TEST BANK HEALTH ASSESSMENT IN
NURSING (7TH) BY JANET R WEBER &
JANE H KELLEY CHAPTERS 1-34
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, Chapter 01: Introduction to Health Assessment
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Standing Position Position used to examine male genitalia and to assess gait, posture, and
balance
Prone Position Client lies on abdomen with head turned to the side; may be used to assess
back and mobility of hip joint
Lithotomy Position Back-lying position with hips at edge of examining table and feet supported
in stirrups; used for examination of female genitalia, reproductive tract, and rectum
What part of the examiner's hand is used to feel for fine discriminations: pulses, texture, size,
consistency, shape, and crepitus Fingerpads
Part of the examiner's hand used to feel for vibration, thrills, or fremitus Ulnar surface or
palm of hand
Part of the examiner's hand used to feel for temperature Dorsal surface of hand
Smaller end of stethoscope used to detect low-pitched sounds (abnormal heart sounds and
bruits) Bell of stethoscope
Larger end of stethoscope used to detect breath sounds, normal heart sounds, and bowel
sounds Diaphragm of stethoscope
Name the four basic techniques used for physical assessment Inspection, palpation,
percussion, auscultation
Name the five steps of the nursing process Assessment, diagnosis, planning,
implementation and evaluation
What are the four sections of the nursing assessment framework? History of present health
concern, past health history, family history and lifestyle and health practices
What are the four basic types of assessments? Initial comprehensive assessment, ongoing or
partial assessment, focused or problem oriented assessment and emergency assessment
Name the four major steps of the assessment phase Collection of subjective data, collection
of objective data, validation of data and documentation data
Explain the importance of a contextual approach to nursing health assessment The
client's culture, family, community and spirituality all affect their overall health
What is the purpose of conducting a health history interview? Establishing rapport and a
trusting relationship with the client to elicit accurate and meaningful information and to gather
information on the client's developmental, psychological, physiologic, sociocultural and spiritual
statuses
What are the steps or phases of the health history interview? Introductory phase, working
phase, summary and closing phase
What are the three variations in communication that must be considered as you interview
clients? Gerontologic, cultural and emotional
, AssessmentCollection of subjective and objective data
Diagnoses Analysis of subjective and objective data to make a professional nursing judgement
Planning Developing a plan of nursing care and outcome criteria
Implementation Carrying out the plan of care
Evaluation Assessing whether outcome criteria have been met and revising the plan of care if
necessary
Nursing Diagnosis Clinical judgement about individual, family or community responses to
actual or potential health problems and life processes
Subjective Data Sensations or symptoms that can be verified only by the client (ex. pain)
Objective Data Findings directly observed or indirectly observed through measurements (ex.
body temperature)
Collaborative Problem Physiologic complications that nurses monitor to detect their onset
or changes in status
Referral Problem Problem that requires the attention or assistance of other health care
professionals
A medical examination differs from a comprehensive nursing examination in that the medical
examination focuses primarily on the client's Physiologic status
The result of a nursing assessment is the Formulation of nursing diagnoses
Although the assessment phase of the nursing process precedes the other phases, the
assessment phase is Continuous
When a client first enters the hospital for an elective surgical procedure, the nurse should
perform an assessment termed Comprehensive
An ongoing or partial assessment of a client Includes a brief reassessment of the client's
normal body system
The purpose of the comprehensive health assessment is to Arrive at conclusions about the
client's health
The use of this type of question can keep a client interview from going off track Closed-
ended
A nurse can clarify a client's statements by Rephrasing the client's statements
During what phase of the interview between a nurse and client do you collaborate to identify
problems and goals Working phase
When dealing with a manipulative client it is important for the nurse to Provide structure
and set limits
The primary purpose of the health history is to Identify risk factors to the client and his or her
significant others
Define the "COLDSPAA" accronym Character, Onset, Location, Duration, Severity,
Pattern, Associated factors, how it Affects the client
Sim's position Side-lying position used during the rectal examination
Sitting Position Position used during much of the physical examination including
examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper
extremities
Supine Position Back-lying position used for examination of the abdomen (with one small
pillow under the head and another under the knees); this position also allows easy access for
palpation of peripheral pulses
