Health Assessment Final Review

Card Set Information

Health Assessment Final Review
2012-10-25 02:07:11
Health Assessment

Final Exam Review
Show Answers:

  1. What is the next step after data collection during a patient health history interview?
    Summarize highlights of the interview and let the patient add or clarify information.
  2. What sound comes from percussing lungs with emphysema?
  3. What is one risk factor that is likely to contribute to an elevated blood pressure?
    A high pressure job.
  4. What is assessment finding of fluid volume deficit?
    Tenting of the skin.
  5. What is the normal range for capillary refill time?
    1-3 seconds.
  6. How would you test the gag reflex?
    Touch the back of the throat with a cotton-tipped applicator.
  7. Define pulse pressure.
    The diff between systolic and diastolic blood pressure. 
  8. A visual acuity of 20/60 with a Snellen chart and the 60 indicates what?
    This is the distance at which a person with normal vision could read the chart.
  9. What should you do if there is no movement with a patellar reflex test?
    Tap the tendon again while the patient is pulling against interlaced, locked fingers.
  10. Would indications of anxiety or the presence of assistive devices for vision and hearing have a larger impact on a physical assessment?
    The presence of the devices.
  11. What are the characteristics of vesicular lung sounds?
    Soft and low-pitched breezy sounds overmost of the periperal lung fields. 
  12. What is Nystagmus?
    Involuntary rapid eye movement from side to side.
  13. Where would you assess the pedal pulse?
    On the top of the foot.
  14. What are Cheyne-Stokes respirations?
    Irregular patterns of rapid waxing and waning breathing alternating with periods of apnea.
  15. What equipement is needed to assess a patients ears and hearing?
    A tuning fork and na otoscope.
  16. After collecting demographic data during an initial health history interview, what is the next area of assessment?
    The reason the patient was seeking healthcare.
  17. What is a clarity for urine?
    yellow and clear. 
  18. What is the average pulse range for an adult?
    60-100 bpm.
  19. What is the correct procedure for examing a patient's pupil?
    Compare the sizes of both pupilsand check the reaction to light.
  20. What is the best response to a patient's question for the use of an oximetry probe?
    It measure the amount of oxygen circulating in your blood.
  21. Which part of the hand should you use when assessing for tactile fremitus?
    The ulnar and palmar surface of each hand.
  22. Which is the correct area to assess the apical pulse?
    Fifth intercostal space at teh left midclavicular line. 
  23. What should be your first responding action to a patient's complaint of a rash?
    Determine if the patient is taking any new medications.
  24. What position should the patient be in for assessment of the abdomen?
    A supine position with knees flexed.
  25. What is the correct order of techniques for a physical assessment?
    • Inspection
    • Palpation
    • Percussion
    • Auscultation
  26. Comparison/contrast tasks or response to proverb questions are used to assess what client ability?
    Abstract reasoning.
  27. What does an auscultation of a pleural friction rub sound like?
    It is a grating sound or vibration heard during inspiration and expiration.
  28. What is health assessment?
    A systematic method of collecting data related to an individual's health state. 
  29. What are the components of a health assessment?
    • Health history
    • Physical Exam
    • Documentation of data
  30. What are the phases of the nursing process?
    • Assessment
    • Diagnosis
    • Planning
    • Implementation
    • Evaluation
  31. What is involved in the Assessment phase?
    Collecting subjective and objective data and clustering that data.
  32. What is involved in hte Diagnosis phase?
    Analyzing the data to make a professional nursing judgement.
  33. What is involved in the Planning phase?
    Determining outcomes and developing a plan of care.
  34. What is involved in the Implementation phase?
    Carrying out the plan
  35. What is involved in the Evaluation phase?
    Assessing whether outcomes have been met and revising plan of care as necessary.
  36. What is the purpose of Nursing Assessment?
    To collect data.
  37. What are some sources of data?
    • Patient
    • Family and significant others
    • Members of the health care team
    • Medical record
    • Other records and literature
    • Nurse's experience
  38. What are clinical manisfestations?
    The presenting signs and symptoms experienced by the patient.
  39. What is the focus of Nursing Assessment?
    To determine how the patient's health status affects their ability to perform ADLs
  40. What are the types of Nursing Assessment?
    • Comprehensive/Initial
    • Problem-based/Focused
    • Episodic/follow up
    • Emergency
    • Screening
  41. When will a patient have an overnight stay in a hospital?
