WGU HEALTH ASSESSMENT (A+) WITH 100%CORRECT QUESTIONS AND ANSWERS

Subjective data - ANSWERS-Said by the client (S) .Obejective data - ANSWERS-Observed by the nurse (O) .Assessment Techniques is as follows - ANSWERS-Inspect-Palpation-Percussion-Auscultation .Order of Abdomen Assessment - ANSWERS-Inspect-Auscultation-Percuss-Palapate .Inspection - ANSWERS-*always first* 1. Take time to observe with eyes ear nose 2.Use good lighting 3.Look at color shape symmetry position 4.Observe for odors from skin breath wound 5. Develop and use nursing instincts 6.Inspection is done alone and in combination with other assessment techniuqes .Back of hand - ANSWERS-To assess skin temperature use .Deep Palpation - ANSWERS-5-8cm or (2-3") deep is considered .Light Paplpation - ANSWERS-1cm deep is considered .Percussion - ANSWERS-sounds produced by striking body surface sounds are dull resonant flat tympanic action is performed in the wrist .Ausculation - ANSWERS-listening to sounds produced by the body .Bell - ANSWERS-picks up low pitched sounds such as heart murmurs .General Survey - ANSWERS-is an overall review or first impression a nurse has of person's well being. .Appearance - ANSWERS-appears to be reported age sexual development appropriate alert and oriented facial features symmetric no signs of acute distress .Body Structure/mobilty - ANSWERS-weight and height WNL BMI guidelines body parts equal bilaterally stands erect sits comfortably gait is coordinated walk is smooth and well balanced full mobility of joints .Behavior - ANSWERS-maintains eye contact with appropriate expressions comfortable and cooperative speech clear clothing is correct for climate looks cleat and fit appears clean and well groomed .Comprehensive history - ANSWERS-which includes chief complaint or reason for the visit a complete review of systems and complete past family and social history should be obtained on the first encounter with a patient regardless of setting and by a RN .Family Health Hx - ANSWERS-Are completed across three generations looking specifically for patterns in genetic issues that negatively impact quality of life .Health Hx - ANSWERS-gives a picture of patient's current health and documentation must be completed for each visit and or assessment .How to measure height less than 2 years of age - ANSWERS-Obtain height by measuring the recumbent length of children less than 2 years of age and children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary headboard and a sliding vertical foot piece is ideal, but a tape measure can also be used a) Lay the child flat against the center of the board. The head should be held against the headboard by the parent or an assistant and the knees held so that the hips and knees are extended. The foot piece is moved until it is firmly against the child's heels. Read and record the measurement to the nearest 1/8 inch. b) A modified technique in home settings is to lay the child flat and straight where the head should be held by the parent and the knees held so that the hips and knees are extended, mark the flat surface at the top of the head and tip of the heels. Move child and measure the distance between the marks with a tape measure. Read and record the measurement to the nearest 1/8 inch 2. When a recumbent length is obtained for a two year old, it should be plotted on the birth to 36 months growth chart. When a standing height is obtained for a two year old, plot the finding on the 2 year to 18 year chart. After plotting measurements for children on age and gender specific growth charts, evaluate, educate and refer according to findings. .Height children 2-3 and older - ANSWERS-3. Obtain a standing height on children greater than 2 to 3 years of age, adolescents, and adults, using a portable stadiometer. The patient is to be wearing only socks or be bare foot. Have the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees are to be straight and feet flat on the floor, and the patient is asked to look straight ahead. The flat surface of the stadiometer is lowered until it touches the crown of the head, compress the hair. A measuring rod attached to a weight scale should not be used. .Measuring weight: - ANSWERS-1. Balance beam or digital scales should be used to weigh patients of all ages. Spring type scales are not acceptable. CDC recommends that all scales should be zero balanced and calibrated. Scales must be checked for accuracy on an annual basis and calibrated in accordance with manufacturer's instructions. 2. Prior to obtaining weight measurements, make sure the scale is "zeroed". .Weight infants, children, and teens and adults - ANSWERS-3. Weigh infants wearing only a dry diaper or light undergarments. Weigh children after removing outer clothing and shoes. Weigh adolescents and adults with the patient wearing minimal clothing. 