Week 2 Health Assessment
A young Hispanic mother comes to the local clinic to be tested for COVID. She speaks only Spanish and the nurse speaks only English. The nurse should ask ______________for help.
an interpreter
When measuring a patient's height, the examiner is aware of which guideline? Use only a wall-mounted device Instruct patient to put chin to chest The patient should not be wearing shoes Have the patient lay on a platform scale
the patient should not be wearing shoes
The examiner is entering the room to assess a newly admitted patient. Which of the following best describes the purpose for a general survey? To provide information to guide the physical assessment To collect the information necessary for diagnostic testing To give an opportunity for the patient to voice complaints To measure vital signs
to provide information to guide the physical assessment
A _________ is a(n) ___________ abnormal assessment finding detected on physical examination or through diagnostic testing. A s___________ is a(n) __________ feeling a patient has that is associated with a disorder.
sign objective symptom subjective
The examiner is observing physical appearance which includes ________________________________. (select all that apply.) dress skin color level of consciousness sexual development facial features age personal hygiene
skin color level of consciousness sexual development facial features age
While handing back the complete form, Mr. Chaudhury asked why the same questions are asked every year. What is the best response by the nurse? "It is for insurance purposes." "So long as you give answers, I am not sure it matters." "It provides information on your current state of health." "Your answers help determine if it is safe for you to receive the vaccine today."
"Your answers help determine if it is safe for you to receive the vaccine today."
The newborns head measures approximately _________ cm and is about 2 cm larger than the chest circumference. Between _______months and 2 years, head and chest measurements are approximately the same. After age 2 years, the chest circumference will be __________ the head circumference.
32-38 6 greater than
Indicate which aspects of the complete health assessment can be delegated by the nurse to an unlicensed assistive person to complete by placing a checkmark in the appropriate column: Can be Delegated or Cannot be Delegated 1. Vital signs 2. Physical assessment of lungs 3. Known allergies 4. Current medications 5. Height and weight 6. Family history
1. can be delegated 2. can't be delegated 3. can't be delegated 4. can't be delegated 5. can be delegated 6. can't be delegated
Health Assessment Components: Complete, Focused, Follow-up, Emergency, 1. Current state of health= 2. Perception of health= 3. Health maintenance behaviors= 4. Coping patterns= 5. Risk factors= 6. Detailed health history= 7. Full physical assessment= 8. Targeted physical assessment=
1. complete, follow-up 2. complete, follow-up 3. complete, follow-up 4. complete, follow-up 5. complete, follow-up 6. complete 7. complete 8. Complete, focused, follow-up, emergency
Indicate which type of assessment is required for each patient situation provided below. 1. Hospitalized patient experiencing an allergic reaction to a new medication. ______________ 2. Adult with asthma that is stable. _____________ 3. Expectant woman at home with severe morning sickness.____________ 4. Young adult who walks into the emergency department saying they cut their hand on a broken glass. ______________
1. focused 2. follow-up 3. follow-up 4. focused
A nurse has completed a general survey on four patients. Which of the patients should the nurse ask the primary care provider to see first? A 42-year-old with even skin tone A 22-year-old who appears in distress A 49-year-old who appears anxious A 72-year-old whose clothes are disheveled
A 22-year-old who appears in distress
A nurse has four patients who have just had a health history done. Which of the patients should the nurse request the provider see first? An 82-year-old with a family history of breast cancer A 30-year-old who complains of shortness of breath and has a history of asthma A 42-year-old who complains of fever and takes acetaminophen for it An 89-year-old with a walker and reports difficulty ambulating
A 30-year old who complains of shortness of breath and has a history of asthma
What assessment finding associated with undernutrition is found in the following picture? Neuropathy Atrophy Dystrophy Scurvy
Atrophy
Put the following aspects of the general survey in the correct order: When you touch the patient, is the patient's skin dry or moist? Ask the patient to state name. Does the patient respond immediately and accurately? Note your first impression. Are there any outstanding features? As the patient is describing reason for visit, observe the patient's conversation with you. Can he or she participate in conversation?
