Health Assessment

Question 1

What is the purpose of doing a health assessment?

Answer 1

To establish nurse/pt relationship, gather data about pt general health, identify strengths, identify actual and potential problems, changes in status, and establishing base

Question 2

What are the two components of a health assessment?

Answer 2

health history (subjective), and physical assessment (objective)

Question 3

What factors do you assess during health assessment?

Answer 3

biographical data, reason for seeking health care, history of present illness, past medical history, lifestyle, expectations of hospital stay, elicit patient values and preferences

Question 4

Ophthalmoscope

Answer 4

visualizes the interior structures of the eye

Question 5

Otoscope

Answer 5

examines the external ear canal and tympanic membrane

Question 6

Snellen Chart

Answer 6

screens for distant vision

Question 7

Nasal speculum

Answer 7

visualizes the lower and middle turbinates of the nose

Question 8

Vaginal Speculum

Answer 8

examines the vaginal canal and cervix

Question 9

Tuning fork

Answer 9

tests auditory function and vibratory perception

Question 10

Percussion hammer

Answer 10

tests deep tendon reflexes and determines tissue density

Question 11

Sitting

Answer 11

used to take vitals

Question 12

Supine

Answer 12

allows relaxation of abdominal muscles

Question 13

Dorsal recumbent

Answer 13

used for patients having difficulty maintaining supine position

Question 14

Sims

Answer 14

assessment of rectum or vagina

Question 15

Prone

Answer 15

assessment of hip joint and posterior thorax

Question 16

Lithotomy

Answer 16

assessment of female rectum and vagina; used for brief period only

Question 17

Knee-chest

Answer 17

assessment of rectal area; used for brief period only

Question 18

Standing

Answer 18

assessment of posture, gait, and balance

Question 19

Auscultation

Answer 19

listening for sounds within the body; assess the four characteristics of sound, that is, pitch loudness, quality, and duration

Question 20

Inspection

Answer 20

purposeful and systematic observation; assess size, color, shape, position and symmetry

Question 21

Palpation

Answer 21

method of examining by feeling a part of the body with the fingers or hand; assess temperature, turgor, texture, moisture, tenderness, and shape

Question 22

Percussion

Answer 22

act of striking one object against the other for the purpose of producing sound; assess location, shape, size, and density of tissue

Question 23

What systems are involved with head-toe-assessment?

Answer 23

Neurologic, pulmonary, cardio, genitourinary, gastrointestinal, musculoskeletal, integumentary

Question 24

Neurologic (head to toe assessment)

Answer 24

Sensory/Perceptual

Question 25

Pulmonary (head to toe assessment)

Answer 25

oxygenation

Question 26

Cardiovascular (head to toe assessment)

Answer 26

O2 transport

Question 27

Genitourinary (head to toe assessment)

Answer 27

elimination

Question 28

Gastrointestinal (head to toe assessment)

Answer 28

elimination

Question 29

Musculoskeletal (head to toe assessment)

Answer 29

mobility

Question 30

Integumentary (head to toe assessment)

Answer 30

skin integrity

Question 31

Wheezes

Answer 31

High pitched continuous sounds originating in small air passages that are narrowed by secretions, swelling or tumors; may be inspiratory or expiratory but louder in expiration (sounds like whistle blowing)

Question 32

Pleural Friction Rub

Answer 32

Grating or rubbing sound caused by inflamed pleura rubbing against the chest wall (sound like rubbing)

Question 33

Rhonchi

Answer 33

(Sonorous rales congested) = low pitched continuous rumbling, snoring sound produced by narrowing of the LARGER airways due to thick secretions or muscle spasms. May be heard on inspiration and expiration usually expirations. Often clears or changes with coughing; air passing through or around sections

Question 34

Stridor (crowing)

Answer 34

Harsh, loud, high pitched auscultation on inspiration; narrowing of the upper airways (larynx or trachea); presence of foreign body in airway

Question 35

Entropion

Answer 35

Eyelid rolled inward against eyeball typically caused by muscle spasm

Question 36

Ectropion

Answer 36

Lower lid sags away from eye exposing inner eye surface

Question 37

Convergence test

Answer 37

Ask client to follow finger as she slowly moved it towards client nose

Question 38

Extraocular movement

Answer 38

Following pencil side to side

Question 39

Oh, Oh, Oh, To Touch And Feel Virgin Girls Vaginas, AH

Answer 39

Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Vestibulocochlear, Glossopharyngeal, Vagus, Accessory, Hypoglossal

Question 40

(I) Olfactory

Answer 40

Sensory; sense of smell

Question 41

(II) Optic

Answer 41

Sensory; sense of vision

Question 42

(III) Oculomotor

Answer 42

Motor; pupil constriction, raise eyelids

Question 43

(IV) Trochlear

Answer 43

Motor/proprioceptor; downward, inward eye movement

Question 44

(V) Trigeminal

Answer 44

Motor; jaw movements like chewing and mastication Sensory; sensation of the face and neck

Question 45

(VI) Abducens

Answer 45

Motor; lateral movement of the eyes

Question 46

(VII) Facial

Answer 46

Motor; muscles of the face Sensory; sense of taste on the anterior two thirds of the tongue

Question 47

(VIII) Vestibulocochlear

Answer 47

Sensory; sense of hearing

Question 48

(IX) Glossopharyngeal

Answer 48

Motor; pharyngeal movement and swallowing Sensory; sense of taste on the posterior one third of the tongue

Question 49

(X) Vagus

Answer 49

Motor/sensory; swallowing and speaking

Question 50

(XI) Accesory

Answer 50

Motor/sensory; movement of shoulder muscle

Question 51

(XII) Hypoglossal

Answer 51

Motor; movement of the tongue; strength of tongue

Question 52

Crackles

Answer 52

Bubbling or popping type sounds that are usually heard during inspiration (air moving through fluid in the lungs)

Question 53

Bruit

Answer 53

occur when artsy is partially obstructed or distended, which prevent blood flow from moving straight through the vessel