb strength.
Asking the patient what caused the fall and about past back pain and experience with pain mess would offer the nurse new info about the patient
The nurse enters the room of a 82 year old patient for whom she has not cared previously. The nurse notices the the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult?
Listen attentively to the patient's story
Use gestures that reinforce your questions or comments
Maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue.
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Which type of question is used when starting the assessment of a patient?
Which type of question is used when starting the assessment of a patient? The nurse uses open-ended questions when beginning the assessment of a patient. This allows patients to talk about their concerns and problems in detail.
What are the 4 general components of a nursing assessment?
4 types of nursing assessments:.
Initial assessment. Also called a triage, the initial assessment's purpose is to determine the origin and nature of the problem and to use that information to prepare for the next assessment stages. ... .
Focused assessment. ... .
Time-lapsed assessment. ... .
Emergency assessment..
What is the preparatory phase of the nursing interview?
Preparatory Phase: During the Preparatory Phase the nurse reviews all data and does not let his/her own prejudices and stereotypes affect the nurse-patient relationship. During this phase the nurse should assure that the environment is private and relaxed.
What should a clinical interview ideally focus on?
The best clinical interview focuses on the patient. It helps to get a detailed history of the patient's problem and provide care accordingly. Focusing on the nurse's agenda or hospital policy may distract the nurse's efforts from the patient.