NR302 Health Assessment Exam 1
Question 1.
health history
ANSWER
Provides subjective data Components in Order: Biographic data Reason for seeking care Present health history/ history of present illness past history
medication reconciliation family history review of systems functional assessment of ADLs
Question 2.
General Survey
ANSWER
Objective data, and starts as soon as nurse sees patient. Four areas of focus: physical appearance, body structure, mobility, behavior Assessing
appearance is consistent with chronological age observe for signs of acute distress observes behavior: facial expressions, mood/affect, speech assessing
how they dress, hygiene Assess levels of consciousness (A & O) Alert and oriented to person, place, time, and situation Assess for visible devices
Question 3.
Types of Assessment
ANSWER
Complete Rapid Focused Emergency Follow-up
Question 4.
Rapid assessment
ANSWER
Used each time patient is seen and determines urgency of client's condition Includes: ease of breathing, level of consciousness, and body position Used in
urgent and nonurgent situations.
Question 5.
Focused assessment
ANSWER
Used to obtain more data about specific concerns or abnormal findings related to a body system Includes: collecting data related to the findings of concern
Used after abnormal findings are identified during any assessment
Question 6.
Complete assessment
ANSWER
Used at first interaction between health care provider and individual seeking care. Includes: health history, physical assessment, and interpretation of data to
determine if further assessment is needed.
1/9
, Question 7.
Follow-up assessment
ANSWER
Used to determine effectiveness during or after treatment includes: a focused assessment used to evaluate how the client is responding to treatment
Evaluates treatment
Question 8.
Emergency assessment
ANSWER
used to collect key data during an urgent or emergent medical situation Includes: assessment of ABCDE Airway Breathing Circulation Disability and
Exposure Used when their is a life-threatening situation
Question 9.
Providing Comfort
ANSWER
Communication: Therapeutic and culturally sensitive Emotional state: reduce anxiety for self and client, take your time Environment: quiet, warm, no
distractions, private Lighting: Natural lighting is most accurate Equipment: exam table is at proper height to prevent bending over and can access and
assess both sides of client
Question 10.
Safety
ANSWER
Hand hygiene Bed wheels locked Bed Alarm On Bed must be lowest position Call bell within reach Side rails up except one Clean walking pathway Return
side table Remove clutter/waste and unclean items Separate clean from dirty
Question 11.
setting priorities
ANSWER
utilize maslows hierarchy ABC's any sudden onsets
Question 12.
1st priority
ANSWER
Critical findings, deterioration, life-threatening, urgent action needed. Think ABCs Airway open? Breathing? Perfusion? Examples: Cardiac arrest, choking,
losing consciousness, difficulty breathing Situations: Client has labored breathing tachypnea chest pain
Question 13.
2nd priority
ANSWER
Possibility of deterioration, may become life-threatening, prompt action needed but not immediate. Examples: MAAUAR 2nd acronym Mental status change
Acute pain Acute urinary elimination issues Untreated medical problem Abnormal labs Risk of infection or safety Situations: Lacerations that opens Pain
Nausea
2/9
Question 1.
health history
ANSWER
Provides subjective data Components in Order: Biographic data Reason for seeking care Present health history/ history of present illness past history
medication reconciliation family history review of systems functional assessment of ADLs
Question 2.
General Survey
ANSWER
Objective data, and starts as soon as nurse sees patient. Four areas of focus: physical appearance, body structure, mobility, behavior Assessing
appearance is consistent with chronological age observe for signs of acute distress observes behavior: facial expressions, mood/affect, speech assessing
how they dress, hygiene Assess levels of consciousness (A & O) Alert and oriented to person, place, time, and situation Assess for visible devices
Question 3.
Types of Assessment
ANSWER
Complete Rapid Focused Emergency Follow-up
Question 4.
Rapid assessment
ANSWER
Used each time patient is seen and determines urgency of client's condition Includes: ease of breathing, level of consciousness, and body position Used in
urgent and nonurgent situations.
Question 5.
Focused assessment
ANSWER
Used to obtain more data about specific concerns or abnormal findings related to a body system Includes: collecting data related to the findings of concern
Used after abnormal findings are identified during any assessment
Question 6.
Complete assessment
ANSWER
Used at first interaction between health care provider and individual seeking care. Includes: health history, physical assessment, and interpretation of data to
determine if further assessment is needed.
1/9
, Question 7.
Follow-up assessment
ANSWER
Used to determine effectiveness during or after treatment includes: a focused assessment used to evaluate how the client is responding to treatment
Evaluates treatment
Question 8.
Emergency assessment
ANSWER
used to collect key data during an urgent or emergent medical situation Includes: assessment of ABCDE Airway Breathing Circulation Disability and
Exposure Used when their is a life-threatening situation
Question 9.
Providing Comfort
ANSWER
Communication: Therapeutic and culturally sensitive Emotional state: reduce anxiety for self and client, take your time Environment: quiet, warm, no
distractions, private Lighting: Natural lighting is most accurate Equipment: exam table is at proper height to prevent bending over and can access and
assess both sides of client
Question 10.
Safety
ANSWER
Hand hygiene Bed wheels locked Bed Alarm On Bed must be lowest position Call bell within reach Side rails up except one Clean walking pathway Return
side table Remove clutter/waste and unclean items Separate clean from dirty
Question 11.
setting priorities
ANSWER
utilize maslows hierarchy ABC's any sudden onsets
Question 12.
1st priority
ANSWER
Critical findings, deterioration, life-threatening, urgent action needed. Think ABCs Airway open? Breathing? Perfusion? Examples: Cardiac arrest, choking,
losing consciousness, difficulty breathing Situations: Client has labored breathing tachypnea chest pain
Question 13.
2nd priority
ANSWER
Possibility of deterioration, may become life-threatening, prompt action needed but not immediate. Examples: MAAUAR 2nd acronym Mental status change
Acute pain Acute urinary elimination issues Untreated medical problem Abnormal labs Risk of infection or safety Situations: Lacerations that opens Pain
Nausea
2/9