Note your first impression. Are there any outstanding features? Ask the patient to state name. Does the patient respond immediately and accurately? As the patient is describing reason for visit, observe the patient's conversation with you. Can he or she participate in conversation? When you touch the patient, is the patient's skin dry or moist?
Which of the following best describes the purpose for a general survey? To collect information about chronic conditions To provide vital signs To determine the focus and depth of the physical assessment To collect subjective information
To determine the focus and depth of the physical assessment
Which statements about holistic health are correct? (Select all that apply.) Societal influences, including family, have little influence on individual health practices. Views the mind, body, and spirit as vital to overall wellness. Lifestyle choices have no impact on overall health. Each person is an active part of their own health and wellness. Disease results from factors within and outside of the body.
Views the mind, body, and spirit as vital to overall wellness. Each person is an active part of their own health and wellness. Disease results from factors within and outside of the body.
The examiner would like to assess the quality of the patient's pain. Which of the following questions should the examiner ask? "What does the pain feel like?" "What makes the pain better?' "On a scale of 0-10, how would you rate your pain?" "How is the pain impacting your life?"
what does the pain feel like
Which of the following questions would be asked as part of a developmental assessment? When was your child born? Does your child have a cough? When did your child get his first tooth? Are the child's grandparent's still living?
when did you child get his first tooth
An examiner is performing a health history on a patient who is being admitted to the hospital. Which of the following questions should be used to gather subjective data? Select all that apply. "Do you have a history of heart disease?" "You don't miss doses of your medication, do you?" "Where are you working right now?" "Can I listen to your lungs?" "How does the shortness of breath impact your life?"
"Do you have a history of heart disease?" "Where are you working right now?" "How does the shortness of breath impact your life?"
During a clinic appointment, the examiner notes a patient with cancer looks fatigued and is wearing dirty clothes. The patient has lost 20 pounds since the last visit. Which of the following statements by the examiner therapeutically assesses the patient's functional ability? (Select all that apply.) "How is your lack of energy impacting what you want to do?" "Can you tell me how you are doing at home managing your daily activities?" "Tell me more about your support system." "I am going to contact the social worker since it seems you need assistance at home." "I think you need a home care nurse to come in at least once a week."
"How is your lack of energy impacting what you want to do?" "Can you tell me how you are doing at home managing your daily activities?" "Tell me more about your support system."
The examiner is assisting a school-aged gymnast who fell from a balance beam during practice. The gymnast is crying and holding their malformed lower leg. _______________________________ is the proper sequence in which the initial assessment of the lower extremities should be performed.
inspection, light palpitation
Which conditions contribute to undernutrition? Constipation and Appendicitis Bronchitis and Emphysema Anorexia and Cancer Pneumonia and Asthma
Anorexia and Cancer
Having misplaced their stethoscope, a health examiner borrows one from a colleague. After entering the patient's room, washing their hands, making introductions, and stating the purpose of the assessment, the examiner performs proper identification of the patient before correctly auscultating the lungs. Which critical health assessment steps were omitted? Select all that apply. Running warm water over stethoscope for patient comfort. Assuring privacy and confidentiality by closing the door. Using alcohol-based hand disinfectant. Cleaning the stethoscope with alcohol. Asking the individual to change into a hospital gown.
Assuring privacy and confidentiality by closing the door. Cleaning the stethoscope with alcohol.
___________________ is a marker of health and indicator of nutritional status
BMI (body mass index)
The patient appears to be thin with pronounced bony prominences. The nurse would document this under______________________.
body structure
A patient in the emergency department is complaining of right lower abdominal pain. The comprehensive abdominal examination would include which techniques, listed in order performed? Percussion, inspection, auscultation. Inspection, palpation, percussion. Inspection, palpation, auscultation. Inspection, auscultation, palpation.
