NR 302 Health Assessment Final Exam
______ is exhibiting an accurate understanding of the other person's feelings within a
communication-context.---ANS-empathy
"Positive-consensual-light-reflex"-means...---ANS-simultaneous-constriction
A-24-hour-recall-of-dietary-intake-is-used-as:---ANS-a-questionnaire-of-everything-eaten-in-last-
day
A-30-year-old-woman-reports-having-persistent-intense-pain-in-her-right-arm-related-to-trauma-
from-a-car-accident-5-months-ago.-She-states-that-the-slightest-touch-or-clothing-exacerbates-
the-pain.-This-report-suggest:---ANS-Complex-regional-pain-I
A-barrel-shaped-chest-is-characterized-by:---ANS-equal-anteroposterior-transverse-diameter-and-
ribs-being-horizontal
A-configuration-of-individual-lesions-arranged-in-circles-or-arcs,-like-ringworm,-is:---ANS-annular-
lesions
A-genogram-is-used-for-which-reasons?---ANS-family-history
A-major-characteristic-of-dementia-is:---ANS-impairment-of-short-and-long-term-memory
A-murmur-heard-after-S1-and-before-S2-is-classified-as:---ANS-systolic,-possibly-benign
A-nasal-polyp-is-distinguished-from-the-nasal-turbinates-by-3-things---ANS-moveable,-pale/gray,-
nontender
A-patient-asks-the-nurse-"May-I-ask-you-a-question?"-This-is-an-example-of---ANS-a-closed-
question
A-patient-has-recently-received-health-insurance-and-would-like-to-know-how-often-to-see-his-
provider.-How-do-you-respond?---ANS-Your-visits-may-very,-depending-on-your-level-of-wellness
A-patient-is-in-the-emergency-department-with-nausea-and-vomiting.-Which-would-you-include-in-
the-database?---ANS-A-diet-and-GI-history
A-patient-is-requesting-pain-medication-and-says-pain-is-9/10,-but-is-up-and-smiling.-How-should-
you-proceed?---ANS-Use-therapeutic-communication-to-determine-patients-pain-scale-goal-and-
history-of-chronic-pain
,A-patient-presents-with-acute-pain-of-the-abdomen.-After-the-initial-exam,-how-would-you-
proceed?---ANS-give-pain-meds-as-ordered
A-patient-says-she-is-very-nervous-and-nauseated,-and-she-feels-as-if-she-will-vomit.-This-is-what-
type-of-data?---ANS-Subjective
A-pregnant-woman-explains-that-she-does-not-intend-to-stop-drinking-bc-her-friends-didnt-and-
their-kids-are-fine.-How-should-you-respond?---ANS-No-amount-of-alcohol-has-been-determined-
to-be-safe-for-a-pregnant-woman-so-i-ask-you-to-stop-completely
A-risk-factor-for-melanoma-is:---ANS-skin-that-freckles-or-burns-before-tanning
A-throbbing,-unilateral-pain-associated-with-nausea,-vomiting,-and-photophobia-is-characteristic-
of:
A. cluster-headache
B. subarachnoid-hemorrhage
C. migraine-headache
D. tension-headache---ANS-migraine-headache
ABCDE-of-skin-cancer---ANS-Asymmetry
Border
Color
Diameter
Elevation
Abdomen-/-Genitourinary--bedside---ANS-Abdomen•Assess-contour-of-abdomen:-flat,-
rounded.•Listen-to-bowel-sounds-in-all-four-quadrants.•Check-any-tube-placement-for-drainage-
and-insertion-site-integrity.•Inquire-whether-passing-flatus-or-stool.•Be-aware-of-dietary-orders.
•Genitourinary•Inquire-whether-voiding-regularly.•Check-urine-for-color,-clarity.•If-Foley-catheter-
is-in-place:-check-color,-quantity,-clarity,-and-amount-.•If-urine-output-is-below-expected-value,-
perform-a-bladder-scan-according-to-agency-protocol.
Abdomen:-infant---ANS-Inspect
ØShape-of-abdomen-and-skin-condition
ØUmbilicus,-count-cord-vessels,-condition-of-cord-or-stump,-detection-of-hernia
ØSkin-turgor
Palpate
ØLight-palpation-to-note-muscle-tone,-liver,-spleen-tip,-and-bladder
ØDeep-palpation-to-note-kidneys-and-potential-masses
ØFemoral-arteries-and-inguinal-lymph-nodes
Percuss-all-quadrants
, Abnormal-finding-of-jugular-venous-pressure---ANS-patient-elevated-to-45-degrees-,-Internal-
jugular-vein-pulsation-at-4-cm-above-sternal-angle
Acculturation---ANS-process-of-social-and-psychological-exchanges-with-encounters-between-
persons-of-different-cultures,-resulting-in-changes-in-either-group
Acrocyanosis---ANS-bluish-color-around-the-lips,-hands-and-fingernails,-feet-and-toenails.