    When they are admitted to the hospital.
  42. When is a comprehensive assessment done?
    Performed at the onset of care in a primary care facility
  43. When is a problem based assessment done?
    Performed in walk-in clinics or in the emergency department
  44. When is a episodic/follow up assessment done?
    During follow up doctor appointments for specific problems or conditions.
  45. When are emergency assessments done?
    During a patient crisis.
  46. When is a screening assessment done?
    During an examination that will focus on the detection of a disease
  47. What is a shift assessment and when is it performed?
    A focused assessment done every 8 hours, based on patient's condition and treatment response. 
  48. Outcome of Nursing Assessment includes:
    • physical status
    • strengths and weaknesses
    • abilities
    • support system 
    • health beliefs
    • activities to maintain health
  49. What are the 4 phases of a patient interview?
    • Preparation
    • Introduction/orientation
    • Discussion/working
    • Summary/termination
  50. What data will be collected during the interview?
    Complete health history.
  51. What do you need to do to prepare for the interview?
    • Gather all equipment
    • Review known information
    • Prepare the physical environment
  52. What is included in the introduction phase?
    • Introduce yourself to the pt
    • Describe the purpose
    • Describe the process
  53. What is the focus of the discussion phase?
    Client centered and nurse facilitated
  54. The summary phase includes
    • summarization of data
    • clarification of data
    • validation of understanding
  55. What is the method for assessing patient complaints?
    • Charater
    • Observation
    • Location
    • Duration
    • Severity
    • Pattern
    • Associated factors
  56. When does collecting objective data begin?
    The moment you meet the patient and begin a general survey
  57. What are the components of a general survey?
    • Physical appearance
    • Body structure
    • Mobility
    • Behavior
  58. What does supine mean?
    laying face up
  59. What does prone mean?
    laying face down
  60. When does data need to be validated?
    when a discrepency or gap exists between data
  61. What is the normal temperature range?
  62. What is the avg body temp?
  63. What is the difference with rectal and axillary temps?
    • Rectal temps are 1 degree higher= -1
    • Axillary temps are 1 degree lower= +1
  64. What are the assessment sites for temp?
    • mouth
    • axilla
    • ear
    • rectal
    • forhead
  65. How long should you wait to take a temp after smoking or eating?
    15 min
  66. Who are rectal temps recommended for?
    infants and young children, but not newborns
  67. what is the sims position?
    pt laying on left side, left leg straight, right knee bent
  68. the tympanic membrane temp is easiest to meaure in whom?
    children under 6
  69. in electronic thermometers which probe is used for what?
    • blue for oral and axilla
    • red for rectal
  70. What type of pulse feels weak?
    A thready pulse, 1+ or less
  71. Which pulse feels strong?
    A bounding pulse, 3+
  72. What is the indication of a normal pulse?
  73. What is the normal range of respirations in an adult?
  74. What is the normal range for pulse oximetry?
    above 92%
  75. What O2 saturation indicates respiratory failure and tissue damage?
  76. What percentage of O2 sat. is normal for COPD patients?
  77. At what O2 sat. level will cyanosis appear?
  78. What is considered a life-threatening O2 sat?
    below 70%
  79. What is a normal pulse pressure range?
    btwn 30-40 mmHg
  80. What are the false readings for wrong cuff sizes?
    • too small: false high
    • too big: false low
  81. When should you not take a BP in an arm?
    If that arm has a fistula or it is on the same side as a mastectomy
  82. How many lbs are in 1 kg
  83. What is the purpose of documentation?
    communication between members of the health care team
  84. Closed questions ask for what?
    specific information
  85. What are the different types of pain?
    • acute
    • chronic
    • deep somatic
    • cutaneous
    • visceral
    • referred
  86. What are the 7 dimensions of pain?
    • physical
    • sensory
    • behavioral
    • cognitive
    • spiritual
    • affective
    • sociocultural
  87. What is pain threshold?
    the point at which a stimulus is perceived as pain
  88. What should you use to assess pain?
  89. What are the different pain assessment tools?
    • visual analog scale
    • numeric rating scale
    • wong-baker FACES pain rating scale
    • FLACC pediatric pain assessment
    • PAINAD dementia pain assessment
  90. What are the components of a mental status exam?
    • appearance
    • behavior 
    • cognitive function
    • thought processes and perceptions
    • orientation 
    • level of consciousness
  91. what are the levels of consciousness
    • alert
    • lethargic
    • obtunded
    • stupor
    • coma