NUR 305 Health Assessment Exam 1
Types of Databases - answer1. Complete
2. Episodic
3. Follow-up
4. Emergency
Subjective Data - answer what patient says about himself or herself during history
taking
Objective Data - answer Observed when inspecting, percussing, palpating, and
auscultating during patient physical examination
Nursing Process - answer1. Assessment
2. Diagnosis
3. Goal
4. Planning
5. Implementation
6. Evaluation
Prioritizing Problems - answer1. First-level priority: emergency
2. Second-level priority: next in urgency
3. Third-level priority: addressed after more urgent health problems
4. Collaborative: treatment involves multiple disciplines
Appropriate Interview Setting - answerEnsure privacy, refused interruptions, physical
environment
Note Taking - answerMay be unavoidable, shifts attention away from person, interrupts
patient's narrative flow, impedes observations, breaks eye contact, may be threatening
to patient's discussion of sensitive issues
Open-Ended Questions - answerVague, general terms
Closed or Direct Questions - answerYes/no answers
Reliability of Informative - answerRecord who furnishes information, judge reliability
(reliable patient will always answer the same no matter how the question is phrased)
Review of Systems - answerEvaluate past and present health of each body system,
double check in case any significant data was omitted, evaluate heath promotion
practices, head to toe
, Health History - answerBiological data, source of history, reason for seeking care,
present health or history present illness, past health, family history
PQRSTU - answerP: provocative or palliative
Q: quantity or quality
R: region or radiation
S: severity scale (0-10)
T: timing or onset
U: understanding patient's perception of problem
Order of Physical Exam - answer1. Inspection
2. Palpation
3. Percussion
4. Auscultation
Vital Sign: Temperature - answer37.2 C/99 F (C*1.8+32)= F(F-32/1.8)=C
Vital Sign: Pulse - answer60-100 bpm (<60: bradychardia, >100: tachycardia)
Vital Sign: Respiration - answer14-20 resp/min
Vital Sign: Blood Pressure/MAP - answerBP: 120/80 (systolic/diastolic)
MAP: 70-100 mmHg
(SBP + 2(DBP)/3)
Vital Sign: Pulse Ox - answer90-100%
Orthostatic Blood Pressure - answerTake serial measurement of pulse and blood
pressure while patient is: lying down, sitting, then standing) - make sure to document
patient position, arm used, and cuff size
False Readings: Blood Pressure - answerLarge cuff: false low BP
Small cuff: false high BP
0-10 Pain Scale - answer
Face Pain Scale - answerUsed with children
PAINAD Scale - answerUsed with dementia patients
NIPS Scale - answerUsed with infants
FLACC Scale - answerUsed with pediatric patients
Mental Disorder - answersignificant behavioral or psychological pattern (greater than
expected response) associated with organic and psychiatric disorders/illnesses
Types of Databases - answer1. Complete
2. Episodic
3. Follow-up
4. Emergency
Subjective Data - answer what patient says about himself or herself during history
taking
Objective Data - answer Observed when inspecting, percussing, palpating, and
auscultating during patient physical examination
Nursing Process - answer1. Assessment
2. Diagnosis
3. Goal
4. Planning
5. Implementation
6. Evaluation
Prioritizing Problems - answer1. First-level priority: emergency
2. Second-level priority: next in urgency
3. Third-level priority: addressed after more urgent health problems
4. Collaborative: treatment involves multiple disciplines
Appropriate Interview Setting - answerEnsure privacy, refused interruptions, physical
environment
Note Taking - answerMay be unavoidable, shifts attention away from person, interrupts
patient's narrative flow, impedes observations, breaks eye contact, may be threatening
to patient's discussion of sensitive issues
Open-Ended Questions - answerVague, general terms
Closed or Direct Questions - answerYes/no answers
Reliability of Informative - answerRecord who furnishes information, judge reliability
(reliable patient will always answer the same no matter how the question is phrased)
Review of Systems - answerEvaluate past and present health of each body system,
double check in case any significant data was omitted, evaluate heath promotion
practices, head to toe
, Health History - answerBiological data, source of history, reason for seeking care,
present health or history present illness, past health, family history
PQRSTU - answerP: provocative or palliative
Q: quantity or quality
R: region or radiation
S: severity scale (0-10)
T: timing or onset
U: understanding patient's perception of problem
Order of Physical Exam - answer1. Inspection
2. Palpation
3. Percussion
4. Auscultation
Vital Sign: Temperature - answer37.2 C/99 F (C*1.8+32)= F(F-32/1.8)=C
Vital Sign: Pulse - answer60-100 bpm (<60: bradychardia, >100: tachycardia)
Vital Sign: Respiration - answer14-20 resp/min
Vital Sign: Blood Pressure/MAP - answerBP: 120/80 (systolic/diastolic)
MAP: 70-100 mmHg
(SBP + 2(DBP)/3)
Vital Sign: Pulse Ox - answer90-100%
Orthostatic Blood Pressure - answerTake serial measurement of pulse and blood
pressure while patient is: lying down, sitting, then standing) - make sure to document
patient position, arm used, and cuff size
False Readings: Blood Pressure - answerLarge cuff: false low BP
Small cuff: false high BP
0-10 Pain Scale - answer
Face Pain Scale - answerUsed with children
PAINAD Scale - answerUsed with dementia patients
NIPS Scale - answerUsed with infants
FLACC Scale - answerUsed with pediatric patients
Mental Disorder - answersignificant behavioral or psychological pattern (greater than
expected response) associated with organic and psychiatric disorders/illnesses