Activity--bedside---ANS-Note-activity-order—If-patient-is-on-bed-rest,-HOB-should-be-
elevated.Note-if-SCDs-are-ordered-and-follow-protocol.If-ambulatory,-assist-patient-to-sitting-
level-and-move-to-chairNote-any-assistance-needed-and-ability-to-transfer.Assess-need-for-
ambulatory-aid-or-equipment.Complete-any-standardized-scales-per-protocol-to-quantify-fall-
risk.Initiate-or-continue-appropriate-plan-of-care-and-follow-core-measures-as-needed.Complete-
documentation.
Ad-hoc-interpreter---ANS-using-a-patient's-family-member,-friend,-or-child-as-interpreter-for-a-
patient-with-limited-English-proficiency-(LEP)
african-american-with-flat,-3cm,-nontender,-gray/white-lesion-on-bucal-mucosa-ANS-leukodema,-
normal
Although-a-full-mental-status-examination-may-not-be-required-for-every-patient,-the-health-care-
provider-must-address-the-four-main-components-during-a-health-history-and-physical-
examination.-The-four-components-are:
A) memory,-attention,-thought-content,-and-perceptions.
B) language,-orientation,-attention,-and-abstract-reasoning.
C) appearance,-behavior,-cognition,-and-thought-processes.
D) mood,-affect,-consciousness,-and-orientation.---ANS-appearance,-behavior,-cognition,-and-
thought-processes
An-18-month-old-is-brought-into-the-clinic-for-a-health-screening.-To-assess-height-of-child-use:--
ANS-horizontal-measuring-board
An-area-of-thin-shiny-skin-with-decreased-visibility-of-normal-skin-markings-is-most-likely:-ANS-
atrophy-angle-of-nail-is-less-than-160-and-spongy,-indicates----ANS-congenital-heart-disease-and-
COPD
______ is exhibiting an accurate understanding of the other person's feelings within a
communication-context.---ANS-empathy
"Positive-consensual-light-reflex"-means...---ANS-simultaneous-constriction
A-24-hour-recall-of-dietary-intake-is-used-as:---ANS-a-questionnaire-of-everything-eaten-in-last-
day
A-30-year-old-woman-reports-having-persistent-intense-pain-in-her-right-arm-related-to-trauma-
from-a-car-accident-5-months-ago.-She-states-that-the-slightest-touch-or-clothing-exacerbates-
the-pain.-This-report-suggest:---ANS-Complex-regional-pain-I
A-barrel-shaped-chest-is-characterized-by:---ANS-equal-anteroposterior-transverse-diameter-and-
ribs-being-horizontal
A-configuration-of-individual-lesions-arranged-in-circles-or-arcs,-like-ringworm,-is:---ANS-annular-
lesions
A-genogram-is-used-for-which-reasons?---ANS-family-history
A-major-characteristic-of-dementia-is:---ANS-impairment-of-short-and-long-term-memory
A-murmur-heard-after-S1-and-before-S2-is-classified-as:---ANS-systolic,-possibly-benign
A-nasal-polyp-is-distinguished-from-the-nasal-turbinates-by-3-things---ANS-moveable,-pale/gray,-
nontender
A-patient-asks-the-nurse-"May-I-ask-you-a-question?"-This-is-an-example-of---ANS-a-closed-
question
A-patient-has-recently-received-health-insurance-and-would-like-to-know-how-often-to-see-his-
provider.-How-do-you-respond?---ANS-Your-visits-may-very,-depending-on-your-level-of-wellness
A-patient-is-in-the-emergency-department-with-nausea-and-vomiting.-Which-would-you-include-in-
the-database?---ANS-A-diet-and-GI-history
A-patient-is-requesting-pain-medication-and-says-pain-is-9/10,-but-is-up-and-smiling.-How-should-
you-proceed?---ANS-Use-therapeutic-communication-to-determine-patients-pain-scale-goal-and-
history-of-chronic-pain
,A-patient-presents-with-acute-pain-of-the-abdomen.-After-the-initial-exam,-how-would-you-
proceed?---ANS-give-pain-meds-as-ordered
A-patient-says-she-is-very-nervous-and-nauseated,-and-she-feels-as-if-she-will-vomit.-This-is-what-
