NRS 2014 - Health Assessment -
Lecture Exam 1 Study Guide
Questions with Actual Answers 2025-
2026 Updated.
Nursing Process Steps - Answer 1. Assessment - collection of data from multiple sources
(interview, health history, physical exam, review of clinical records)
2. Diagnosis - interpretation of data to make inferences and validate findings
3. Outcome Identification - identify expected outcomes based on individual patient ensuring
they are realistic and measurable
4. Planning - Establish priorities, develop outcomes and time frames, identify interventions and
interdisciplinary health care team members, and document plan of care
5. Implementation
6. Evaluation - Evaluate patient's condition and compare actual outcomes with expected
outcomes, summarize results, identify issues and modify plan of care accordingly
Priority Levels for Problems - Answer First-Level Priority - emergent, life threatening and
immediate
Second-Level Priority - Next in urgency, requiring attention to avoid further deterioration
Third-Level Priority - Important to patient's health, but can be addressed after more urgent
problems are addressed
Collaborative Problems - Approach to treatment involves multiple disciplines (i.e nurse,
physician, dietician, etc.)
Hand Hygiene - Answer Wash hands before and after physical contact with each patient and
after contact with body fluids, contaminated equipment and removing gloves.
Hand washing is the single most important step to decrease microorganism transmission
Assessment Order - Answer Performed one at a time, in this order always (with a few
exceptions)
1. Inspection - what you see
2. Palpation - touch and feel
,3. Percussion - tapping
4. Auscultation - listening with stethoscope
- Auscultation exceptions
- Exception for auscultation being last is when evaluating the abdomen
- When the patient is in a lot of pain
Palpation Techniques - Answer Different parts of hands are best suited for assessing different
factors:
Fingertips: best for fine tactile discrimination of skin texture, swelling, pulsation, determining
presence of lumps
Fingers and thumb: detection of position, shape, and consistency of an organ or mass
Dorsum of hands and fingers: best for determining temperature because skin here is thinner
than on palms
Base of fingers or ulnar surface of hand: best for vibration
Percussion - Answer Tapping person's skin with short, sharp strokes to assess underlying
structures
Uses:
-Mapping location and size of organs
-Signaling density of a structure
-Detecting a superficial abnormal mass
-Eliciting pain if underlying structure is inflamed
-Eliciting deep tendon reflex using percussion hammer
Percussion Methods - Answer -Direct, sometimes called immediate, the striking hand
directly contacts body wall
-Indirect, or mediate, using both hands, the striking hand contacts stationary hand fixed on
person's skin
Auscultation - Answer Listening to sounds produced by the body
Used for heart, lung and bowel sounds
, General Survey - Answer The general survey is an objective study of the whole person that
covers general health state and any obvious physical characteristics
It's an introduction for a physical examination that will follow and should give an overall
impression a of person
The general survey should begin the moment you first encounter a person
General Surgery Objective Data - Physical Appearance - Answer Age
Gender
Sexual Development - appropriate for gender and age
Level of Consciousness
Skin Color
Facial Features - symmetric movements
Any signs of Acute Distress
General Surgery Objective Data - Body Structure - Answer Stature
Nutrition - weight appearing within normal range for person's size
Symmetry - bilaterally
Posture
Position
Body Build and Contour - proportions
Obvious Physical Deformities
General Surgery Objective Data - Behavior - Answer Facial Expression
Mood
Speech
Dress
Personal Hygiene
Vital Signs - Answer Objective data that includes temperature, respiratory rate, pulse and
blood pressure
Temperature - Answer Body maintains steady temperature through feedback mechanism
regulated in the hypothalamus of the brain
Lecture Exam 1 Study Guide
Questions with Actual Answers 2025-
2026 Updated.
Nursing Process Steps - Answer 1. Assessment - collection of data from multiple sources
(interview, health history, physical exam, review of clinical records)
2. Diagnosis - interpretation of data to make inferences and validate findings
3. Outcome Identification - identify expected outcomes based on individual patient ensuring
they are realistic and measurable
4. Planning - Establish priorities, develop outcomes and time frames, identify interventions and
interdisciplinary health care team members, and document plan of care
5. Implementation
6. Evaluation - Evaluate patient's condition and compare actual outcomes with expected
outcomes, summarize results, identify issues and modify plan of care accordingly
Priority Levels for Problems - Answer First-Level Priority - emergent, life threatening and
immediate
Second-Level Priority - Next in urgency, requiring attention to avoid further deterioration
Third-Level Priority - Important to patient's health, but can be addressed after more urgent
problems are addressed
Collaborative Problems - Approach to treatment involves multiple disciplines (i.e nurse,
physician, dietician, etc.)
Hand Hygiene - Answer Wash hands before and after physical contact with each patient and
after contact with body fluids, contaminated equipment and removing gloves.
Hand washing is the single most important step to decrease microorganism transmission
Assessment Order - Answer Performed one at a time, in this order always (with a few
exceptions)
1. Inspection - what you see
2. Palpation - touch and feel
,3. Percussion - tapping
4. Auscultation - listening with stethoscope
- Auscultation exceptions
- Exception for auscultation being last is when evaluating the abdomen
- When the patient is in a lot of pain
Palpation Techniques - Answer Different parts of hands are best suited for assessing different
factors:
Fingertips: best for fine tactile discrimination of skin texture, swelling, pulsation, determining
presence of lumps
Fingers and thumb: detection of position, shape, and consistency of an organ or mass
Dorsum of hands and fingers: best for determining temperature because skin here is thinner
than on palms
Base of fingers or ulnar surface of hand: best for vibration
Percussion - Answer Tapping person's skin with short, sharp strokes to assess underlying
structures
Uses:
-Mapping location and size of organs
-Signaling density of a structure
-Detecting a superficial abnormal mass
-Eliciting pain if underlying structure is inflamed
-Eliciting deep tendon reflex using percussion hammer
Percussion Methods - Answer -Direct, sometimes called immediate, the striking hand
directly contacts body wall
-Indirect, or mediate, using both hands, the striking hand contacts stationary hand fixed on
person's skin
Auscultation - Answer Listening to sounds produced by the body
Used for heart, lung and bowel sounds
, General Survey - Answer The general survey is an objective study of the whole person that
covers general health state and any obvious physical characteristics
It's an introduction for a physical examination that will follow and should give an overall
impression a of person
The general survey should begin the moment you first encounter a person
General Surgery Objective Data - Physical Appearance - Answer Age
Gender
Sexual Development - appropriate for gender and age
Level of Consciousness
Skin Color
Facial Features - symmetric movements
Any signs of Acute Distress
General Surgery Objective Data - Body Structure - Answer Stature
Nutrition - weight appearing within normal range for person's size
Symmetry - bilaterally
Posture
Position
Body Build and Contour - proportions
Obvious Physical Deformities
General Surgery Objective Data - Behavior - Answer Facial Expression
Mood
Speech
Dress
Personal Hygiene
Vital Signs - Answer Objective data that includes temperature, respiratory rate, pulse and
blood pressure
Temperature - Answer Body maintains steady temperature through feedback mechanism
regulated in the hypothalamus of the brain