Inspection, auscultation, palpation
Which of the following is included in past history? (Select all the apply.) Childhood illnesses Date of birth Hospitalizations Pain scale Immunizations
Childhood illnesses hospitalizations immunizations
With which aspects of the physical examination should the student examiner adhere when practicing assessment techniques at home or in the learning laboratory? Select all that apply. Comfort Confidentiality Right to refuse Privacy Respect Safety
Comfort Confidentiality Right to refuse Privacy Respect Safety
The examiner has collected the following subjective data from a 55-year-old male patient: Reason for seeking care: Back pain History of present illness: Started two days ago after lifting furniture. Stabbing pain in lower back rated 7/10. Lying flat makes pain decrease. Ice makes it temporarily better. Past history: Left knee replacement 5 years ago Medication reconciliation: acetaminophen 500mg every 6 hours for pain as needed Family history: History of high blood pressure on father's side. Diabetes on mother's side Review of systems: Non-remarkable Functional assessment: Cannot work due to pain What would be the examiner's initial plan of assessment? Complete a focused assessment of the patient's back Take the patient's blood pressure Complete a focused assessment of the patient's left knee Discuss financial options with patient
Complete a focused assessment of the patient's back
A 2-month-old infant has a head measurement of 36 cm and has a chest circumference of 38 cm. Based on these measurements, what would the examiner do? Expect the chest circumference to be greater than the head circumference. Ask the parent to return in a month to re-evaluate the head and chest circumferences. Consider these findings normal for a 2-month-old infant. Refer the infant to a physician for further evaluation.
Consider these findings normal for a 2-month old
The nurse is performing an initial assessment on a new client in the clinic. Which of the following elements would be included as part of the general survey? (Select all that apply.) Takes a calcium supplement Cooperative behavior Clean appearance History of breast cancer Blood pressure 118/82
Cooperative behavior Clean appearance
A patient with anorexia states "I will never be beautiful because I am fat." Which of the following nursing diagnoses would be most appropriate when planning interventions for this patient? Activity intolerance related to fatigue Disturbed body image related to negative evaluation of self Weight loss related to altered nutrition Altered nutrition: Less than body requirements related to low self esteem
Disturbed body image related to negative evaluation of self
Which of the following questions would be asked as part of the Review of Systems? Do you have any family history of cancer? Do you have any difficulty with vision? Do you have any allergies to any medications? Do you use any drugs or alcohol?
Do you have any difficulty with vision
The patient is refusing any treatments ordered by the physician. The nurse advised the patient of the risks and benefits of treatment. The patient continued to refuse. What should the nurse do? Document it, it is the patient's right to refuse Set up another appointment to discuss treatment again Call the physician to convince the patient to take the treatment Tell the patient it is not optional
Document it, it is the patient's right to refuse
At a 6-month follow-up appointment, the nurse notices a difference in the general survey data. At a previous appointment, the patient was clean and appeared healthy. Now the patient appears to have hygiene problems and weight loss. What is the nurse's best response? Stop the assessment and notify the physician Encourage the patient to share experiences of the past 6 months Point out the differences to the patient Document the findings only
Encourage the patient to share experiences of the past 6 months
The nurse knows that the primary purpose of obtaining a health history on a patient is to achieve which of the following? Obtaining an accurate and up to date list of patient medications Identifying information for an appropriate medical diagnosis Gathering pertinent data related to past and present health status Appropriate coding for billing the insurance company
Gathering pertinent data related to past and present health status
A nurse cares for an 13-year-old anorexic female whose physical and sexual developments are not consistent with normal findings for stated age. They are delayed. The patient's mother asks, "What does this mean?" How should the nurse correctly respond? Her physical development is delayed compared to other girls her age It really doesn't mean anything, she is fine and will continue to grow She must have a genetic condition that is causing her to have delayed physical development This is a chronic condition and will impact on her health
Her physical development is delayed compared to other girls her age
The nurse recognizes which of the following statements as an example of an open-ended question? How do you typically deal with an asthma attack? Do you take medication for your asthma? Is your breathing better than the last time you were here? Have you had this type of wheezing episode before?
