Health Assessment Exam 1- Module 1-3
Which is part of the general survey? Eye contact, Speech, or Asking about depression (Ans- Eye contact
When does nurse begin general assessment?(Ans- As soon as you meet the patient
When is the best time to document findings?(Ans- As timely as possible
Which is not part of assessing orientation status? Asking about name, dob, where are you right now, or what meds are you taking (Ans- Asking about medication
Which part of the hand best for evaluating temperature?(Ans- Dorsal aspect
What is the most reliable indicator of pain?(Ans- What patient says they are experiencing- subjective data
What is diaphragm of stethoscope used for?(Ans- High pitched sounds
What part of the assessment uses the palm and fingers to evaluate moisture and swelling?(Ans- Palpation
What is the first thing you do before starting assessment?(Ans- Wash your hands
- / 3
Which step of nursing process includes data collection through health history and interview of the client?(Ans- Assessment
Is counting respirations subjective or objective?(Ans- Objective
Is seeing a scar subjective or objective?(Ans- Objective
Which is objective data? Straining to urinate at home, knee swelling/redness, patient vomiting 2 days at home (Ans- Knee swelling and redness
What critical thinking skill is being used to determine bell versus diaphragm (Ans- Comparative
What level of preventative care is a rehab hospital? (Ans- Tertiary
Which should be part of the last step of health assessment? (select all that apply) Raise the bed, lower the bed, put all 4 side rails up, place call light within reach, or place personal belonging within reach (Ans- All correct except raise bed and put up all 4 side rails
When we palpate what are we looking for? (Ans- Tenderness
When examining older adult nurse should use which technique? As few position changes as possible, avoid touching patient during exam too much, or speak loudly and clearly as most elderly have hearing deficits (Ans- Arrange exam for as few position changes as possible
What technique uses tapping as testing for density?(Ans- Percussion
- / 3
What are the two parts of the stethoscope, what type of sounds can they detect, and what body parts are they used on?(Ans-
o Diaphragm: large side of stethoscope- high pitched
§ Use heavy pressure § Heart (both high and low), bowel, and lung sounds
o Bell: small end- small side- low pitched sounds
§ Use light pressure § Vascular sounds (carotid artery and abdominal aorta)
Which side of the hand is best for detecting moisture?(Ans- Palmar
What kind of palpation do nurses perform?(Ans- Light- less than 1/2 inch
What are the 5 things nurses need to do before leaving the room?(Ans- Wash hands, lower bed, raise side rails (but never all 4 unless ordered), place call bells and personal items within reach
When are the following percussion sounds heard? Resonance, Tympany, Dullness, Hyperresonance (Ans- o Resonance- normal lung
- Tympany- normal abdomen
- Dullness- over liver
- Hyperresonance- COPD
Which of the following are subjective and objective?
- A patient says they are nauseous
- Counting respirations
- Asking about allergies
- Asking about medication use at home
- Observe a scar on their arm
- A patient says they are nauseous- subjective
- / 3
(Ans-