Health Assessment In Nursing Exam
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Assessment Collection of subjective and objective data
Diagnoses Analysis of subjective and objective data to make a professional nursing
judgement
Planning Developing a plan of nursing care and outcome criteria
Implementation Carrying out the plan of care
Evaluation Assessing whether outcome criteria have been met and revising the
plan of care if necessary
Nursing Diagnosis Clinical judgement about individual, family or community responses to
actual or potential health problems and life processes
Subjective Data Sensations or symptoms that can be verified only by the client (ex. pain)
Objective Data Findings directly observed or indirectly observed through
measurements (ex. body temperature)
Collaborative Problem Physiologic complications that nurses monitor to detect their onset or
changes in status
Referral Problem Problem that requires the attention or assistance of other health care
professionals
A medical examination differs from a Physiologic status
comprehensive nursing examination in that the
medical examination focuses primarily on the
client's
The result of a nursing assessment is the Formulation of nursing diagnoses
Although the assessment phase of the nursing Continuous
process precedes the other phases, the
assessment phase is
When a client first enters the hospital for an Comprehensive
elective surgical procedure, the nurse should
perform an assessment termed
An ongoing or partial assessment of a client Includes a brief reassessment of the client's normal body system
The purpose of the comprehensive health Arrive at conclusions about the client's health
assessment is to
, The use of this type of question can keep a client Closed-ended
interview from going off track
A nurse can clarify a client's statements by Rephrasing the client's statements
During what phase of the interview between a Working phase
nurse and client do you collaborate to identify
problems and goals
When dealing with a manipulative client it is Provide structure and set limits
important for the nurse to
The primary purpose of the health history is to Identify risk factors to the client and his or her significant others
Define the "COLDSPAA" accronym Character, Onset, Location, Duration, Severity, Pattern, Associated
factors, how it Affects the client
Sim's position Side-lying position used during the rectal examination
Sitting Position Position used during much of the physical examination including
examination of the head, neck, lungs, chest, back, breast, axilla, heart,
vital signs, and upper extremities
Supine Position Back-lying position used for examination of the abdomen (with one
small pillow under the head and another under the knees); this position
also allows easy access for palpation of peripheral pulses
Standing Position Position used to examine male genitalia and to assess gait, posture, and
balance
Prone Position Client lies on abdomen with head turned to the side; may be used to
assess back and mobility of hip joint
Lithotomy Position Back-lying position with hips at edge of examining table and feet
supported in stirrups; used for examination of female genitalia,
reproductive tract, and rectum
What part of the examiner's hand is used to feel for Fingerpads
fine discriminations: pulses, texture, size,
consistency, shape, and crepitus
Part of the examiner's hand used to feel for Ulnar surface or palm of hand
vibration, thrills, or fremitus
Part of the examiner's hand used to feel for Dorsal surface of hand
temperature
Smaller end of stethoscope used to detect low- Bell of stethoscope
pitched sounds (abnormal heart sounds and bruits)
Larger end of stethoscope used to detect breath Diaphragm of stethoscope
sounds, normal heart sounds, and bowel sounds
Name the four basic techniques used for physical Inspection, palpation, percussion, auscultation
assessment