NSG 101 Beginning Physical Exam and
health assessment chapter
When does the general survey begin ? - Answers -The second the nurse meets the
client
What 5 characteristics does the general survey include ? - Answers -1. physical
appearance
2. Hygiene
3. Body structure
4. Body movement
5. Emotional, mental status, and behavior
The general survey includes... - Answers -everything in the room (patient and
environment)
What is the backbone of nursing ? - Answers -The assessment
What is the first part of the nursing process ? - Answers -assessment
What are the 5 parts of the nursing process ? - Answers -1. assessment
2. diagnosis
3. planning
4. implementing
5. evaluation
What is subjective data ? - Answers -data that the patient states
What is objective data ? - Answers -data that is observed
What is a primary source? - Answers -Information from the patient
What is a secondary source? - Answers -Information from the patients family, friend's or
significant other
What are the three parts of the health assessment ? - Answers -1. Nursing history
interview
2. behavioral assessment
3. physical examination
What are open ended questions? - Answers -Questions that require more than a yes or
no answer
, What are closed ended questions? - Answers -yes or no answers
What are some techniques to enhance data collection ? - Answers -active listening
clarification
restatement
interpretation
facilitate
What does the physical assessment do ? - Answers -supports or denies what the
patient is saying
What are some purposes of the physical examination ? - Answers -gather baseline data
support or refute subjective data
confirm nursing diagnosis
make clinical decisions
evaluate outcomes of care
Restlessness could be the result of ? - Answers -an impending respiratory emergency
What are the ABC's? - Answers -Airway
Breathing
Circulation
Documentation should do what ? - Answers -tell a story
Documentation should be what three things? - Answers -1. complete
2. accurate
3. descriptive
If it is not charted it is ...? - Answers -not done
When should documenting be done? - Answers -right after seeing the patient
What is the EMR? - Answers -electronic medical record
What is a comprehensive assessment ? - Answers -a detailed history and physical
examination upon arrival, full assessment
What is a problem- based/focused assessment? - Answers -more detailed assessment
based on focus of a specific problem
What is an episodic/ follow up assessment? - Answers -assessment following up with a
previous problem
What is a shift assessment ? - Answers -an assessment done early in the shift to know
what baseline is
health assessment chapter
When does the general survey begin ? - Answers -The second the nurse meets the
client
What 5 characteristics does the general survey include ? - Answers -1. physical
appearance
2. Hygiene
3. Body structure
4. Body movement
5. Emotional, mental status, and behavior
The general survey includes... - Answers -everything in the room (patient and
environment)
What is the backbone of nursing ? - Answers -The assessment
What is the first part of the nursing process ? - Answers -assessment
What are the 5 parts of the nursing process ? - Answers -1. assessment
2. diagnosis
3. planning
4. implementing
5. evaluation
What is subjective data ? - Answers -data that the patient states
What is objective data ? - Answers -data that is observed
What is a primary source? - Answers -Information from the patient
What is a secondary source? - Answers -Information from the patients family, friend's or
significant other
What are the three parts of the health assessment ? - Answers -1. Nursing history
interview
2. behavioral assessment
3. physical examination
What are open ended questions? - Answers -Questions that require more than a yes or
no answer
, What are closed ended questions? - Answers -yes or no answers
What are some techniques to enhance data collection ? - Answers -active listening
clarification
restatement
interpretation
facilitate
What does the physical assessment do ? - Answers -supports or denies what the
patient is saying
What are some purposes of the physical examination ? - Answers -gather baseline data
support or refute subjective data
confirm nursing diagnosis
make clinical decisions
evaluate outcomes of care
Restlessness could be the result of ? - Answers -an impending respiratory emergency
What are the ABC's? - Answers -Airway
Breathing
Circulation
Documentation should do what ? - Answers -tell a story
Documentation should be what three things? - Answers -1. complete
2. accurate
3. descriptive
If it is not charted it is ...? - Answers -not done
When should documenting be done? - Answers -right after seeing the patient
What is the EMR? - Answers -electronic medical record
What is a comprehensive assessment ? - Answers -a detailed history and physical
examination upon arrival, full assessment
What is a problem- based/focused assessment? - Answers -more detailed assessment
based on focus of a specific problem
What is an episodic/ follow up assessment? - Answers -assessment following up with a
previous problem
What is a shift assessment ? - Answers -an assessment done early in the shift to know
what baseline is
