INTRO TO ASSESSMENT & THE HEALTH HISTORY / EXAM 1 /
NUR 112 / STANDRIDGE QUESTIONS WITH ACCURATE
ANSWERS
- *General appearance*
Personal appearance, grooming, hygiene, whether the patient is
dressed appropriately for the weather; posture during the
assessment.
- *Emotional reaction*
- Blunted affect is greatly diminished emotional response to a
situation or condition.
- Flat affect is virtual absence of emotional response to a situation
or condition
- *Speech pattern*
- Clarity, coherent, volume, articulation of words.
- *Memory/cognition*
- Immediate, short term and long term
- Orientation to *person, place, time, and situation:*
Person: What is your name?
Place: Where are you right now? What is your address?
Time: What is the today's date? What season are we in?
Situation: What are you doing right now?
- *Behavior and mood*- Oppositional/resistant, submissive,
defensive, open and friendly, candid and cooperative, shows
subdued mistrust and hostility, excessive shyness, happy, sad,
indifferent
- *Suicide assessm correct answer The Health History- *Mental
Health Assessment*
- A cognitive assessment is performed to determine a patient's
level of cognitive function. The Mini-Mental State Examination is a
short assessment of 11 questions that test five areas of cognitive
function: (1) orientation, (2) registration, (3) attention and
calculation, (4) recall, and (5) language. *The maximum score is
30. A score of 23 or lower is indicative of cognitive impairment.* It
,takes only 5 to 10 minutes to administer, so it is practical to use
repeatedly and routinely. correct answer Mini- Mental State
Examination *(Page 39)*:
- Comprehensive assessments
-Focused assessments
- Follow-up assessments correct answer What are the three types
of assessments?
- Directly tapping the area
- Steps:
1. Explain the technique to your patient.
2. Expose only the area that you will be percussing.
3. Using one or two fingertips, directly and lightly tap the area
that needs to be assessed.
*Strike twice* correct answer Assessment techniques- Percussion-
*Direct Percussion*
- Do not assume a patient's sexuality.
- Gender-neutral language such as "partner or spouse"
communicates to lesbian, gay, bisexual, and transgender patients
that it is safe for them to be honest and open with the
interviewer.
- *Healthy People 2020 Goal*: Promote healthy sexual behaviors,
strengthen community capacity, and increase access to quality
services to prevent STIs and their complications. correct answer
The Health History- *Sexuality*
- First step when assessing a client
-Surveying the whole client
- Using your senses of sight, hearing, and smell.
- What is your *overall impression?* correct answer General
Survey:
- Get or give information
- Identify a problem
- Evaluate change
- Teach
- Provide support or counseling correct answer 5 reasons to obtain
, an interview:
- Know the difference between Religion and Spirituality.
- Know FICA tool correct answer The Health History- *Spiritual
assessment*
- Mini mental health examination (Pg.39)
- 5 areas of cognitive function correct answer The Health History-
*Cognitive assessment*
- Primary (patient)
- Secondary (Family, friends, caregiver, records, other healthcare
workers..) correct answer What are two sources of data?
- Read the client's chart *before* you enter the client's room.
- Pick a time when the client is *comfortable* and when
*disruptions* will be minimal.
- Arrange the right *environment.*
- Gather all of your *equipment.*
- Position yourself at *eye level.*
- Interview distance is typically *2-3* feet.
- Don't be *rushed.*
- Educate yourself on information you may be unfamiliar with
*before* you enter the client's room. correct answer How to
prepare for an Assessment / Interview / Health history:
- The *observation* part of the assessment
- *Purpose*: To look and examine the physical aspects of the
body, posture, appearance, and behavior carefully.
- Using your senses of *sight, hearing, and smell.*
- We *look before we touch.*
- During inspection, no touching is involved.
