WGU Health Assessment Exam –
Comprehensive Nursing Practice
Questions & Exam Prep
Subjective data Said by the client (S)
Obejective data Observed by the nurse (O)
Assessment Techniques is as follows Inspect-Palpation-Percussion-Auscultation
Order of Abdomen Assessment Inspect-Auscultation-Percuss-Palapate
Inspection always first
1. Take time to observe with eyes ear nose
2. Use good lighting
3. Look at color shape symmetry position
4. Observe for odors from skin breath wound
5. Develop and use nursing instincts
6. Inspection is done alone and in combination with
other assessment techniuqes
Back of hand To assess skin temperature use
Deep Palpation 5-8cm or (2-3") deep is considered
Light Paplpation 1cm deep is considered
Percussion sounds produced by striking body surface
sounds are dull resonant flat tympanic
action is performed in the wrist
Ausculation listening to sounds produced by the body
Bell picks up low pitched sounds such as heart murmurs
General Survey is an overall review or first impression a nurse has of person's
well being.
Appearance appears to be reported age
sexual development appropriate
alert and oriented
facial features
symmetric no signs of
acute distress
,Body Structure/mobilty weight and height WNL BMI guidelines
body parts equal bilaterally
stands erect
sits comfortably
gait is coordinated
walk is smooth and well balanced
full mobility of joints
, Behavior maintains eye contact with appropriate expressions
comfortable and cooperative
speech clear
clothing is correct for climate
looks cleat and fit
appears clean and well groomed
Comprehensive history which includes chief complaint or reason for the visit a
complete review of systems and complete past family and
social history should be obtained on the first encounter with a
patient regardless of setting and by a RN
Family Health Hx Are completed across three generations looking specifically
for patterns in genetic issues that negatively impact quality of
life
Health Hx gives a picture of patient's current health and documentation
must be completed for each visit and or assessment
How to measure height less than 2 years of Obtain height by measuring the recumbent length of children
age less than 2 years of age and
children between 2 and 3 who cannot stand unassisted. A
measuring board with a stationary headboard and a sliding
vertical foot piece is ideal, but a tape measure can also be
used
a) Lay the child flat against the center of the board. The
head should be held against the
headboard by the parent or an assistant and the knees held so
that the hips and knees are extended. The foot piece is moved
until it is firmly against the child's heels. Read and record the
measurement to the nearest 1/8 inch.
b)A modified technique in home settings is to lay the child
flat and straight where the head should be held by the parent
and the knees held so that the hips and knees are extended,
mark the flat surface at the top of the head and tip of the
heels. Move child and measure the distance between the
marks with a tape measure. Read and record the
measurement to the nearest 1/8 inch
2. When a recumbent length is obtained for a two year old,
it should be plotted on the birth to 36 months growth
chart. When a standing height is obtained for a two year
old, plot the finding on the 2 year to 18 year chart. After
plotting measurements for children on age and gender
specific growth charts, evaluate, educate and refer
according to findings.
Comprehensive Nursing Practice
Questions & Exam Prep
Subjective data Said by the client (S)
Obejective data Observed by the nurse (O)
Assessment Techniques is as follows Inspect-Palpation-Percussion-Auscultation
Order of Abdomen Assessment Inspect-Auscultation-Percuss-Palapate
Inspection always first
1. Take time to observe with eyes ear nose
2. Use good lighting
3. Look at color shape symmetry position
4. Observe for odors from skin breath wound
5. Develop and use nursing instincts
6. Inspection is done alone and in combination with
other assessment techniuqes
Back of hand To assess skin temperature use
Deep Palpation 5-8cm or (2-3") deep is considered
Light Paplpation 1cm deep is considered
Percussion sounds produced by striking body surface
sounds are dull resonant flat tympanic
action is performed in the wrist
Ausculation listening to sounds produced by the body
Bell picks up low pitched sounds such as heart murmurs
General Survey is an overall review or first impression a nurse has of person's
well being.
Appearance appears to be reported age
sexual development appropriate
alert and oriented
facial features
symmetric no signs of
acute distress
,Body Structure/mobilty weight and height WNL BMI guidelines
body parts equal bilaterally
stands erect
sits comfortably
gait is coordinated
walk is smooth and well balanced
full mobility of joints
, Behavior maintains eye contact with appropriate expressions
comfortable and cooperative
speech clear
clothing is correct for climate
looks cleat and fit
appears clean and well groomed
Comprehensive history which includes chief complaint or reason for the visit a
complete review of systems and complete past family and
social history should be obtained on the first encounter with a
patient regardless of setting and by a RN
Family Health Hx Are completed across three generations looking specifically
for patterns in genetic issues that negatively impact quality of
life
Health Hx gives a picture of patient's current health and documentation
must be completed for each visit and or assessment
How to measure height less than 2 years of Obtain height by measuring the recumbent length of children
age less than 2 years of age and
children between 2 and 3 who cannot stand unassisted. A
measuring board with a stationary headboard and a sliding
vertical foot piece is ideal, but a tape measure can also be
used
a) Lay the child flat against the center of the board. The
head should be held against the
headboard by the parent or an assistant and the knees held so
that the hips and knees are extended. The foot piece is moved
until it is firmly against the child's heels. Read and record the
measurement to the nearest 1/8 inch.
b)A modified technique in home settings is to lay the child
flat and straight where the head should be held by the parent
and the knees held so that the hips and knees are extended,
mark the flat surface at the top of the head and tip of the
heels. Move child and measure the distance between the
marks with a tape measure. Read and record the
measurement to the nearest 1/8 inch
2. When a recumbent length is obtained for a two year old,
it should be plotted on the birth to 36 months growth
chart. When a standing height is obtained for a two year
old, plot the finding on the 2 year to 18 year chart. After
plotting measurements for children on age and gender
specific growth charts, evaluate, educate and refer
according to findings.
