RASMUSSEN, HEALTH ASSESSMENT,
FINAL EXAM QUESTIONS AND
ANSWERS
Levels of Prevention - Answer-Primary-Preventing the onset of disease. Example-
Immunization
Secondary- Aims to reduce the impact disease or injury that has already occurred.
Example- Colonoscopy or mammogram
Tertiary-Aims to soften the impact of an ongoing illness or injury. Example- Cancer
support group or Diabetic support group.
Steps of Nursing Process - Answer-A= Assessment- Collecting Data
D= Diagnosis- Formulation as to what is wrong
O= Outcome- expected outcome
P= Planning- What you are going to do.
I= Implementation- Intervention
E= Evaluation- where it helped or not
Communication Barriers - Answer-False Assurance- Telling them it will be ok.
Giving unwanted advice- It's what they want to do, not the nurses.
Using authority- Saying your doctor says you need to do this.
Using avoidance- Saying a person has passed on instead of saying they died.
Distancing- Saying the patients left breast instead of your left breast.
Professional Jargon- using terms that they client does not understand.
Leading or bias questions- You don't smoke, do you?
Talking too much- Not letting the client say what they need to say.
Interrupting- Interrupting when the client is talking
Assisting the Narrative - Answer-Confrontation- Bring attention to behavior. Clarifying
inconsistent information.
Summarizing- End of appointment, plan of action.
Facilitation- encouraging them to keep speaking, to go on. Shes person you are
interested.
Clarification- used to clarify something you do not understand.
Reflection- Repeat back what you have heard.
Empathy- Putting yourself in someone elses shoes.
Silence-Communicates that client has time to think. Provides time to observe client and
note nonverbal cues.
The Complete Health History - Answer-Subjective vs objective data, open ended and
closed ended questions, biographic data, reason for seeking care, present health or
history of present illness, past history, medication reconciliation, family history, review of
systems- subjective, functional assessment and ADL's - subjective
, Subjective Data - Answer-What the subject tells you
Objective Data - Answer-What you can see, feel, measure
Open ended questions - Answer-Gives more information, allows patient to explain more
details.
Closed ended questions - Answer-One or two word answers like yes or no. Used in
critical situations.
General survey - Answer-Not touching the patient, Just observing.
Physical appearance, body structure, mobility, and behavior. Also can include posture,
appropriate hygiene and dressed appropriate for weather.
Radial Pulse and How to chart - Answer-Rate, Rhythm, and force. Example- 60, regular,
2+
What to do if pulse is irregular - Answer-Count for a full minute, starting with zero.
Pain Assessment - Answer-PQRST Scale
P=Provocative/palliative- what makes it worse/better.
Q= quality/quantity- how does it look/feel/sound, how intense is it.
R- radiation/region- where is it? does it radiate?
S= severity- what is it rated on scale of 1-10?
T= timing- when did it start, how long does it last?
U= understand perception, what does the patient think it means/is?
Changes in vital signs w/ pain - Answer-Cardiac:
Tachycardia, Increased BP, Increased Myocardial O2 demand, Increased Cardiac
output.
Pulmonary:
Hypoventilation, Hypoxia, Decreased Cough, Atelectasis ( partial/complete collapse of
lung)
Gastrointestinal:
Nausea, vomiting
Renal:
Oliguria, Urinary retention
Musculoskeletal:
Spasm, joint pain
Endocrine:
Increased adrenergic activity
CNS:
Fear, anxiety
Immune:
Impaired cellular immunity, impaired wound healing