HEALTH ASSESSMENT
EXAM REVIEW
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,1. What are the four main steps of the nursing process
Correct Answer
Assessment, Analysis, Planning, Implementation, Evaluation.
2. What does the assessment step in the nursing process involve
Correct Answer
A systematic, dynamic collection of subjective and objective data.
3. What does the acronym IPPA stand for in physical examination
Correct Answer
Inspection, Palpation, Percussion, and Auscultation.
,4. What is the purpose of the analysis step in the nursing process
Correct Answer
To cluster assessment data to identify problems or nursing diagnoses.
5. What is an example of a nursing diagnosis
Correct Answer
Disturbed sleep pattern, decreased cardiac output, impaired nutrition.
6. How should goals in the planning step of the nursing process be
characterized
Correct Answer
Specific, measurable, achievable, and relevant.
7. What is the implementation step in the nursing process
Correct Answer
Carrying out appropriate nursing interventions to meet expected outcomes.
8. What does the evaluation step in the nursing process entail
Correct Answer
Comparing actual outcomes with expected outcomes and modifying the
care plan as needed.
9. What should be done if there is a language barrier during patient
assessment
Correct Answer
An interpreter should always be obtained.
,10. What are some Native American remedies mentioned in the notes
Correct Answer
Sweat lodges, Smudging, Amulets.
11. What should be assessed regarding herbal supplements during
medication reconciliation
Correct Answer
Always assess the use of herbal supplements.
12. What are the types of databases used in health assessment
Correct Answer
Episodic/focused, Complete, Follow-up, Emergency.
13. What is included in a complete health history
Correct Answer
Biographical data, Chief Complaint, History of Present Illness, Past Medical
History, Family History, Review of systems.
14. What does OPQRSTU stand for in the History of Present Illness
Correct Answer
Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing,
Understanding.
15. What are Activities of Daily Living (ADLs)
Correct Answer
Basic self-care tasks such as ambulating, feeding, dressing, personal
hygiene, continence, and toileting.
,16. What are Instrumental Activities of Daily Living (IADLs)
Correct Answer
More complex skills needed for independent living, such as using the
telephone, shopping, and managing finances.
17. What is the purpose of a functional assessment in nursing
Correct Answer
To assess the ability to perform ADLs, especially in older adults or those
with chronic illness.
18. What is the Get Up and Go Test used for
Correct Answer
To assess gait and balance in older adults.
19. What are some components of a functional assessment
Correct Answer
Self-esteem/self-concept, nutrition, activity and exercise, sleep/rest,
interpersonal relationships, stress management.
20. Why is medication reconciliation important
Correct Answer
To assess for interactions and ensure patient safety regarding medications.
21. What should be documented in the patient's record during the
implementation phase
Correct Answer
All nursing interventions performed.
,22. What is the significance of assessing nonverbal behaviors in
cultural assessments
Correct Answer
To understand patient responses and cultural practices that may affect
care.
23. What questions should be asked during a cultural assessment
Correct Answer
24. What are your religious or spiritual preferences
Correct Answer
What cultural practices are important to you
What are your health goals
25. What is the total score for fall risk assessment in elderly patients
Correct Answer
Gait score (out of 12) + Balance score (out of 16). A total score of ≤ 18
indicates high fall risk, 19-23 indicates moderate fall risk, and ≥ 24 indicates
low fall risk.
26. What are common signs and symptoms of dehydration in elderly
patients
Correct Answer
Confusion, weakness, dizziness, headaches, dry mouth, sunken eyes,
inability to sweat or produce tears, tachycardia, low blood pressure, low
urine output, and constipation.
27. What should be assessed during the interview process with
elderly patients
Correct Answer
,Hearing and vision impairments.
28. What is the best way to document health history during an
interview
Correct Answer
Document electronically in the room to avoid forgetting details, but be
aware it may cause the interviewer to miss important nonverbal cues.
29. What type of questions are best for allowing clients to express
their story during an interview
Correct Answer
Open-ended questions.
30. When are closed questions appropriate in patient interviews
Correct Answer
In time-sensitive situations or when specific information is needed.
31. What is the significance of silence during patient interviews
Correct Answer
Silence allows patients to express emotions.
32. What should be avoided in communication with patients
Correct Answer
Avoid 'why' questions and leading questions, as they may elicit untrue
responses.
33. What is the purpose of the nursing process
Correct Answer
,To identify needs, create a plan of care, and determine the effectiveness of
interventions.
34. In the nursing process, which stage involves assessing the
success of interventions
Correct Answer
Evaluation.
35. What should a nurse do first for a client with a history of HIV
complaining of chest pain
Correct Answer
Inspect for chest expansion and accessory muscle use.
36. What should be included in the assessment of a post-operative
patient six weeks after a cesarean section
Correct Answer
Collection of data about the client's health in the past 6 weeks.
37. What is the nurse's top priority for a patient claiming to be having
a heart attack
Correct Answer
Start a focused assessment of the patient immediately.
38. How do you calculate pack years for a patient who smokes 1 pack
per day for 30 years
Correct Answer
30 pack years.
39. What is the first step in assessing mental status
Correct Answer
, Assess level of consciousness (LOC).
40. What should be done if a patient is lethargic or unresponsive
during a mental status exam
Correct Answer
Do not proceed with the exam; focus on determining responsiveness.
41. When is a full mental status exam necessary
Correct Answer
For anyone presenting with confusion, signs of anxiety or depression,
substance abuse, or signs of psychiatric illness.
42. What does A&O x4 stand for in assessing level of consciousness
Correct Answer
Alert and oriented to person, place, time, and situation.
43. What steps should be taken if a patient's eyes do not open
spontaneously
Correct Answer
Use voice, then touch, and finally pain to elicit a response.
44. What does a Glasgow Coma Scale (GCS) score of less than 7
indicate
Correct Answer
It can indicate severe neurological damage.
45. What are the four levels of consciousness described in the notes
Correct Answer