Nursing Assessment

Question 1

the nursing assessment includes information gathered from 2 sources

Answer 1

historical (interview) and Physical examination

Question 2

assessments are prioritized based on

Answer 2

presenting signs and symptoms

Question 3

8 components of complete health assessment

Answer 3

chief complaint, Hx of illness, past medical Hx, family Hx, personal/social Hx, allergies, body system review, and phys exam

Question 4

data that comes from the pt through interview, observation, physical exam

Answer 4

primary data

Question 5

data gathered about pt from other sources. i.e. family/sig other, health care team, med records, scientific lit, nurse’s experience

Answer 5

secondary data

Question 6

general survey (physical examination) begins when?

Answer 6

the time of the first contact with client

Question 7

6 areas of physical examination (general survey)

Answer 7

appearance/behavior, body type/ Posture, dress/hygiene, mental state, vitals, ht/wt/BMI

Question 8

4 types of examination

Answer 8

inspection, palpitation, percussion, auscultation

Question 9

exam using the process of observation

Answer 9

inspection

Question 10

type of exam technique that occurs on the first contact with the client and every encounter afterward

Answer 10

inspection

Question 11

auscultation technique used with stethoscope

Answer 11

indirect

Question 12

auscultation technique used withOUT stethoscope

Answer 12

direct

Question 13

order of assessment for all areas (except abdomen)

Answer 13

1. inspection 2. palatation 3. percussion 4. auscultation

Question 14

order of abdominal assessment

Answer 14

1. inspection 2. auscultation 3. percussion 4. palpatation

Question 15

the last component of a complete assessment

Answer 15

YOUR DOCUMENTATION

Question 16

examination findings are documented in ____ order

Answer 16

logical

Question 17

the physical examination coincides with the nursing history how

Answer 17

by supplementing, confirming, or refuting subjective (not gathered from pt) data

Question 18

physical examination coincides with which what components of the nursing process

Answer 18

assessment, diagnosis, planning and evaluation

Question 19

how physical examination is involved in Planning during the nursing process

Answer 19

required in decisions about a pt’s changing health status and management

Question 20

inspection involves use of what senses for detection

Answer 20

sight, sound, smell

Question 21

occurs when interacting with a pt, watching for nonverbal expressions of emotional and mental status

Answer 21

inspection

Question 22

type of examination which gathers data of size, shape, color, symmetry, position, and abnormality

Answer 22

inspection

Question 23

body tempurature is assessed using which exam teqnique

Answer 23

palpatation

Question 24

areas examined using palpatation

Answer 24

skin, organs, glands, blood vessells, thorax

Question 25

gender/race, age, signs of distress, body type, posture, gait, body movements, hygiene and grooming, dress, body odor, affect and mood, speech, and signs of patient abuse are all components of

Answer 25

a general survey of appearance and behavior

Question 26

____ _____ findings reflect a pt’s functional abilities and serve as the basis for comparison with subsequent assessment findings

Answer 26

baseline assessment

Question 27

a pt must be prepared prior to physical examination

Answer 27

physcaly and psychologically