NURN 155- Final
NURN 155 - Final Exam - converted
Exam
NURN 155 - Final Exam
Study online at https://quizlet.com/_d2hbtr
1. 1. Interview and
Health Assess-
ment
2. a. Assessment-
Interview, Health
History, and
Physical Assess-
ment
3. Interview § Obtained on first patient encounter.
§ Completed by RN, cannot be delegated.
§ Consider age-specific prevention guidelines.
§ Gives a picture of the patient's current health history and health risk status.
4. Health History - Bio Data
- Historian - Usually the source of history is the patient (primary source), but can
be a family member or friend, a letter of referral, or the medical record (secondary
source).
- Reason for Seeking Care - chief complaint.
- Present Health/Illness.
- PQRSTU: The mnemonic ''PQRSTU'' is used to illicit information about the HPI.
Provoking Factors.
Quality/ quantity.
Region and Radiation.
Severity scale.
Timing.
Understanding.
- PMH: All of the patient's past medical history.
PagePage 1
1 of 35
, NURN 155- Final
NURN 155 - Final Exam - converted
Exam
NURN 155 - Final Exam
Study online at https://quizlet.com/_d2hbtr
- Family History - The health history of family members.
ROS - The nurse evaluates each body system's past and present state of health.
- Medication Reconciliation.
- ADL - The patient's ability to provide self care-bathing, toileting, walking, etc.
5. Physical Assess- objective data: Observations or measurements of the patient's health status.
ment Example- Checking Vital signs, nurse observing patient's behavior.
6. c. Health Histo- Primary or Secondary Source:
ry-sources •Patient.
•Family member.
•Observer.
•Caretaker.
•Health care team
•Electronic Medical Record (EMR).
•Other records- Immunization, educational, military, employment.
•Nurses Experience
7. d. Inter- Interview techniques:
view- Technique, § Observation.
sources, § Open-ended Questions.
§ Closed-ended Questions.
§ Non-verbal skills - body language. I.e., posture, gesture, facial expression, eye
contact, foot tapping, touch etc.
8. d. Communica- • Sending - verbal and non-verbal communication.
tion technique • Receiving - the receiver uses his or her own interpretations of your own words.
• Internal Factors- Respect, Empathy, Listening, Self-awareness
• External Factors- Privacy, No Interruptions, Environment
• Dress - the client must remain in street clothes when conducting the interview.
PagePage 2
2 of 35
, NURN 155- Final
NURN 155 - Final Exam - converted
Exam
NURN 155 - Final Exam
Study online at https://quizlet.com/_d2hbtr
The interviewer's appearance should be appropriate to the setting.
• Note-taking - keep note-taking to a minimum.
9. e. Data collec- • Subjective data - what the person says about himself or herself.
tion- Subjective • Objective data - what the interviewer obtains through physical examination.
and Objective • Open-ended - allow clients to discuss their concerns freely.
data, Open end- • Closed-ended - can be answered with "Yes" or "No," or they have a limited set
ed, closed ended of possible answers.
10. 2. General
and Environmen-
tal survey, PA
technique, docu-
mentation
11. a. SWIPE Safety/Survey, Wash your hands, Identify yourself & client, Provide for privacy, and
Explain.
12. b. General sur-
vey- Physical Ap-
pearance, Body
structure, Mobili-
ty, and Behavior
13. Physical Appear- 1. Age- appears stated age.
ance 2. Sex - sexual development is appropriate for sex and age.
3. Level of consciousness.
4. Skin Color - color tone is even, pigmentation varying with genetic background.
5. Facial Features - are symmetric with movement.
6. Overall appearance - no signs of acute distress are present.
14. Body Structure 1. Stature - the height appears within the normal range for age and genetic
heritage.
PagePage 3
3 of 35
, NURN 155- Final
NURN 155 - Final Exam - converted
Exam
NURN 155 - Final Exam
Study online at https://quizlet.com/_d2hbtr
2. Nutritional Status - the weight appears within the normal range for height and
body build.
3. Symmetry - body parts are equal bilaterally and are in relative proportion.
4. Posture - the client stands comfortably erect as appropriate for their age.
5. Position/Deformities - posture and how the patient holds him/or herself is
surveyed.
15. Mobility 1. Gait - Descriptors of normal gait include: smooth, well-balanced with symmet-
rical arm swings. The base of the gait should be as wide as the shoulder width.
2. Range of Motion - note full mobility for each joint and that movement is
deliberate, accurate, smooth, and coordinated .
16. Behavior 1. Facial expression - the client maintains eye contact.
2. Mood and Affect - the client is comfortable and cooperative with the nurse and
interacts pleasantly.
3. Speech- Articulation clear.
4. Speech pattern - the stream of talking is fluent with an even pace.
5. Dress - clothing is appropriate to the climate, looks clean, fits the body, and is
appropriate to the client's culture and age group.
6. Personal hygiene - the client appears clean and groomed appropriately for his
or her age, occupation, and socioeconomic group.
17. c. Environmental Safety.
survey-what to
look for?
18. d. Physi-
cal Assess-
ment-Types, pur-
pose, Prepara-
tion
19.