4. Place the patient in the middle of the scale. Read the measurement and record results immediately. Plot measurements on age and gender specific growth charts and evaluate accordingly .Measuring head circumference - ANSWERS-Obtain measurement on children from birth to 36 months of age by extending a non stretchable measuring tape around the broadest part of the child's head For greatest accuracy the tape is placed 3 times with a reading taken at the right side at the left side and at the mid forehead and the greatest circumference is plotted. The tape should be pulled adequately compress the hair Should be measured each visit .Chest circumference - ANSWERS-This is measured at the nipple line in a newborn the head circumference with be about 2 cm larger than the chest circumference AS the child ages the chest circumference becomes larger than the head circumference .Vital Signs - ANSWERS-generally described as the measurement of temp pulse resp and b/p give an immediate picture of a person's current state of health and well being. Normal and abnormal ranges with management guidelines follow for children and adults .Temperture - ANSWERS-oral usually 98.6 axillary 97.6 litter lower rectal and aural (ear) 99.6 slightly higher .Resperiations - ANSWERS-1. Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations 2. Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or labored? 3. Count breaths for 15 seconds and multiply this number by 4 to yield the breaths per minute. 4. In adults, normal resting respiratory rate is between 14-20 breaths/minute. 5. Rapid respiration is called tachypnea. .Pulse - ANSWERS-Count for 15 seconds multiply x4 Always cont for a full minute if the pulse is irregular Record the rate and rhythm .Interpretation - ANSWERS-1. A normal adult heart rate is between 60 and 100 beats per minute (see below for children). 2. A pulse greater than 100 beats/minute is defined to be tachycardia. A pulse less than 60 beats/minute is defined to be bradycardia. 3. Tachycardia and bradycardia are not necessarily abnormal. Athletes tend to be bradycardic at rest (superior conditioning). Tachycardia is a normal response to stress or exercise. .Birth - ANSWERS-Pulse 140 SBP 70 .6 months - ANSWERS-Pulse 130 SBP 90 .1 year - ANSWERS-Pulse 115 SBP 90 .2 year - ANSWERS-Pulse 110 SBP 92 .6 year - ANSWERS-Pulse 103 SBP 95 .8 year - ANSWERS-Pulse 100 SBP 100 .10 year - ANSWERS-Pulse 95 SPB 105 .B/P Norm - ANSWERS-S <130 D <85 .High Norm BP - ANSWERS-S 130-139 D 85-89 .Mild Hypertension - ANSWERS-S 140-159 D 90-99 .Moderate Hypertension - ANSWERS-S 160-179 D 100-109 .Servere Hypertension - ANSWERS-S 180-209 D 110-119 .Crisis HTN - ANSWERS-S >210 D >120 .Inspect Skin - ANSWERS-color uniformity moisture hair pattern rashes lesions pallor edema .Palpate skin - ANSWERS-temp turgor lesions edema texture .Indicative of heat stroke shock or other cardiac complications - ANSWERS-pale cool moist skin .Posterior fontanel - ANSWERS-triangle shaped closes 1-2 months .anterior fontanel - ANSWERS-diamond shaped closes at 9months - 2 years .Assess ears using otoscope - ANSWERS-1. Hold the otoscope upside down with your thumb and fingers so that the ulnar aspect of your hand makes contact with the pt 2. for adults pull the ear upwards and backwards to straighten canal 3. For PEDS pul the ear down and back 4. Use the largest speculum that will fit comfortably .Normal color of eardrum - ANSWERS-shiny translucent, pearly gray .Ear Abnormal findings - ANSWERS-Erythema-suppurative ottis media, purulent drainage Dull nontransparent gray serous otitis media effusion .Conductive hearing Loss - ANSWERS-Due to mechanical dysfunction of inner or middle ear .Sensory neural loss - ANSWERS-Due to pathological problem of inner ear, CNS or cerebral cortex .Hearing in older adults - ANSWERS-there may be some normal high tone hearing loss .Tubinates - ANSWERS-should be pink and moist in the nose .maxillary sinuses - ANSWERS-are below the zygomatic arch .hard palate - ANSWERS-located in the anterior part of the mouth it is made of bone and is pale or whitish .soft palate - ANSWERS-located in the posterior part of the mouth it is softer more mobile and pink in color .deep cervical chain of lymph nodes - ANSWERS-lies below the sternomastoid and cannot be palpated without getting underneath the muscle inform the pt this procedure will cause discomfort .Lymph nodes - ANSWERS-note the size and location of any palpable nodes and weather they were soft or hard non tender or tender and mobile or fixed .thyroid glan - ANSWERS-one way to look is to have a person swallow sip of water the thyroid gland will move upward with a swallow .sinus transillumination - ANSWERS-1. Darken the room as much as possible. 