HA 3

Question 1

→ usually requires a complete health history

Answer 1

COLLECTING SUBJECTIVE DATA

Question 2

is an excellent way to begin assessment
because: it provides
 foundation for identifying nursing problems
 provides focus for the physical examination – identify
areas for intense examination

Answer 2

HEALTH HISTORY
→ The health history

Question 3

(maybe deleted to protect client’s
privacy)
in Biographical data

Answer 3

Address and Phone

Question 4

B. REASONS FOR SEEKING HEALTHCARE

Answer 4

MAJOR HEALTH PROBLEM OR CONCERN

2. FEARS AND PAST EXPERIENCES

Question 5

C. HISTORY OF PRESENT HELATH CONCERN

Answer 5

1. COLDSPAR
2. PQRST

Question 6

→ include information about the client that the nurse directly
observes during interaction with the client and information
elicited through physical assessment (examination) techniques.

Answer 6

OBJECTIVE DATA

Question 7

USE: HEAD, NECK, LUNGS, CHEST, BACK,
BREASTS, AXILLAE, HEART, VITAL SIGNS,AND
UPPER EXTREMITIES.
 It is useful because it permits:
A. FULL EXPANSION OF THE LUNGS
B. Allows ASSESSMENT OF SYMMETRY OF UPPER
BODY PARTS
 If the client is not able to tolerate this position –
alternative position is letthe client lie down with the head
of the bed elevated.

Answer 7

1. SITTING POSITION

Question 8

 Lie down with the legs together on the examining table or
bed
 Place small pillow under the head to promote comfort
 If with DOB – elevate head of the bed
 this position allows the abdomen to relax and provides
easy access toperipheral pulses sites.
USE: HEAD, NECK, CHEST, BREASTS, AXILLAE,
ABDOMEN, HEART, LUNGS, AND ALL
EXTREMITIES ASSESSMENT

Answer 8

2. SUPINE POSITION

Question 9

 Client lies down with the knees bent, legs separated and
feet flat on the table or the bed. – more comfortable
for client than supine for clientswith pain in the back
of abdomen.
USE: HEAD, NECK, CHEST, AXILLA, LUNGS,
HEART, EXTREMITIES, BREASTS
AND PERIPHERAL PULSES
NOT USED : for assessment of the abdomen because
the abdominal musclesare contracted in this
position

Answer 9

3. DORSAL RECUMBENT POSITION

Question 10

 Client lies in either right or left side with the lower arm
placed behind thebody and the upper arm flexed at the
shoulder and the elbow.
 The lower leg is slightly flexed at the knee while the
lower leg is flexed ata sharoper angle and pulled
forward.
 Elderly and those with joint problems may have
difficulty In assuming andmaintaining this position.
 Assist the client to assume this position
USE: RECTAL AND VAGINAL ASSESSMENT

Answer 10

4. SIM’S POSITION

Question 11

 The client stand still in normal, comfortable, resting
position
USE: POSTURE, BALANCE, AND GAIT
USE: MALE GENITALIA ASSESSMENT

Answer 11

5. STANDING POSITION

Question 12

 The client lies down on the abdomen with the head to the
side
USE: primarily for assessment of hip joint or back
CAUTION: patients with cardiac and respiratory
problems – cannot toleratethis position

Answer 12

6. PRONE POSITION

Question 13

 The client kneels on the examination table with
weight of the bodysupported by the chest and knees
 A 90-degree angle should exist between the body and the
hips
 The arms are placed above the head with the head turned
to one side
 A small pillow maybe used to provide comfort
 Place client in limited time as much as possible
because this position isembarrassing and
uncomfortable for the client.
USE: RECTAL EXAMINATION
CAUTION: elderly clients and those with cardiac
or respiratory problems may be unable to tolerate
this position

Answer 13

7. KNEE-CHEST POSITION

Question 14

 Place client on back with the hips at the edge of the
examining table andfeet supported by stirrups
USE: FEMALE GENITALIA EXAMINATION,
REPRODUCTIVE TRACTS, RECTUM
CAUTION: can’t be assumed for long by the elderly
client
 Drape patient – because it is embarrassing for the client
 Be quick

Answer 14

8. LITHOTOMY