How do you typically deal with an asthma attack?
Which question by the nurse would be the most effective way to assess the intensity of pain? Is this pain similar to pain you have experienced in the past? How would you rate your pain on a scale from 0-10? Is the pain located on the left or right side of the abdomen? Is the pain constant or intermittent?
How would you rate your pain on a scale of 0-10?
The health examiner preparing to perform a physical assessment of the abdomen is aware that which techniques will be used? Drag the correct answers into the order in which they will be used starting with the first. Percussion Auscultation Palpation Inspection
Inspection Auscultation Palpation Percussion
Before placing a patient on a medication, it is important to verify other current medications or supplements the patient may be taking. This is called which of the following? Drug testing Drug recall Medication reconciliation Medication examination
Medication reconciliation
Which of the following is included in the general survey? (Select all that apply) Mobility Family history Behavior Palpation Vital Signs Physical appearance Body structure
Mobility Behavior Physical appearance Body structure
Assuring the lighting in the examination room is bright is key to an accurate inspection for which reasons? Select all that apply. Noticing thrills. Observing alterations in skin color. Seeing differences in skin texture. Visualizing deeper masses. Detecting odors from wounds.
Noticing thrills. Observing alterations in skin color. Seeing differences in skin texture.
A Spanish-speaking client arrives at the triage desk in the ER department and states to the health examiner, "No speak English, need interpreter." What is the best action for the health examiner to take? Page an interpreter from the hospital's interpreter services. Have one of the client's family members interpret. Have the Spanish speaking triage receptionist interpret. Obtain a Spanish-English dictionary and attempt to triage the client.
Page an interpreter from the hospital's interpreter services.
Which of the following findings during the general survey indicate a change in mobility? Patient's body is symmetric Patient is seated in a tripod position Patient had a stroke 2 years ago and has a walker. Patient is 5'2" and 160 pounds
Patient had a stroke 2 years ago and has a walker
The examiner is documenting the reason for seeking care. Which of the following statements is documented correctly? Assessment of right ankle is needed due to "pain." Patient presents with a sprained ankle. Patient has pain in the right ankle. Patient states "I have pain in my right ankle."
Patient states "I have pain in my right ankle"
The novice nurse completing a focused assessment prior to administering a cardiovascular medication notices a rubbing sound when assessing the apical pulse. The patient denies pain and the vital signs are normal. The abnormal sound has not been previously documented on the patient's health record. The highest priority action for the nurse to take at this time is:
Request a more experienced colleague assess the heart sounds.
Which parts of the health history collect subjective information? (Select all that apply.) Review of systems Past health history Family history History of present illness
Review of systems Past health history Family history History of present illness
The health professional responds to an emergency call for help in the lobby of the health facility and finds a car in the lobby and several people injured. Which person will the health professional examine first? The colleague with a torn uniform, walking with a limp, directing people out of the lobby. The individual lying on the floor screaming that their leg is broken. The older adult bleeding from the head sitting quietly on the floor talking to a crying child. The car's driver who is slumped over the steering wheel, not moving.
The car's driver who is slumped over the steering wheel, not moving.
Which of the following outcomes would be appropriate for a patient with COVID who has been sent home to self-isolate? The patient will notify friends and family of the COVID diagnosis The patient will have friends and family care for her The patient can describe the symptoms of COVID The patient will record daily temperatures
The patient will notify friends and family of the COVID diagnosis
What determines the frequency of assessment needed for each individual? The age of the individual being assessed. The person's health and wellness needs. Guidelines from the Centers for Disease Control and Prevention (CDC). Insurance company regulations.
