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Client Assement

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Term
Definition
Active Listening   participation in a conversation with a client in which the nurse attend to what the client says and has a part in helping the client clarify, elaborate, and give additional pertinent information  
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Active Processing   a systematic series of mental actions to analyze and interpret information about a client  
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Assessment   the process of gathering data about a client's health status to identify the concerns and needs health status to identify the concerns and needs that can be treated or manages by nursing care  
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Biographical data   information that identifies and describes a client, such as name, address, age, gender, religious affiliation, race, or population  
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Cardinal signs & symptoms   the data of greatest significance in diagnosing a particular illness, disease, or health problem  
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chief complaint   the problem that causes a client to seek health services, call the doctor, or request a visit from a nurse; a description of what a client thinks is the problem  
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closed question   a question that calls for a specific short response from a client  
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cue   an indicator of the presence of existence of a problem or condition that represents a client's underlying health status  
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data   pieces of subjective or objective information about a client or the signs and symptoms of disease  
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database   all of the information that has been collected about a client and recorded in the health record as a baseline for the initial place of care  
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demographic data   factual information that can be aggregated to describe populations of clients  
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functional health patterns   the positive and negative behavior a person uses to interact with the environment and maintain health  
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inference   the process of attaching meaning to data or reaching a conclusion about data; bases on a premise or proposition that supports or helps support a conclusion  
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interview   a planned series of questions designed to elicit information for a particular purpose  
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intuition   a process of reasoning from understanding the whole without having systematically examined the parts  
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leading question   a question that suggests a possible appropriate response from a client  
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minimum data set   the least information allowable to be collected on every client entering an institution or being admitted to a particular service within the institution  
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nursing history   a narrative of a client's past health and health practices that focuses on information needed to plan nursing care  
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objective data   any directly observable information about a client  
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open-ended question   a question designed to allow a client freedom in the manner of response  
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orientation phase   a brief exchange to establish the purpose, procedure, and nurses role in the interview process  
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signs   objective data that are evidence of disease or dysfunction  
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subjective data   information that is provided by a client and cannot be directly observed  
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symptoms   subjective information supplied by the client that describes characteristics of disease or dysfunction  
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termination   skillfully ending an interview so that the nurse and client feel satisfied that the purpose has been accomplished  
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validation   substantiating or confirming the accuracy of the information against another source or by another method  
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working phase   a phase of the interview process during which a client and nurse work together to review the client's health history and establish potential and actual problems that will be addressed as part of the care plan  
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Created by: dortega52
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