NUR 2180 Physical Assessment Exam 1
What is the difference in subjective and objective data? - ANSWER subjective- what the person says about herself or himself during history taking
Objective- what you as the health professional observe during the examination
What is Diagnostic reasoning? - ANSWER The process of analyzing health data and drawing conclusions to identify
diagnosis
What are the four major components of deductive reasoning? - ANSWER 1) attending to initially available cues 2) formulating diagnostic hypothesis 3) gathering data relative to the tentative hypothesis 4) evaluating each hypothesis with the new data collected, thus arriving at a final diagnosis
What are the six phases in nursing process? - ANSWER assessment, diagnosis, outcome identification, planning, implementation, evaluation What are the main objectives in "assessment"? - ANSWER Collect data (health history), use evidence-based assessment techniques, and document relevant data
What are the main objectives in "diagnosis"? - ANSWER Compare clinical findings with normal and abnormal variation and developmental events, Interpret data (make and test hypothesis), validate
diagnosis, document diagnosis
What are the main objectives in "outcome identification"? - ANSWER Individualize to the person, culturally appropriate, realistic and measurable, and include a timeline
What are the main objectives in "planning"? - ANSWER Establish priorities, develop and set timeline for outcomes, identify interventions, Integrate evidence-based trends and research, and document plan of care
What are the main objectives in "implementation"? - ANSWER Implement in a safe and timely manner, use evidence- based interventions, collaborate with colleagues, coordinate care delivery, provide health teaching and promotion, and document implementation and any modification What are the main objectives in "evaluation"? - ANSWER Progress towards outcomes, conduct systematic, ongoing criterion-based
evaluation, include patient and significant others, use ongoing assessment to revise diagnosis, outcomes, plan, and disseminate results to patient and family
What are examples of first-level priority problems? - ANSWER life-threatening, emergent, and immediate. Example: establishing an airway or supporting breathing. "ABC plus V" A-airway, B-breathing problems, C-cardiac/ circulation problems, V- vital sign concerns
What are examples of second- level priority problems? - ANSWER Next in urgency. Example: risks of infection, get blood drawn for labs, in case there is another problem to address, mental status change
What are examples of third-level priority problems? - ANSWER Important to the patient's health but can be addressed after more urgent health problems are addressed. Example: changing bed sheets that are somewhat dirty
What are examples of collaborative problems? - ANSWER The approach to treatment involves multiple disciplines. Example: Patient with alcohol-use disorder presents to the hospital for unrelated surgery and experiences sudden alcohol withdrawal symptoms What are the two steps for identifying immediate priorities? - ANSWER 1) make a complete list of current medications, medical problems, allergies, and reason for seeking care 2) Determine the relationships among the problems
What is evidence-based practice? (EBP) - ANSWER Systematic approach to practice that emphasizes the use of best evidence
in combination with the clinician's experience, as well as the patient's preferences and values, to make decisions about care and treatment
What are the four types of data to collect? - ANSWER Complete (total health) database- complete health history and a full physical examination, Focused or problem-centered database- for short term problem and is more focused than the complete database, Follow-
up database- evaluate any identified problem, Emergency database- urgent, rapid collection of crucial information
What is holistic health? - ANSWER Consideration of the whole person. Views the mind, body, and spirit as independent and functioning as a whole within the environment
What are the principles of critical thinking? - ANSWER Proceed though sequential steps from novice to expert- incorporation of experience provides foundation for development of clinical practice, Utilize a multidimensional thinking approach to interpret data- use an organized, systematic assessment format, Validate and confirm findings