The person's health and wellness needs
A patient with COVID asks the nurse why they have to know where I have traveled in the last 30 days. Which of the following responses by the nurse is correct? (Select all that apply.) Symptoms begin 2 to 14 days after you come into contact with the virus Everyone who has recently traveled has to be tested for the virus The questions help slow the spread of the virus Those questions allow us to track where you could have gotten it from or who you exposed the virus to
The questions help slow the spread of the virus Those questions allow us to track where you could have gotten it from or who you exposed the virus to
In which situations is verifying a person's identity required when they are in the hospital? Select all that apply. When meeting the person for the first time. Prior to administering blood pressure medication. Before completing an assessment. When answering their call for assistance. Before transporting an individual to a test. When delivering a meal tray.
When meeting the person for the first time. Prior to administering blood pressure medication. Before completing an assessment. Before transporting an individual to a test. When delivering a meal tray.
A patient is symptomatic for coronavirus (COVID-19), a contagious respiratory disease. Which of the following health history questions is most important to ask? Are you currently pregnant? What is your ethnicity? Who lives in your house with you? What medications are you taking?
Who lives in your house with you?
During an interview with a COVID positive patient, the nurse wants to assess the client's background and health history. Which of the following are examples of leading questions that the nurse should avoid? (Select all that apply.) Do you have a history of respiratory disease? Where are you working right now? You feel pretty good right now, right? Who do you live with? You didn't expose anyone to COVID, did you?
You feel pretty good right now, right? You didn't expose anyone to COVID, did you?
A patient appears anxious in the general survey. How should the nurse respond? I will ask your provider to prescribe you an antianxiety medication Everyone is anxious coming to the clinic You are fine, there is no need to be anxious You seem nervous, tell me about how you are feeling
You seem nervous, tell me about how you are feeling
Structures with relatively more _________typically produce a louder, deeper, and longer sound because it _______________ fails to penetrate tissues . A solid structure, like the thigh ____________ intestine gives a softer, higher, _______________ sound because it does not vibrate as easily.
air, vibrates freely, liver, shorter
Which information should be included in a medication reconciliation? (Select all that apply.) Tobacco 6 cigarettes per day atenolol 50mg for high blood pressure acetaminophen 500mg as needed for pain Multivitamin 1 tablet St. John's Wort 300mg for depression
atenolol 50mg for high blood pressure acetaminophen 500mg as needed for pain Multivitamin 1 tablet St. John's Wort 300mg for depression
A health history is a comprehensive record of a patient's past and present health status. The __________ health history is usually collected during the patient's first visit. A _____________ health history is completed when a patient presents with a specific problem. The most accurate history is furnished by the friends or ____________. Less accurate sources include ____________.
comprehensive focused patient or an interpreter friends or family
During an admission assessment on a 19-year-old patient with anorexia, the nurse learns the patient has a sister with the same health condition. What should the nurse do with this information? Contact the primary care provider Contact the patient's parents Nothing, this is typical for patients in this age range Ask if the patient can bring her sister in
contact the primary care provider
The examiner is completing a health history on a patient who presents with abdominal pain. Which is an example of biographic information that may be obtained during a health history? Past surgeries Personal values and beliefs Current occupation History of immunizations
current occupation
Complete each sentence by selecting the correct term from the dropdown menu. The _________________ is often collected in a primary care setting, such as a women's health clinic. When a patient is experiencing a short-term problem, such as a rash, the care provider conducts a problem_____________________. Persons with chronic conditions, such as sickle-cell anemia, are seen by their primary care provide for ______________________. For a patient in cardiac arrest an _________________ assessment may be obtained from relatives.
complete problem-centered assessment follow-up emergency
Which assessment data are abnormal in a general survey? (Select all that apply.) Depressed Gait steady Appears older than stated age Face symmetric Pallor Confusion Oriented x2 Even skin tone Calm
depressed, appears older than stated age, pallor, confusion, oriented x2
The examiner is observing behavior which includes ________ , ____________, _______________, and ________________.
