Exam One

Question 1

What is a Health Assessment?

Answer 1

The collection of data, essential as the first step in the nursing process.

Question 2

What are the types of patient data in a health assessment?

Answer 2

Subjective Data: What the patient tells you (e.g., “I have a headache”).

Objective Data: What you can observe or measure (e.g., heart rate, bleeding).

Question 3

What are the methods for gathering patient data?

Answer 3

Interview (subjective)
Observation
Physical exam
Charts/EHR/old records
Collaboration with other healthcare providers

Question 4

What are the different types of health histories?

Answer 4

Complete health history
Focused/problem-centered
Follow-up
Emergency

Question 5

What are the priority levels in health assessment?

Answer 5

First-level: Emergency (e.g., airway issues)
Second-level: Acute problems (e.g., broken bones)
Third-level: Long-term issues (e.g., physical therapy)

Question 6

What are some patient considerations during a health assessment?

Answer 6

Developmental stage
Cultural needs
Spiritual beliefs
Education level
Language barriers

Question 7

What are the phases of a patient interview?

Answer 7

Pre-interaction
Beginning (introductions)
Working phase (data gathering)
Closing phase (summary & next steps)

Question 8

What is included in a health history sequence?

Answer 8

Demographic data
Past medical & surgical history
Medication reconciliation
Social history
Lifestyle
Family history
Functional assessment/ADLs

Question 9

What are the steps in physical assessment techniques?

Answer 9

Inspection: Observation
Palpation: Sense of touch
Percussion: Tapping to assess underlying structures
Auscultation: Listening with a stethoscope

Question 10

What are some abnormal findings in a mental status assessment?

Answer 10

Changes in LOC (lethargy, stupor, coma)
Mood and affect abnormalities (flat, euphoric, anxious)

Question 11

What is the normal range for oral body temperature?

Answer 11

96.4°F–99.1°F (average ~98.6°F).

Question 12

What are the normal values for pulse and common abnormalities?

Answer 12

Normal pulse: 60–100 BPM
Abnormalities: Bradycardia (<60 BPM), Tachycardia (>100 BPM)

Question 13

What is the normal respiratory rate?

Answer 13

12–20 breaths per minute.

Question 14

What is considered a normal oxygen saturation level (SpO2)?

Answer 14

95%–100%.

Question 15

How do you document blood pressure?

Answer 15

Record systolic/diastolic (e.g., 120/80 mmHg), measurement arm, and position (e.g., lying down).

Question 16

What are the types of pain and how are they assessed?

Answer 16

Acute: Short-term
Chronic: >6 months
Assessment tools: Numeric scale (1–10), Wong-Baker Faces Scale

Question 17

What are the components of a general survey?

Answer 17

Physical appearance
Body structure
Mobility
Behavior

Question 18

Describe the importance of measuring height, weight, and BMI.

Answer 18

Essential for assessing general health, determining medication dosages, and monitoring changes in nutritional status.

Question 19

Explain the significance of vital signs in patient assessment.

Answer 19

Objective measures reflecting basic physiological functions, used to monitor health status and detect abnormalities.

Question 20

What is included in the documentation of vital signs?

Answer 20

Temperature
Pulse
Respirations
Blood pressure
Pain assessment

Question 21

What is the most effective temp route method

Answer 21

oral

Question 22

How do you perform a pain assessment?

Answer 22

Use scales like the Numeric Rating Scale or Wong-Baker Faces Scale to evaluate pain intensity, location, quality, onset, duration, and relief measures.

Question 23

Case Study: Mrs. Smith, 68 years old, presents with shortness of breath and chest pain. What is the priority nursing intervention?

Answer 23

Priority nursing intervention: Assess ABCs (Airway, Breathing, Circulation) and administer oxygen as needed. Consider cardiac monitoring and notify the healthcare provider.

Question 24

Scenario: Mr. Johnson, 55 years old, admitted with abdominal pain and vomiting. His vital signs are: Temperature 100.4°F, Pulse 110 BPM, Respirations 22 breaths/min, Blood Pressure 130/80 mmHg. What is the potential nursing diagnosis?

Answer 24

Potential nursing diagnosis: Acute Pain R/T gastrointestinal disturbance AEB abdominal pain and vomiting.

Question 25

Case Study: Ms. Garcia, 42 years old, complains of headache and dizziness. She has a history of hypertension. What assessment findings are concerning for potential complications?

Answer 25

Concerning assessment findings: Elevated blood pressure (150/95 mmHg), headache, and dizziness. Monitor for signs of hypertensive crisis and neurological changes.

Question 26

Scenario: Baby Smith, 6 months old, brought to the ER with fever (temperature 102°F) and irritability. What nursing interventions are appropriate for managing the fever?

Answer 26

Nursing interventions: Administer antipyretics as ordered, encourage fluid intake, monitor temperature, assess for signs of dehydration, and provide comfort measures.

Question 27

Writing Nursing Interventions: Mr. Johnson, admitted with dehydration. What is a relevant nursing intervention?

Answer 27

Administer IV fluids as ordered to restore fluid balance and monitor intake and output closely.

Question 28

Writing Patient Goals: Ms. Smith, post-operative day 1 after knee replacement surgery. What is a realistic goal for pain management?

Answer 28

Realistic goal: Patient will report pain level ≤ 4 on a scale of 0-10 within 24 hours, using pain management strategies.

Question 29

Nursing Interventions: Mrs. Brown, admitted with pneumonia. What is an appropriate nursing intervention to promote airway clearance?

Answer 29

Appropriate nursing intervention: Encourage deep breathing exercises, provide chest physiotherapy, and suction as needed to clear respiratory secretions.

Question 30

Writing Nursing Interventions: Elderly patient with impaired mobility due to stroke. What is an appropriate nursing intervention to prevent complications?

Answer 30

Appropriate nursing intervention: Implement range of motion exercises, turn and reposition every 2 hours, and use pressure-relieving devices to prevent pressure ulcers.