PagePage 4
4 of 35
NURN 155 - Final Exam - converted
Exam
NURN 155 - Final Exam
Study online at https://quizlet.com/_d2hbtr
1. 1. Interview and
Health Assess-
ment
2. a. Assessment-
Interview, Health
History, and
Physical Assess-
ment
3. Interview § Obtained on first patient encounter.
§ Completed by RN, cannot be delegated.
§ Consider age-specific prevention guidelines.
§ Gives a picture of the patient's current health history and health risk status.
4. Health History - Bio Data
- Historian - Usually the source of history is the patient (primary source), but can
be a family member or friend, a letter of referral, or the medical record (secondary
source).
- Reason for Seeking Care - chief complaint.
- Present Health/Illness.
- PQRSTU: The mnemonic ''PQRSTU'' is used to illicit information about the HPI.
Provoking Factors.
Quality/ quantity.
Region and Radiation.
Severity scale.
Timing.
Understanding.
- PMH: All of the patient's past medical history.
PagePage 1
1 of 35
, NURN 155- Final
NURN 155 - Final Exam - converted
Exam
NURN 155 - Final Exam
Study online at https://quizlet.com/_d2hbtr
- Family History - The health history of family members.
ROS - The nurse evaluates each body system's past and present state of health.
- Medication Reconciliation.
- ADL - The patient's ability to provide self care-bathing, toileting, walking, etc.
5. Physical Assess- objective data: Observations or measurements of the patient's health status.
ment Example- Checking Vital signs, nurse observing patient's behavior.
6. c. Health Histo- Primary or Secondary Source:
ry-sources •Patient.
•Family member.
•Observer.
•Caretaker.
•Health care team
•Electronic Medical Record (EMR).
•Other records- Immunization, educational, military, employment.
•Nurses Experience
7. d. Inter- Interview techniques:
view- Technique, § Observation.
sources, § Open-ended Questions.
§ Closed-ended Questions.
§ Non-verbal skills - body language. I.e., posture, gesture, facial expression, eye
contact, foot tapping, touch etc.
8. d. Communica- • Sending - verbal and non-verbal communication.
tion technique • Receiving - the receiver uses his or her own interpretations of your own words.
• Internal Factors- Respect, Empathy, Listening, Self-awareness
• External Factors- Privacy, No Interruptions, Environment
• Dress - the client must remain in street clothes when conducting the interview.
PagePage 2
2 of 35
, NURN 155- Final
NURN 155 - Final Exam - converted
Exam
NURN 155 - Final Exam
Study online at https://quizlet.com/_d2hbtr
The interviewer's appearance should be appropriate to the setting.
• Note-taking - keep note-taking to a minimum.
9. e. Data collec- • Subjective data - what the person says about himself or herself.
tion- Subjective • Objective data - what the interviewer obtains through physical examination.
and Objective • Open-ended - allow clients to discuss their concerns freely.
data, Open end- • Closed-ended - can be answered with "Yes" or "No," or they have a limited set
ed, closed ended of possible answers.
10. 2. General
and Environmen-
tal survey, PA
technique, docu-
mentation
11. a. SWIPE Safety/Survey, Wash your hands, Identify yourself & client, Provide for privacy, and
Explain.
12. b. General sur-
vey- Physical Ap-
pearance, Body
structure, Mobili-
ty, and Behavior
13. Physical Appear- 1. Age- appears stated age.
ance 2. Sex - sexual development is appropriate for sex and age.
3. Level of consciousness.
4. Skin Color - color tone is even, pigmentation varying with genetic background.
5. Facial Features - are symmetric with movement.
6. Overall appearance - no signs of acute distress are present.
14. Body Structure 1. Stature - the height appears within the normal range for age and genetic
heritage.
PagePage 3
3 of 35
, NURN 155- Final
NURN 155 - Final Exam - converted
Exam
NURN 155 - Final Exam
Study online at https://quizlet.com/_d2hbtr
2. Nutritional Status - the weight appears within the normal range for height and
body build.
3. Symmetry - body parts are equal bilaterally and are in relative proportion.
4. Posture - the client stands comfortably erect as appropriate for their age.
5. Position/Deformities - posture and how the patient holds him/or herself is
surveyed.
15. Mobility 1. Gait - Descriptors of normal gait include: smooth, well-balanced with symmet-
rical arm swings. The base of the gait should be as wide as the shoulder width.
2. Range of Motion - note full mobility for each joint and that movement is
deliberate, accurate, smooth, and coordinated .
16. Behavior 1. Facial expression - the client maintains eye contact.
2. Mood and Affect - the client is comfortable and cooperative with the nurse and
interacts pleasantly.
3. Speech- Articulation clear.
4. Speech pattern - the stream of talking is fluent with an even pace.
5. Dress - clothing is appropriate to the climate, looks clean, fits the body, and is
appropriate to the client's culture and age group.
6. Personal hygiene - the client appears clean and groomed appropriately for his
or her age, occupation, and socioeconomic group.
17. c. Environmental Safety.
survey-what to
look for?
18. d. Physi-
cal Assess-
ment-Types, pur-
pose, Prepara-
tion
19.
PagePage 4
4 of 35
