EXAM1NURS3325QUESTIONSWITH t t t t t
CORRECTANSWERS t t
Components of health assessment - CORRECT ANSWERV-Health History (subjective data) t t t t t t t t t
Physical Examination (objective data)
t t t t
Documentation of Data (complete, concise, factual) t t t t t
Why we Learn about health assessments - CORRECT ANSWERV- Systematic
t t t t t t t t t
way of collecting and analyzing
t t t t t
Used to start patient plan of care Firstt t t t t t t
step in the health assessment
t t t t t
The types of health assessments depends on - CORRECT ANSWERV-Context of Care Patient
t t t t t t t t t t t t
Need
t
Nurse Expertise t
Type of health assessments - CORRECT ANSWER -Comprehensive Assessment Focused
t t t t t t t t t
Assessment
t
Follow-upAssessment t
Shift Assessment
t t
Screening Assessment
t t
Clinical reasoning and judgment - CORRECT ANSWER -Collect, organize, analyze, and
t t t t t t t t t t
interpret data
t t
Create plan of care using clinical judgment t t t t t t
CLINICAL JUDGMENT - CORRECT ANSWER - t t t t t
"interpretation or conclusion about a patient's needs, concerns, or health programs and/or the decision t o t t t t t t t t t t t t t t t
take action (or not), use or modify standard approaches, or improvise new ones as deemed by the pat ient
t t t t t t t t t t t t t t t t t t t
response."
t
health promotion - CORRECT ANSWERV-increase well-being and actualize human health potential
t t t t t t t t t t
primary health promotion - CORRECT ANSWER -
t t t t t t t
prevent disease development through healthy lifestyle choices t t t t t t
secondary health promotion - CORRECT ANSWERV- t t t t t
screening efforts to promote early detection of disease
t t t t t t t t
tertiary health promotion - CORRECT ANSWER -minimizing disability from acute or chronic disease health
t t t t t t t t t t t t t
protection - CORRECT ANSWER -
t t t t t
actively avoid illness, early detection, maintain function with illness t t t t t t t t
Healthy people 2030 - CORRECT ANSWERV- t t t t t
goal of reducing most significant preventable health threats and reducing preventable health threats
t t t t t t t t t t t t
Skin assessment- when documenting a skin assessment, the nurse should: - CORRECT ANSWER -
t t t t t t t t t t t t t
Use standardized terminology to report findings
t t t t t t t
, • Use standardized terminology to record findings
t t t t t
• Perform assessment when risk factors identified t t t t t
• Allow information from the history to help direct the assessment t t t t t t t t t
• Document both normal and abnormal skin strategies from the assessment t t t t t t t t t
OLD CARTS - CORRECT ANSWER - t t t t t
Onset, Location, Duration, Characteristics, Aggravating Factors, Related Symptoms, Treatment, and Se verity
t t t t t t t t t t t
• Example:
• When did the rash start (onset) t t t t t
• What makes the rash worse (aggravating factors) t t t t t t
• What do you do to make the rash better (treatment) t t t t t t t t t
• Describe the sensation from the burn, does it burn or itch (related symptoms) t t t t t t t t t t t t
• Describe what the rash looked like initially (duration/characteristics) t t t t t t t
stage 1 pressure injury - CORRECT ANSWER -intact skin, non- blanchable
t t t t t t t t t t
redness over coccyx, tender, warm
t t t t t
stage 2 pressure injury - CORRECT ANSWER -
t t t t t t t
partial thickness loss of dermis, pink wound bed, no slough or bruising
t t t t t t t t t t t
stage 3 pressure injury - CORRECT ANSWER -
t t t t t t t
full thickness skin loss, subcutaneous fat visible, no visible bone
t t t t t t t t t
stage 4 pressure injury - CORRECT ANSWER -
t t t t t t t
full thickness tissue loss, tendon exposed, tunneling, slough present
t t t t t t t t
Nail Assessment - CORRECT ANSWERV-
t t t t
Nail surface should be smooth and flat in the center and slightly curved downward at the edges. The s kin
t t t t t t t t t t t t t t t t t t t
adjacent to the nail should be intact, the same color as adjacent skin and without edema. The expec ted angle of
t t t t t t t t t t t t t t t t t t t t t
the nail base is 160 degrees. The nail should have uniform thickness and the base should f eel firm and adhere to
t t t t t t t t t t t t t t t t t t t t t t
the nail bed.
