Weber Chapter 1 - Nursing Assessment: Key Steps, Data Types, and Analysis in Client Care

What is the first step of the nursing process?

Assessment, which is critical for all subsequent steps.

Why is ongoing assessment important in nursing?

It ensures that data is accurate and continuously updated throughout care.

What does nursing health assessment aim to collect?

Holistic data, including subjective and objective information.

What is the primary focus of a nursing health assessment?

The client's overall functioning in various health domains.

What is the goal of assessing how health affects ADLs?

To understand how daily activities impact health and vice versa.

How do nurses differ from physicians in their health assessments?

Nurses take a holistic view, while physicians focus mainly on physiological status.

What are the four types of nursing health assessments?

Initial Comprehensive, Ongoing/Partial, Focused/Problem-Oriented, Emergency.

What is involved in the initial comprehensive assessment?

A complete history and physical exam to establish baseline data.

What are the four steps of assessment in nursing?

Collect subjective data, collect objective data, validate data, document data.

What constitutes subjective data in nursing assessments?

Client-reported symptoms, feelings, beliefs, and health history.

What does objective data include?

Observable and measurable information such as vitals and lab results.

What should a nurse do to prepare for an assessment?

Review the client's record, avoid assumptions, and gather necessary tools.

What is the purpose of health promotion and disease prevention in nursing?

To understand risk factors and client behavior using evidence-based resources.

What are the phases of the nursing process?

Assessment, Diagnosis, Planning, Implementation, Evaluation.

What is the purpose of clinical judgment in nursing?

To interpret data from assessments and determine client concerns.

What is the process of data analysis in nursing assessments?

Identify cues, cluster them, prioritize concerns, propose problems, and document conclusions.

Give an example of a nursing problem.

Impaired mobility or ineffective coping.

What is a collaborative problem in nursing?

A potential or actual complication that requires monitoring by both nurse and provider.

When should a nurse refer a client to another professional?

For problems outside the nursing scope, such as medical or psychological issues.

What is the significance of accurate documentation in nursing?

It serves as the foundation for the rest of the nursing process.

How does the nursing process emphasize a holistic approach?

By considering the client as a whole person within their cultural and community context.