216 Final Exam Review Guide Module 1- Introduction to Health Assessment
7 views 0 purchase
Course
216 Health Assessment
Institution
216 Health Assessment
216 Final Exam Review Guide
Module 1- Introduction to Health Assessment
1. What are the steps in the nursing process? Be able to identify examples of each step. Assessment: Obtaining subjective and objective data
Diagnosis: Nursing diagnosis analyzes the data collected, identifying act...
Module 1- Introduction to Health Assessment
1. What are the steps in the nursing process? Be able to identify examples of each step.
Assessment: Obtaining subjective and objective data
Diagnosis: Nursing diagnosis analyzes the data collected, identifying actual and
potential problems.
Planning: Using SMART to create a plan based off data and diagnosis
Implementation: Use skills to implement appropriate therapeutic interventions.
Evaluation: Monitor the effectiveness and achievability of goals and the need for
intervention or adjustment
2. What are the components of the general survey?
Physical Appearance
Body structure
Mobility/Gait
Behavior
Speech
Dress, hygiene, grooming, and odors (body, breath)
Vital signs with asking about Pain
3. What types of questions may be asked in the review of systems?
Start with the head all the way down to toes and ask relevant questions that are
age-appropriate for each system
o Integumentary
o Head, neck, cognitive
o Eyes, ears, nose, mouth
o Respiratory
o Cardiovascular
o GI
o GU
o MSK
o Neuro
o Endocrine
o Mental
4. What are the four techniques used in physical assessment?
Inspection
Palpation
Auscultation
Percussion
5. What are the techniques used when assessing the abdomen?
Inspection
Auscultation
Palpation
6. How do you properly palpate for temperature?
With the dorsal side of the hand
7. What is each side of the stethoscope called and used for?
Diaphragm: used for high pitched
Bell: Low pitched (heart murmur)
Module 2- General Survey
1. What are the vital signs you typically need to collect from every patient?
Temperature 96.8-100.4F
Pulse 60-100 bpm
Respiration rate 12-20 bpm
Pulse Ox 95 100%
, Diaphragm: used for high pitched
Bell: Low pitched (heart murmur)
Module 2- General Survey
1. What are the vital signs you typically need to collect from every patient?
Temperature 96.8-100.4F
Pulse 60-100 bpm
Respiration rate 12-20 bpm
Pulse Ox 95-100%
Blood pressure <120 / <80
o Hypotension <90 / <60
o Hypertension >130--90
2. Be able to identify the most common pulse points.
Radial (or thumb side of the wrist)
3. What are the different ways to take a temperature? What is the technique for each one?
Oral
Rectal -- sims position with upper leg flexed. 2.5-3.5 cm (1-1.5 inches) for adult.
Axillary
Tympanic -- Pull the ear up and back (for adults) or down and back (for a child)
Temporal
4. Which sources are considered core and surface temperatures?
CORE = Oral and Rectal
SURFACE = Axillary, Tympanic, and Temporal
5. What are some causes of out-of-range vital signs?
Exercise, Medication, smoking, lifestyle habits, drinking a cold drink, food,
diseases, conditions, hormonal changes, stress, ect.
6. How do you perform a two-step blood pressure?
Palpate brachial pulse, wait 30 secs, place diaphragm and up 20 above, let out
pressure
7. What are the stages of hypertension?
Hypotension: <90 systolic, <60 diastolic
HTN 1: 130 - 139 sys, 80-90 diastolic
HTN 2: >140 sys, > 90 diastolic
8. How do you describe the behavior and effect of a patient?
AOX4
Questions you ask --> Name, DOB, Location, Situation
o Orientation needs to know where they are, who they are and time
9. Be able to differentiate between mobility, posture and body structure.
Mobility: ability to move
Posture: the position in which someone holds their body when they are sitting or
standing
Body structure: a particular complex anatomical part of a living thing
10. What does each BMI range represent?
Less than 18.5 is underweight
18.5-24.9 Normal BMI
25-29.9 overweight
Obese 30 or greater
, Mobility: ability to move
Posture: the position in which someone holds their body when they are sitting or
standing
Body structure: a particular complex anatomical part of a living thing
10. What does each BMI range represent?
Less than 18.5 is underweight
18.5-24.9 Normal BMI
25-29.9 overweight
Obese 30 or greater
11. When is a focused assessment appropriate? A full physical examination?
Focused assessment: focuses on a particular topic, body part, or functional ability
rather than an overall health status
Physical exam: uses techniques of inspection, palpation, percussion, auscultation
(head to toe assessment)
Module 3- Health History
1. What questions would you ask to obtain a complete health history from a patient?
Childhood illnesses, chronic illness, hospitalizations, surgeries, immunizations,
examinations, screenings, allergies
2. What is the difference between subjective and objective data? How do you collect each?
Subjective = symptoms (only what the pt an tell you how they feel)
o Pain scale, Feelings, Symptoms
Objective = what you can see (5 senses) and observe
o Vital signs, Bruises/cuts, Assessment
3. What is an open-ended question? When is it most appropriate to use them?
Open-ended questions are not yes or no questions
o Tell me more about...
Useful when you need to probe but respectfully for more information
4. What question types would you want to avoid?
Close ended questions/Yes or no
5. What is a functional assessment?
Determines the pt’s ability to care for themselves
o Are they able to do things for themselves (physically, mentally)
o ADL’s
6. How does culture influence a patient’s health?
FICA
o F = Faith
o I = Influence
o C = Community
o A = Address preferences
7. What is the history of present illness (HPI) assessment?
Description of the development of the pt’s present illness --> S/S
o OLD CART
O = Onset
L = Location
D = Duration
C = Characteristics
A = Aggravating and Alleviating Factors
R = Related symptoms
T = Treatment
S = Severity
Health Assessment Modules 4-5 Review
1. What findings would lead a nurse to suspect abuse?
Examine all body surfaces for signs of physical abuse
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller ScoreSmart. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $10.29. You're not tied to anything after your purchase.
