Health Assessment Exam 1 Review

Question 1

What are the Steps in the Nursing Process?

Answer 1

Assessment

Analyze (diagnose)

Planning

Implementation

Evaluation

Question 2

What finding may indicate infection?

Answer 2

Elevated WBC count

Wound is warm, swollen, drainage is present

Elevated vitals

Infection is common after surgery or IVs

Question 3

PN scope of practice

Answer 3

PNs can assist a nurse with every step of the nursing process except analysis (diagnosis)

Question 4

Define HIPPA

Answer 4

Health Insurance Portability & Accountability Act

Question 5

What is ISBAAR

Answer 5

A tool for clear effective communication between staff for client care

Identify
Situation
Background
Assessment
Recommendations
Read back order

Question 6

What does Therapeutic Communication involve?

Answer 6

Touch

Open-ended questions

Calm, relaxed posture, nodding

Actively listening, expressing empathy, being respectful & accepting

Question 7

Infection control measures

Answer 7

Hand hygiene (washing & hand rub)

Clean contaminated equipment & surfaces

Sharps safety

Cough & sneeze etiquette

PPE

Standard & transmission based precautions

Question 8

What is included in a behavioral assessment?

Answer 8

Client speech
Client clothing
Client affect

Question 9

Visceral Pain

Answer 9

Pain related to large internal organs (stomach, lungs, heart)

Question 10

Somatic pain

Answer 10

Pain related to bones, tendons, ligaments, & muscles

Question 11

Neuropathic pain

Answer 11

Nerve pain characterized as sharp or burning

Question 12

Referred pain

Answer 12

Pain in one area that originates from another

Question 13

FICA

Answer 13

Used to assess a client’s spirituality

Faith
Influence
Community
Address

Question 14

Purpose for health history

Answer 14

To establish a baseline of client’s health status

Question 15

Language barriers

Answer 15

Use a professional interpreter, never a family member

Helps increase the accuracy of communication

Question 16

Family History

Answer 16

Collected for 3 generations (grandparents, parents, siblings)

Diseases are passed down not infections

Question 17

Open ended questions

Answer 17

Questions that a client can elaborate on an answer giving detailed information

Question 18

Close ended questions

Answer 18

Questions that a client can respond with simple yes or no answers, short & to the point. Who, what, when, or where.

Question 19

Underweight BMI

Answer 19

less than 18.5

Question 20

Normal BMI

Answer 20

18.5-24.9

Question 21

Overweight BMI

Answer 21

25.9 to 29.9

Question 22

Obese BMI

Answer 22

30 or above

Question 23

What route is used to collect the most accurate core body temp

Answer 23

Rectal route

Question 24

Tools required for inspection

Answer 24

Penlight, tape measure, pulse ox, stadiometer

Question 25

Tools required for auscultation

Answer 25

stethoscope & doppler

Question 26

What is percussion

Answer 26

Advanced nursing technique with swift tapping used to assess the size, consistency, & presence/absence of fluid in organs & body areas

Question 27

Palpate procedure

Answer 27

Use the palmar side of the hands & pads of the finger Palpate with gloves Assess for variation in temperature, moisture, texture, elevation, & pain

Question 28

Areas that are palpated

Answer 28

Sinus cavities – sinus cavities are palpated to rule out sinus infections Abdomen, head, neck, other areas depending on assessment type Only after inspection

Question 29

ABCDE

Answer 29

Acronym used to assess moles for malignancies Asymmetry Border - irregular Color - multiple colors Diameter - larger than 6mm (pencil eraser) Evolving - constantly changing Mole may also be itchy, draining, or elevated

Question 30

Unexpected skin findings

Answer 30

Smooth velvety skin Diaphoresis Cyanosis Erythema Pallor Ecchymosis Petechia Hyperthermia Hypothermia Tinting, pitting edema Roughness/dryness/flakiness

Question 31

Define Vessicle

Answer 31

Primary lesion Small, fluid filled blister Varicella

Question 32

Erosion

Answer 32

Secondary lesion Shallow loss of epithelium Cold sore

Question 33

Fissure

Answer 33

Secondary lesion Linear cracks in skin Eczema, psoriasis

Question 34

Wheal

Answer 34

Primary lesion Allergic reaction Hives

Question 35

Stage 1 pressure injuries

Answer 35

red, non-blanchable over a bony prominence with intact skin

Question 36

Stage 2 pressure injuries

Answer 36

partial dermis loss, shallow ulcer with a dry/shiny pink wound area (blister)

Question 37

Stage 3 pressure injuries

Answer 37

Extends from past the epidermis to the subcutaneous tissue, fat may be visible; necrosis

Question 38

Stage 4 pressure injuries

Answer 38

Extends through all layers of skin, exposes muscle, bones, or tendons; necrosis

Question 39

Unexpected nail findings

Answer 39

Brown nail with linear streaks - melanoma Bluish tinge Whitish nails Clubbed nails Jagged/rigid/brittle nails Pits/transverse grooves

Question 40

Health promotion: Skin protection

Answer 40

Bathe frequently Know skin products, discard products after 4 months Dry skin - bathe less frequently, alcohol free lotion, hydrate, mild soap UV tanning can cause cancer Wear sun protection, avoid midday sun

Question 41

Risk Factors for Skin Cancer

Answer 41

Significant UV exposure (includes childhood) Family or past history Red/light hair, eyes, or skin More than 50 moles, large moles, freckles Immunosupression

Question 42

Unexpected head/scalp findings

Answer 42

Asymetrical/drooping Protrusion/lumps/ecchymosis Lesions/redness Hair loss Edema Hirsutism Lice Tense

Question 43

Unexpected Eye Findings

Answer 43

Green/yellow sclera Unequal pupils Pupils greater than 7 mm or less than 3mm Cloudy pupils Conjunctivitis Subconjunctival hemorrhage Ptosis – drooping of eyelid Entropion – eyelids roll inward Sudden onset of vision problems may be a medical emergency

Question 44

Unexpected ear findings

Answer 44

Clear or bloody drainage – skull fracture; medical emergency! Hearing deficits Crusts/scaling Redness