FINAL EXAM REVIEW HEALTH
ASSESSMENT LATEST
Final Exam Study Guide
1. History taking/symptom analysis – components of a health history (what is in each
component, for ex. Past medical history); subjective vs objective data; examples of open
and closed ended questions; history first; signs vs symptoms; health promotion levels
2. Therapeutic communication: examples of effective and ineffective (barriers) techniques
e.g. clarification, sequencing, reflection, blaming, etc.; questions; preparing for
interviews
3. Cultural assessment: culturally competent care; religion vs spirituality;
4. Nursing process steps
5. General survey – what is included?
6. Vital signs: BP – proper method, findings if not done properly; normal ranges-adults;
terminology used, e.g. bradycardia, tachypnea, etc.
7. Pain assessment techniques; 4 classical techniques of assessment
8. Nutrition: Dietary assessment methods fastest vs most comprehensive vs frequency;
abnormal eating patterns, for example, anorexia.
9. Skin: measurement; staging of decubitus ulcers, primary skin lesions like nodules,
pustules, etc.; common skin lesions, for ex. Psoriasis, contact dermatitis; signs of
malignant skin lesions; color differences seen in dark skinned individuals; lesion
configurations, like annular, petechiae, linear, etc.;
10. HEENT: eye examination techniques; PERRLA; hearing tests; lymph nodes; problems
seen in head, ears, eyes, nose, and throat, ex. cataracts, tonsillitis, glaucoma
11. Thorax/Respiratory assessment – auscultation, palpation; normal sounds and locations;
abnormal sounds & when you might hear them; proper method of auscultation;
methods- e.g. voice sounds such as egophony, thoracic expansion, etc.; chest shapes;
respiratory vocabulary
12. Heart: cardiac cycle; auscultation sites; what causes the heart sounds; use of apical
pulse; bruit vs murmur
13. Breasts: Risk factors for cancer
14. Abdomen – methods and order of assessment, anatomy, expected findings; colon cancer
risk factors
15. GU: testicular cancer; assessing
16. Pulses- where are they, how do you document information about them, including rate,
amplitude, rhythm; peripheral vascular assessment, edema – appearance, scale; arterial
vs venous insufficiency
17. Musculoskeletal – range of motion techniques; points for comparison; osteoporosis risk
factors; spinal assessment findings; testing various joints including jaw; types of
fractures; osteoarthritis risk factors; problems such as rheumatoid arthritis, gout, etc.;
movements like abduction/adduction, flexion/extension
,18. Neuro – Glasgow coma scale; reflexes; cranial nerves – how do you test each one; testing
for cerebellar function; tests such as graphesthesia, position sense, stereo gnosis, etc.,
part of the brain being tested? headache types;
19. Geriatrics: functional assessment-what is it, what is being tested, best approach to
testing; caregiver concerns/burnout; IADLs, ADLs; disability concerns; expected changes
in the elderly; fall risk factors
20. Pediatrics – best methods for assessing; pain assessment
,Steps of the nursing process:
• Assessment
• Diagnosis
• Outcome identification
• Planning
• Implementation
• Evaluation
Nursing process – Assessment:
• Collecting of data from multiple sources
• review of clinical record
• health history
• physical examination
• functional assessment
• cultural and spiritual assessment
Assessment – the starting point:
• subjective data – what patient says about themselves during history taking.
• Objective data – observed when inspecting, percussing, palpating, and auscultating
patient during physical examination.
Nursing process- diagnosis:
• Cluster data that seem to be associated in some way
• Validate data, confirm accuracy
• Look for gaps in your information
• Interpret data and identify problems
• Document the diagnosis
Nursing process- outcome identification
• Identify expected outcomes related to patient individualization
• Ensure outcomes have the SMART components
• Specific short term and long term goal measurement criteria
S – SPECIFIC
M – MEASURABLE
, A – ATTAINABLE
R – RELEVANT
T – TIME BOUND
Nursing process – planning:
• Establishing priorities based on meeting identified patient care goals
• Develop outcomes and set time frames for meeting proposed outcome
• Identify relevant interventions and utilize interdisciplinary health care team members in
the care planning process for the patient
• Document plan of care
Nursing process – evaluation:
• Refer to established outcomes
• Evaluate individuals condition and compare actual outcomes with expect outcomes
• If outcome reached, does something else need to be done or does client no longer have
this diagnosis
• If failure, identify reasons for not achieving expected outcomes
• Take corrective action to modify plan of care
• Document evaluation in plan of care
Priority problems level
• First level priority – emergent life threatening and immediate
• Second level priority – next in urgency, requiring attention so as to avoid further
deterioration
• Third level priority – important to patient’s health but can be addressed after more
urgent problems are addressed
Evidence – based clinical decision making:
• Best evidence from critical review of search literature
• The providers clinical expertise
• Patient preferences and values
• Physical examination and assessment of patient
Health promotion/prevention
• Primary – prevents health problems (e.g. safety glasses, vaccines, exercise)
ASSESSMENT LATEST
Final Exam Study Guide
1. History taking/symptom analysis – components of a health history (what is in each
component, for ex. Past medical history); subjective vs objective data; examples of open
and closed ended questions; history first; signs vs symptoms; health promotion levels
2. Therapeutic communication: examples of effective and ineffective (barriers) techniques
e.g. clarification, sequencing, reflection, blaming, etc.; questions; preparing for
interviews
3. Cultural assessment: culturally competent care; religion vs spirituality;
4. Nursing process steps
5. General survey – what is included?
6. Vital signs: BP – proper method, findings if not done properly; normal ranges-adults;
terminology used, e.g. bradycardia, tachypnea, etc.