2. Place a bright otoscope or other point light source on the maxilla. 3. Ask the patient to open their mouth and look for an orange glow on the hard palate. 4. A decreased or absent glow suggests that the sinus is filled with something other than air. 5. Not always definitive of disease process. .Visual Acuity - ANSWERS-In cases of eye pain, injury, or visual loss, always check ______ ___________ before proceeding with the rest of the exam or putting medications in your patients eyes. 1. Allow the patient to use their glasses or contact lens if available. You are interested in the patient's best corrected vision 2. Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum pocket card at 14 inch "reading" distance) 3. Have the patient cover one eye at a time with an opaque card. .Visual Fields, by Confrontation - ANSWERS-1. Stand two feet in front of the patient and have them look into your eyes. 2. Hold your hands to the side half way between you and the patient. 3. Wiggle the fingers on one hand. 4. Ask the patient to indicate which side they see your fingers move. 5. Repeat two or three times to test both temporal fields. 6. If an abnormality is suspected, test the four quadrants of each eye while asking the patient to cover the opposite eye with a card .Extraocular Movement - ANSWERS-1. Check gaze in the six cardinal directions using a cross or "H" pattern. 2. Check convergence by moving your finger toward the bridge of the patient's nose. 3. Pause during upward and lateral gaze to check for nystagmus (involuntary eye movement which differs in each eye). 4. Tests CN 3, 4, and 6 .EOM - ANSWERS-Test Cranial Nerves 3, 4, 6 .Pupillary Reactions - ANSWERS-PERRLA is a common abbreviation for Pupils Equal Round Reactive to Light and Accommodation but use the term PERRL is you do not check for accommodation .Accomodation - ANSWERS-a) Hold your finger about 10cm from the patient's nose. b) Ask them to alternate looking into the distance and at your finger. c) Observe the pupillary response in each eye. .Ophthalmoscopic Exam - ANSWERS-3. Use your left hand and left eye to examine the patient's left eye. Use your right hand and right eye to examine the patient's right eye. Place your free hand on the patient's shoulder for better control. 4. Ask the patient to stare at a point on the wall or corner of the room. 5. Look through the ophthalmoscope and shine the light into the patient's eye from about two feet away. You should see the retina as a "red reflex." Follow the red color to move within a few inches of the patient's eye. 6. Adjust the diopter dial to bring the retina into focus. Find a blood vessel and follow it to the optic disk. Use this as a point of reference. 7. Inspect outward from the optic disk in at least four quadrants and note any abnormalities. 8. Move nasally from the disk to observe the macula. 9. Repeat for the other eye. 10. Normal color should be creamy yellow-orange to pink. .Inspection of the chest and lungs - ANSWERS-A-P (anterior-posterior) diameter vs. transverse diameter a) A-P should be less than Transverse in adults; 1:2 - 5:7 b) Elevated A-P size= barrel chest may be COPD in adult, normal in childern .Percussion lungs chest - ANSWERS-Proper Technique 1. Hyperextend the middle finger of one hand and place the distal interphalangeal joint firmly against the patient's chest. 2. With the end (not the pad) of the opposite middle finger, use a quick flick of the wrist to strike first finger. 3. Categorize what you hear as normal, dull, or hyperresonant. 4. Practice your technique until you can consistently produce a "normal" percussion note on your (presumably normal) partner before you work with patients. .Diaphragmatic Excursion - ANSWERS-Diaphragmatic Excursion 1. Find the level of the diaphragmatic dullness on both sides. 2. Ask the patient to inspire deeply. 3.The level of dullness (diaphragmatic excursion) should go down 3-5 m symmetrically .Hyperresonant - ANSWERS-Sound can be emphysema or pneumothorax .breath sounds - ANSWERS-are produced by turbulent air flow. They are categorized by the size of the airways that transmit them to the chest wall (and your stethoscope). The general rule is, the larger the airway, the louder and higher pitched the sound. .Vesicular breath - ANSWERS-sounds are low pitched and normally heard over most lung fields. .Bronchovesicular - ANSWERS-and bronchial sounds are heard in between. Inspiration is normally longer than expiration (I > E). .Adventitious Breath sounds - ANSWERS-Extra breath sounds Crackles Wheezes