- TIP- Fluorescent lights can change the color of the skin. *Natural
lighting* is the best lighting, if available. correct answer
Assessment techniques- *Inspection*
- The *touching* part of the examination correct answer
Assessment techniques- *Palpation*
NUR 112 / STANDRIDGE QUESTIONS WITH ACCURATE
ANSWERS
- *General appearance*
Personal appearance, grooming, hygiene, whether the patient is
dressed appropriately for the weather; posture during the
assessment.
- *Emotional reaction*
- Blunted affect is greatly diminished emotional response to a
situation or condition.
- Flat affect is virtual absence of emotional response to a situation
or condition
- *Speech pattern*
- Clarity, coherent, volume, articulation of words.
- *Memory/cognition*
- Immediate, short term and long term
- Orientation to *person, place, time, and situation:*
Person: What is your name?
Place: Where are you right now? What is your address?
Time: What is the today's date? What season are we in?
Situation: What are you doing right now?
- *Behavior and mood*- Oppositional/resistant, submissive,
defensive, open and friendly, candid and cooperative, shows
subdued mistrust and hostility, excessive shyness, happy, sad,
indifferent
- *Suicide assessm correct answer The Health History- *Mental
Health Assessment*
- A cognitive assessment is performed to determine a patient's
level of cognitive function. The Mini-Mental State Examination is a
short assessment of 11 questions that test five areas of cognitive
function: (1) orientation, (2) registration, (3) attention and
calculation, (4) recall, and (5) language. *The maximum score is
30. A score of 23 or lower is indicative of cognitive impairment.* It
,takes only 5 to 10 minutes to administer, so it is practical to use
repeatedly and routinely. correct answer Mini- Mental State
Examination *(Page 39)*:
- Comprehensive assessments
-Focused assessments
- Follow-up assessments correct answer What are the three types
of assessments?
- Directly tapping the area
- Steps:
1. Explain the technique to your patient.
2. Expose only the area that you will be percussing.
3. Using one or two fingertips, directly and lightly tap the area
that needs to be assessed.
*Strike twice* correct answer Assessment techniques- Percussion-
*Direct Percussion*
- Do not assume a patient's sexuality.
- Gender-neutral language such as "partner or spouse"
communicates to lesbian, gay, bisexual, and transgender patients
that it is safe for them to be honest and open with the
interviewer.
- *Healthy People 2020 Goal*: Promote healthy sexual behaviors,
strengthen community capacity, and increase access to quality
services to prevent STIs and their complications. correct answer
The Health History- *Sexuality*
- First step when assessing a client
-Surveying the whole client
- Using your senses of sight, hearing, and smell.
- What is your *overall impression?* correct answer General
Survey:
- Get or give information
- Identify a problem
- Evaluate change
- Teach
- Provide support or counseling correct answer 5 reasons to obtain
, an interview:
- Know the difference between Religion and Spirituality.
- Know FICA tool correct answer The Health History- *Spiritual
assessment*
- Mini mental health examination (Pg.39)
- 5 areas of cognitive function correct answer The Health History-
*Cognitive assessment*
- Primary (patient)
- Secondary (Family, friends, caregiver, records, other healthcare
workers..) correct answer What are two sources of data?
- Read the client's chart *before* you enter the client's room.
- Pick a time when the client is *comfortable* and when
*disruptions* will be minimal.
- Arrange the right *environment.*
- Gather all of your *equipment.*
- Position yourself at *eye level.*
- Interview distance is typically *2-3* feet.
- Don't be *rushed.*
- Educate yourself on information you may be unfamiliar with
*before* you enter the client's room. correct answer How to
prepare for an Assessment / Interview / Health history:
- The *observation* part of the assessment
- *Purpose*: To look and examine the physical aspects of the
body, posture, appearance, and behavior carefully.
- Using your senses of *sight, hearing, and smell.*
- We *look before we touch.*
- During inspection, no touching is involved.
- TIP- Fluorescent lights can change the color of the skin. *Natural
lighting* is the best lighting, if available. correct answer
Assessment techniques- *Inspection*
- The *touching* part of the examination correct answer
Assessment techniques- *Palpation*
