NR 302 Exam 1

Name

Chamberlain University

NR-302: Health Assessment I

Prof. Name

Date

Concept Review

1. Understanding Physical vs. Emotional Responses

Nursing questions can be objective, requiring simple, direct answers, or they may be more communication-focused, needing interpretative responses. Objective responses are typically prompted by questions such as “How do you?” or “What type of data?” and may specify physical aspects. Communication-focused questions often ask, “What factors?” or “How can improvement be achieved?” indicating an emotional or subjective response is required.

2. Communication Techniques in Nursing

Nurses need to choose between open-ended and closed-ended questions based on the context. Open-ended questions, such as, “Can you describe how you’re feeling today?” allow patients to share in-depth responses, especially helpful when gathering narrative information. Conversely, closed-ended questions like, “Did you take your medication today?” are useful for obtaining specific details or guiding conversations effectively. Cultural awareness also plays a crucial role; respecting and integrating patients’ cultural beliefs into care plans enhances rapport and supports holistic care.

3. Assessing Databases and Using SBAR

Different databases suit various scenarios: a complete database is appropriate for new patients, while a focused database may address a single, acute issue in returning patients. Emergency databases provide critical, immediate data, and follow-up databases focus on longer-term care. The SBAR (Situation, Background, Assessment, Recommendation) model assists in structured communication, summarizing patient situations, background, current assessments, and care recommendations effectively.

Topic	Details	Examples
Question Types	Objective questions require direct answers, while communication questions involve interpretation.	“How do you?” (objective), “What factors?” (communication)
Question Usage	Open-ended questions are used for elaborate responses, closed questions for specific information.	“Can you explain what happened?” (open-ended), “Did you take your medicine?” (closed-ended)
Cultural Considerations	Respecting patient beliefs is critical in nursing. Building culturally appropriate care plans is essential.	Integrate cultural beliefs into care plans, respect patient values.
Communication Tools	Nurses can use techniques like confrontation, interpretation, and summary to enhance understanding.	Confrontation: “Do you smoke?” (with evidence of cigarettes), Summary: “So, you’re experiencing symptoms like…”
Interview Techniques	Successful interviews depend on respecting privacy, body language, empathy, and avoiding common pitfalls like talking too much.	Avoiding jargon, showing empathy, maintaining eye contact
Certified Interpretation	Only trained staff members can act as interpreters in hospital settings, ensuring clarity and minimizing misunderstandings.	Trained interpreters ensure accurate communication, essential in care.

Nursing Assessment & Basics

1. Types of Databases and Their Applications

Different databases are utilized based on patient needs. A complete database captures a new patient’s full health history, while a focused database addresses specific concerns. For emergency cases, immediate critical information is gathered quickly, and follow-up databases support ongoing care. Recording patient histories accurately, including family medical histories using tools like genograms, provides a comprehensive overview of potential health influences.

2. Understanding Subjective vs. Objective Data

Subjective data reflects what the patient expresses (e.g., “I feel dizzy”), while objective data includes observed signs (e.g., an unsteady gait). Differentiating between these types allows for a well-rounded assessment, capturing both patient reports and measurable observations, such as elevated white blood cell counts for infection or visible signs like vomiting.

3. Pain and Priority Assessments

Pain is assessed based on the patient’s self-reported experience, making them the most reliable source for evaluating pain levels. Before administering pain medication, vital signs are reviewed to determine appropriate treatment. Priority assessments are divided into three levels: first-level (life-threatening, such as airway issues), second-level (urgent, non-life-threatening), and third-level (non-urgent needs like patient education).

Assessment Category	Type	Examples
Database Types	Complete, Focused, Emergency, Follow-up	Initial checkup (Complete), sinus issues (Focused), life-saving (Emergency)
Data Collection	Subjective (patient reports) vs. Objective (observed)	“I feel dizzy” (subjective), unsteady gait (objective)
Pain Assessment	Acute vs. Chronic	Assess patient history, vital signs, type (nociceptive for short-term, neuropathic for chronic)
Priority Assessment	First-level, Second-level, Third-level	First: Airway issues, Second: Acute pain, Third: Education

Nursing Process and Developmental Care

1. The Nursing Process (ADOPIE)

The nursing process encompasses six essential steps: Assessment, Diagnosis, Outcome identification, Planning, Implementation, and Evaluation. This approach ensures a structured method to gather, interpret, and act upon patient information effectively. For example, in planning, a patient with a knee injury might have an end goal of ambulation, with physical therapy implemented as part of the care.

2. Developmental Considerations Across Ages

Patient comfort varies with age, from infants who benefit from calm voices to adolescents who require trust and confidentiality to discuss concerns openly. Aging patients may need slower assessment processes but should not be assumed to have cognitive impairments solely due to age.

3. Consciousness and Mental Status Assessment

Mental status assessment evaluates orientation (person, place, time, and situation) and consciousness levels, ranging from alertness to comatose states. The mini-mental exam is a quick tool for cognitive assessment. It is essential to keep safety protocols in mind, especially with patients showing signs of aggression.

NR 302 Exam 1

Process Steps	Developmental Considerations	Mental Status and Safety
ADOPIE: Assessment, Diagnosis, Outcome, Planning, Implementation, Evaluation	Trust and confidentiality with adolescents, calm approaches with infants.	Assessing orientation, mini-mental exams for cognitive function
Planning Example	Patient goals based on diagnosis	Safe handling techniques for aggressive patients
Nursing Techniques	Implementing physical therapy, evaluating success	Conducting assessments with respect to patient comfort

References

American Psychological Association. (2020). Publication Manual of the American Psychological Association (7th ed.). Washington, DC: American Psychological Association.