7. Pain assessment techniques; 4 classical techniques of assessment
8. Nutrition: Dietary assessment methods fastest vs most comprehensive vs frequency;
abnormal eating patterns, for example, anorexia.
9. Skin: measurement; staging of decubitus ulcers, primary skin lesions like nodules,
pustules, etc.; common skin lesions, for ex. Psoriasis, contact dermatitis; signs of
malignant skin lesions; color differences seen in dark skinned individuals; lesion
configurations, like annular, petechiae, linear, etc.;
10. HEENT: eye examination techniques; PERRLA; hearing tests; lymph nodes; problems
seen in head, ears, eyes, nose, and throat, ex. cataracts, tonsillitis, glaucoma
11. Thorax/Respiratory assessment – auscultation, palpation; normal sounds and locations;
abnormal sounds & when you might hear them; proper method of auscultation;
methods- e.g. voice sounds such as egophony, thoracic expansion, etc.; chest shapes;
respiratory vocabulary
12. Heart: cardiac cycle; auscultation sites; what causes the heart sounds; use of apical
pulse; bruit vs murmur
13. Breasts: Risk factors for cancer
14. Abdomen – methods and order of assessment, anatomy, expected findings; colon cancer
risk factors
15. GU: testicular cancer; assessing
16. Pulses- where are they, how do you document information about them, including rate,
amplitude, rhythm; peripheral vascular assessment, edema – appearance, scale; arterial
vs venous insufficiency
17. Musculoskeletal – range of motion techniques; points for comparison; osteoporosis risk
factors; spinal assessment findings; testing various joints including jaw; types of
fractures; osteoarthritis risk factors; problems such as rheumatoid arthritis, gout, etc.;
movements like abduction/adduction, flexion/extension
,18. Neuro – Glasgow coma scale; reflexes; cranial nerves – how do you test each one; testing
for cerebellar function; tests such as graphesthesia, position sense, stereo gnosis, etc.,
part of the brain being tested? headache types;
19. Geriatrics: functional assessment-what is it, what is being tested, best approach to
testing; caregiver concerns/burnout; IADLs, ADLs; disability concerns; expected changes
in the elderly; fall risk factors
20. Pediatrics – best methods for assessing; pain assessment
,Steps of the nursing process:
• Assessment
• Diagnosis
• Outcome identification
• Planning
• Implementation
• Evaluation
Nursing process – Assessment:
• Collecting of data from multiple sources
• review of clinical record
• health history
• physical examination
• functional assessment
• cultural and spiritual assessment
Assessment – the starting point:
• subjective data – what patient says about themselves during history taking.
• Objective data – observed when inspecting, percussing, palpating, and auscultating
patient during physical examination.
Nursing process- diagnosis:
• Cluster data that seem to be associated in some way
• Validate data, confirm accuracy
• Look for gaps in your information
• Interpret data and identify problems
• Document the diagnosis
Nursing process- outcome identification
• Identify expected outcomes related to patient individualization
• Ensure outcomes have the SMART components
• Specific short term and long term goal measurement criteria
S – SPECIFIC
M – MEASURABLE
, A – ATTAINABLE
R – RELEVANT
T – TIME BOUND
Nursing process – planning:
• Establishing priorities based on meeting identified patient care goals
• Develop outcomes and set time frames for meeting proposed outcome
• Identify relevant interventions and utilize interdisciplinary health care team members in
the care planning process for the patient
• Document plan of care
Nursing process – evaluation:
• Refer to established outcomes
• Evaluate individuals condition and compare actual outcomes with expect outcomes
• If outcome reached, does something else need to be done or does client no longer have
this diagnosis
• If failure, identify reasons for not achieving expected outcomes
• Take corrective action to modify plan of care
• Document evaluation in plan of care
Priority problems level
• First level priority – emergent life threatening and immediate
• Second level priority – next in urgency, requiring attention so as to avoid further
deterioration
• Third level priority – important to patient’s health but can be addressed after more
urgent problems are addressed
Evidence – based clinical decision making:
• Best evidence from critical review of search literature
• The providers clinical expertise
• Patient preferences and values
• Physical examination and assessment of patient
Health promotion/prevention
• Primary – prevents health problems (e.g. safety glasses, vaccines, exercise)