type-of-data?---ANS-Subjective
A-pregnant-woman-explains-that-she-does-not-intend-to-stop-drinking-bc-her-friends-didnt-and-
their-kids-are-fine.-How-should-you-respond?---ANS-No-amount-of-alcohol-has-been-determined-
to-be-safe-for-a-pregnant-woman-so-i-ask-you-to-stop-completely
A-risk-factor-for-melanoma-is:---ANS-skin-that-freckles-or-burns-before-tanning
A-throbbing,-unilateral-pain-associated-with-nausea,-vomiting,-and-photophobia-is-characteristic-
of:
A. cluster-headache
B. subarachnoid-hemorrhage
C. migraine-headache
D. tension-headache---ANS-migraine-headache
ABCDE-of-skin-cancer---ANS-Asymmetry
Border
Color
Diameter
Elevation
Abdomen-/-Genitourinary--bedside---ANS-Abdomen•Assess-contour-of-abdomen:-flat,-
rounded.•Listen-to-bowel-sounds-in-all-four-quadrants.•Check-any-tube-placement-for-drainage-
and-insertion-site-integrity.•Inquire-whether-passing-flatus-or-stool.•Be-aware-of-dietary-orders.
•Genitourinary•Inquire-whether-voiding-regularly.•Check-urine-for-color,-clarity.•If-Foley-catheter-
is-in-place:-check-color,-quantity,-clarity,-and-amount-.•If-urine-output-is-below-expected-value,-
perform-a-bladder-scan-according-to-agency-protocol.
Abdomen:-infant---ANS-Inspect
ØShape-of-abdomen-and-skin-condition
ØUmbilicus,-count-cord-vessels,-condition-of-cord-or-stump,-detection-of-hernia
ØSkin-turgor
Palpate
ØLight-palpation-to-note-muscle-tone,-liver,-spleen-tip,-and-bladder
ØDeep-palpation-to-note-kidneys-and-potential-masses
ØFemoral-arteries-and-inguinal-lymph-nodes
Percuss-all-quadrants
, Abnormal-finding-of-jugular-venous-pressure---ANS-patient-elevated-to-45-degrees-,-Internal-
jugular-vein-pulsation-at-4-cm-above-sternal-angle
Acculturation---ANS-process-of-social-and-psychological-exchanges-with-encounters-between-
persons-of-different-cultures,-resulting-in-changes-in-either-group
Acrocyanosis---ANS-bluish-color-around-the-lips,-hands-and-fingernails,-feet-and-toenails.
Activity--bedside---ANS-Note-activity-order—If-patient-is-on-bed-rest,-HOB-should-be-
elevated.Note-if-SCDs-are-ordered-and-follow-protocol.If-ambulatory,-assist-patient-to-sitting-
level-and-move-to-chairNote-any-assistance-needed-and-ability-to-transfer.Assess-need-for-
ambulatory-aid-or-equipment.Complete-any-standardized-scales-per-protocol-to-quantify-fall-
risk.Initiate-or-continue-appropriate-plan-of-care-and-follow-core-measures-as-needed.Complete-
documentation.
Ad-hoc-interpreter---ANS-using-a-patient's-family-member,-friend,-or-child-as-interpreter-for-a-
patient-with-limited-English-proficiency-(LEP)
african-american-with-flat,-3cm,-nontender,-gray/white-lesion-on-bucal-mucosa-ANS-leukodema,-
normal
Although-a-full-mental-status-examination-may-not-be-required-for-every-patient,-the-health-care-
provider-must-address-the-four-main-components-during-a-health-history-and-physical-
examination.-The-four-components-are:
A) memory,-attention,-thought-content,-and-perceptions.
B) language,-orientation,-attention,-and-abstract-reasoning.
C) appearance,-behavior,-cognition,-and-thought-processes.
D) mood,-affect,-consciousness,-and-orientation.---ANS-appearance,-behavior,-cognition,-and-
thought-processes
An-18-month-old-is-brought-into-the-clinic-for-a-health-screening.-To-assess-height-of-child-use:--
ANS-horizontal-measuring-board
An-area-of-thin-shiny-skin-with-decreased-visibility-of-normal-skin-markings-is-most-likely:-ANS-
atrophy-angle-of-nail-is-less-than-160-and-spongy,-indicates----ANS-congenital-heart-disease-and-
COPD