t t t
jaundice - CORRECT ANSWERV-which is a yellowish-green color in light and dark skinned patients Jaundice
t t t t t t t t t t t t t t
can best be assessed in - CORRECT ANSWER -Sclera of the eye
t t t t t t t t t t t t
Palms of the hands t t t
Soles of the feet t t t
The appearance of the normal tympanic membrane is - CORRECT ANSWERV-
t t t t t t t t t t
Translucent and pearly gray t t t
tympanic membrane - CORRECT ANSWER - t t t t t
Redness of the tympanic membrane may indicate infection t t t t t t t
A brown sticky discharge is cerumen which is a normal finding, but may cause the tympanic membran e to be
t t t t t t t t t t t t t t t t t t t
obscured
t
Pink may indicate possible otitis externa or impending infection
t t t t t t t t
CORRECTANSWERS t t
Components of health assessment - CORRECT ANSWERV-Health History (subjective data) t t t t t t t t t
Physical Examination (objective data)
t t t t
Documentation of Data (complete, concise, factual) t t t t t
Why we Learn about health assessments - CORRECT ANSWERV- Systematic
t t t t t t t t t
way of collecting and analyzing
t t t t t
Used to start patient plan of care Firstt t t t t t t
step in the health assessment
t t t t t
The types of health assessments depends on - CORRECT ANSWERV-Context of Care Patient
t t t t t t t t t t t t
Need
t
Nurse Expertise t
Type of health assessments - CORRECT ANSWER -Comprehensive Assessment Focused
t t t t t t t t t
Assessment
t
Follow-upAssessment t
Shift Assessment
t t
Screening Assessment
t t
Clinical reasoning and judgment - CORRECT ANSWER -Collect, organize, analyze, and
t t t t t t t t t t
interpret data
t t
Create plan of care using clinical judgment t t t t t t
CLINICAL JUDGMENT - CORRECT ANSWER - t t t t t
"interpretation or conclusion about a patient's needs, concerns, or health programs and/or the decision t o t t t t t t t t t t t t t t t
take action (or not), use or modify standard approaches, or improvise new ones as deemed by the pat ient
t t t t t t t t t t t t t t t t t t t
response."
t
health promotion - CORRECT ANSWERV-increase well-being and actualize human health potential
t t t t t t t t t t
primary health promotion - CORRECT ANSWER -
t t t t t t t
prevent disease development through healthy lifestyle choices t t t t t t
secondary health promotion - CORRECT ANSWERV- t t t t t
screening efforts to promote early detection of disease
t t t t t t t t
tertiary health promotion - CORRECT ANSWER -minimizing disability from acute or chronic disease health
t t t t t t t t t t t t t
protection - CORRECT ANSWER -
t t t t t
actively avoid illness, early detection, maintain function with illness t t t t t t t t
Healthy people 2030 - CORRECT ANSWERV- t t t t t
goal of reducing most significant preventable health threats and reducing preventable health threats
t t t t t t t t t t t t
Skin assessment- when documenting a skin assessment, the nurse should: - CORRECT ANSWER -
t t t t t t t t t t t t t
Use standardized terminology to report findings
t t t t t t t
, • Use standardized terminology to record findings
t t t t t
• Perform assessment when risk factors identified t t t t t
• Allow information from the history to help direct the assessment t t t t t t t t t
• Document both normal and abnormal skin strategies from the assessment t t t t t t t t t
OLD CARTS - CORRECT ANSWER - t t t t t
Onset, Location, Duration, Characteristics, Aggravating Factors, Related Symptoms, Treatment, and Se verity
t t t t t t t t t t t
• Example:
• When did the rash start (onset) t t t t t
• What makes the rash worse (aggravating factors) t t t t t t
• What do you do to make the rash better (treatment) t t t t t t t t t
• Describe the sensation from the burn, does it burn or itch (related symptoms) t t t t t t t t t t t t
• Describe what the rash looked like initially (duration/characteristics) t t t t t t t
stage 1 pressure injury - CORRECT ANSWER -intact skin, non- blanchable
t t t t t t t t t t
redness over coccyx, tender, warm
t t t t t
stage 2 pressure injury - CORRECT ANSWER -
t t t t t t t
partial thickness loss of dermis, pink wound bed, no slough or bruising
t t t t t t t t t t t
stage 3 pressure injury - CORRECT ANSWER -
t t t t t t t
full thickness skin loss, subcutaneous fat visible, no visible bone
t t t t t t t t t
stage 4 pressure injury - CORRECT ANSWER -
t t t t t t t
full thickness tissue loss, tendon exposed, tunneling, slough present
t t t t t t t t
Nail Assessment - CORRECT ANSWERV-
t t t t
Nail surface should be smooth and flat in the center and slightly curved downward at the edges. The s kin
t t t t t t t t t t t t t t t t t t t
adjacent to the nail should be intact, the same color as adjacent skin and without edema. The expec ted angle of
t t t t t t t t t t t t t t t t t t t t t
the nail base is 160 degrees. The nail should have uniform thickness and the base should f eel firm and adhere to
t t t t t t t t t t t t t t t t t t t t t t
the nail bed.
t t t
jaundice - CORRECT ANSWERV-which is a yellowish-green color in light and dark skinned patients Jaundice
t t t t t t t t t t t t t t
can best be assessed in - CORRECT ANSWER -Sclera of the eye
t t t t t t t t t t t t
Palms of the hands t t t
Soles of the feet t t t
The appearance of the normal tympanic membrane is - CORRECT ANSWERV-
t t t t t t t t t t
Translucent and pearly gray t t t
tympanic membrane - CORRECT ANSWER - t t t t t
Redness of the tympanic membrane may indicate infection t t t t t t t
A brown sticky discharge is cerumen which is a normal finding, but may cause the tympanic membran e to be
t t t t t t t t t t t t t t t t t t t
obscured
t
Pink may indicate possible otitis externa or impending infection
t t t t t t t t
