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NUR1020 Health Assessment Study Set Exam
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NUR1020 Health Assessment StudySet Exam
List the five nursing purposes for performing a physical assessment. - Answer -gather
baseline data about the patient's health status
-support, confirm, or refute subjective data obtained
-identify and confirm nursing diagnoses
-make clinical decisions about a patient's changing health status and management
-evaluate the outcomes of care
Physical Exam - Answer assessment of the patient through physical touch
Patient Profile - Answer A document listing necessary patient personal and health
information, including age, occupation, education, religion, and marital status
Chief Complaint - Answer the main reason for the patient's visit; "why are you here?"
Past History - Answer ask about the patient's history, if they are there due to something
that happened in the past such as surgery
Family History - Answer ask about family history to help gain knowledge on diagnosis;
can inherit things like diabetes, hypertension, breast cancer, etc
Medication - Answer ask what medications the patient is on along with the dosage,
frequency, and when their last dose was; some medications don't mix well together and
affect body performance
Allergies - Answer always need to know a patient's allergies to prevent a reaction; are
they allergic to any medication, latex, etc
Review of System - Answer ask about circulatory, cardiac, and respiratory health; are
they having trouble breathing, periods of apnea, etc
On an area of the body with hair, a patchy, shiny area may indicate what? - Answer
cardiovascular problems due to a problem with circulation
Pain - Answer ask if they are experiencing any pain; if so, ask where, how severe is it,
what is the duration, and what is the quality
Physical Assessment - Answer a head to toe examination that provides objective type
data and establishes a data base for a care plan
4 Primary Assessment Techniques - Answer -inspection
, -palpation
-percussion
-auscultation
Inspection - Answer general observation performed in a systemic fashion; observations
are made using visual, auditory, and olfactory senses
Palpation - Answer examining by touch; gather information such as texture, shape,
moisture, temperature, and vibration
Percussion - Answer tapping on a surface to determine the difference in the density of
the underlying structure by sound
Auscultation - Answer act of listening for sounds within the body using a stethoscope
Flatness Sound - Answer a soft, short tone produced by tissue over a bone or muscle
Dullness Sound - Answer a thud like sound produced by dense tissue such as the liver,
spleen or heart
Resonance Sound - Answer a hollow, low pitched sound produced by tissue around the
lungs; filled with air rather than dense tissue producing the hollow sound
Hyperresonance Sound - Answer an abnormal drum-like sound over the lungs, indicates
a problem with the lungs (such as air filling the space around the lungs, preventing them
from expanding fully)
Tympany Sound - Answer drum-like, loud, empty quality (with longer duration) sound;
heard over gastric air bubble such as stomach, intestines, pneumothorax
Ecchymosis - Answer collection of blood in subcutaneous tissues that causes a purplish
discoloration (bruise)
Petechiae - Answer small hemorrhagic spots caused by capillary bleeding
Diaphoresis - Answer profuse sweating
Chubbing (Nail) - Answer enlarged and curved nail; often a sign of respiratory problems
and found in patients with COPD
Pluckable Hair - Answer lightly pulling hair during an assessment in which it comes off;
often a sign of malnutrition
Sclera Inspection - Answer examine to ensure it is white; pink = conjunctivitis, yellow =
jaundice, pale = anemia
Strabismus - Answer cross-eyed
Nystagmus - Answer involuntary, jerking movements of the eyes; "dancing eyes"
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