dress, grooming, mood, personal hygiene,
While dining with friends, the health professional notices a woman at the next table holding her hands to her neck and goes to help. They begin a ___________ assessment of her ___________ by asking her "Are you ________?"
emergency, airway, choking
When palpating a client's abdomen to check for an abdominal aortic aneurysm during a physical assessment, which part of the hand will the examiner use? Ball of the hand Palmar surface Dorsum Finger pads
finger pads
The general survey begins_______________________ with the patient and continues with each interaction that follows. Begin the data collection as soon as you begin _________________ and continue until you leave
first moment of the encounter enter the room
The examiner observes the patient staggering into the room. The examiner notes this activity as a way to obtain data related to which of the following? Mood Level of Consciousness Gait Range of Motion
gait
The examiner is assessing an individual who arrives at the emergency department after falling down multiple times. After introductions, the person states, "I am so dizzy I can't stay standing up." What is the examiner's highest priority? Place the following steps in an order of priority. Obtain vital signs. Perform a focused neurologic assessment. Ask about current medications. Get the individual a chair. Call for assistance.
get the individual a chair call for assistance ask about current medications obtain vital signs perform a focused neurologic assessment
The nurse asks the patient, "Have you ever used tobacco products?" The nurse recognizes that this question addresses the ____________ history section of the health history.
health maintenance
In the scenario, which part of the health history was most important in the primary care provider making the diagnosis? History of present illness Functional assessment Past health history Family history
history of present illness
The examiner is performing an assessment of a client's abdomen. Upon palpation of the upper left quadrant, an abnormal lump that is extremely painful for the client is felt. Based on knowledge of normal anatomy and pathophysiology, which organ is likely causing the pain? Spleen Gallbladder Liver Appendix
liver
The examiner is assessing an 90-year-old female patient. Which assessment findings would be considered normal? More prominent bony landmarks Presence of scoliosis and flexion in the knees and hips Additional deposits of fat on the thighs and lower legs Increase in body weight
more prominent bony landmarks
While performing a cardiac assessment on a client with an incompetent heart valve, the examiner anticipates hearing a _______ using the _________portion of the _______________.
murmur, bell, stethoscope
When auscultating a client's heart sounds, which sounds are most likely heard when using the bell of the stethoscope? Closing of the aortic valve. Extra heart sounds. Murmurs. Closing of the tricuspid valve.
murmurs
For which portion of the physical assessment are gloves required?
oral
The examiner notes an elderly patient is confused regarding the time and date. The examiner would document this finding in which section of the general survey? Mood Alertness Orientation Affect
orientation
If a patient is 5'6" and 160lbs, what would the BMI be? Underweight Obese Normal Overweight
overweight
_________________will provide the best information regarding early alterations in arterial blood flow to the legs.
palpitation of pulses
The patient states she had her appendix removed 10 years ago. The examiner would document this under which portion of the health history? Review of Systems Past History Functional Assessment Family History
past history
Which of the following are abnormal general survey findings? (Select all that apply.) Patient appears older than stated age Posture is upright while sitting Speech is clear Hair appears thin
patient appears older than stated age hair appears thin
A patient is struggling to complete the health history questionnaire because English language is not their primary language. Which of the following should the examiner implement? Request an interpreter to assist the patient. Read the questionnaire to the patient. Have the patient call a family member. Do not have the patient complete the questionnaire.
request an interpreter to assist the patient
The patient states "My last physical exam was last year." This would be documented under ____________________.
review of systems
The examiner is completing a general survey on the patient below. What should be documented? Skin tone uneven Appears emaciated Face symmetric Right-sided facial drooping
right-sided facial drooping
The examiner calculates a body mass index of 17 for a young adult male. Based on the result, the patient is considered to be in which of the following categories? Underweight Obese Healthy weight Overweight
underweight