Nursing Health Assessment A
Best Practice Approach Edition
Actual EXAM
What is the purpose of nursing health assessment? - ANSWER>>>1) determine clients health status
2) identify risk factors
3) identify need for education as a basis for developing a nursing plan of care
What are the components of the nursing health assessment? - ANSWER>>>health history and physical
exam
The extent of the nursing assessment is determined by what? - ANSWER>>>the acuity of the clients
condition and the site of care
During the health history, what does the nurse do? - ANSWER>>>asks pertinent questions to gather data
from the client and/or family
When can past medical records be used to collect data during the health history? - ANSWER>>>if the
patient is unreliable or has no family or support system available
Physical exam is a structured _____ to _____ examination. - ANSWER>>>head to toe
What is the role of the nurse in assessment? - ANSWER>>>- collect data
- assess client needs
- formulate a nursing plan of care
- develop interventions based on identified needs
- educate and counsel patient
- collaborate with others in health care team
What are the two types of data? - ANSWER>>>subjective and objectice
What is subjective data? - ANSWER>>>- what the patient says
- obtained from the patient and/or family
,- includes past medical history, chief complaint (reason for seeking care) & review of systems
- ex. "shortness of breath," "my head hurts"
Always open the chief complaint interview with what type of question? - ANSWER>>>open ended
What are examples of an open ended question you can ask when beginning the chief complaint
interview? - ANSWER>>>- "what brought you here today"
- "tell me about the chest pressure, from when it begin until now"
- "what problems are you experiencing"
What is objective data? - ANSWER>>>- what you observe
- physical examination findings
- ex. BP, pulse, height, weight, etc.
What is a symptom? - ANSWER>>>subjective sensation described by the client
What is a sign? - ANSWER>>>objective abnormality that the examiner detects on physical examination
Symptom is the same as what type of data? - ANSWER>>>subjective
Sign is the same as what type of data? - ANSWER>>>objective
What are the three steps in exploring symptoms? - ANSWER>>>1) ask open-ended questions to hear
"the story of the symptom" in the patients own words
2) ask more specific questions to elicit "the seven features of every symptom" ( OLD CART)
3) ask yes or no questions or "pertinent positives and negatives" from the relevant section of the review
of systems
What are the 7 features of every symptom? (history of present illness) - ANSWER>>>OLD CART
- onset
- location
- duration
- character
- associated manifestations
- relieving/exacerbating factors
- treatment
What is onset? - ANSWER>>>when the sign or symptom began
What is location? - ANSWER>>>where the sign or symptom is located
What is duration? - ANSWER>>>how long the sign or symptom has been going on
, What is character? - ANSWER>>>What it feels like, how it is described, the severity/pain
- ex. "describe on a scale of 1 to 10"
What is associated manifestations? - ANSWER>>>what else is going on when the sign or symptom is
occurring (headache, vomit, sweating)
What is relieving/exacerbating factors? - ANSWER>>>what makes it better/worse, anything the patient
has tried to make to relieve the sign/symptom
What are treatments? - ANSWER>>>what treatments might the patient try, any interventions
What is health history? - ANSWER>>>-home medications (and how they take them)
-biographic data
-source of history
-reason for seeking care
-history of health
-family health history
-review of systems
-functional assessment (ADL's)
What are topics of data pertaining to lifestyle and health practices? - ANSWER>>>- description of typical
day
- nutrition and weight management
- activity and exercise
- sleep and rest patterns
- medication and substance use
- self concept
- social activities
- relationships
- values/beliefs
- education/work
- stress and coping styles
- environment
What are the different types of health histories? - ANSWER>>>1) comprehensive
2) focused of problem oriented
Best Practice Approach Edition
Actual EXAM
What is the purpose of nursing health assessment? - ANSWER>>>1) determine clients health status
2) identify risk factors
3) identify need for education as a basis for developing a nursing plan of care
What are the components of the nursing health assessment? - ANSWER>>>health history and physical
exam
The extent of the nursing assessment is determined by what? - ANSWER>>>the acuity of the clients
condition and the site of care
During the health history, what does the nurse do? - ANSWER>>>asks pertinent questions to gather data
from the client and/or family
When can past medical records be used to collect data during the health history? - ANSWER>>>if the
patient is unreliable or has no family or support system available
Physical exam is a structured _____ to _____ examination. - ANSWER>>>head to toe
What is the role of the nurse in assessment? - ANSWER>>>- collect data
- assess client needs
- formulate a nursing plan of care
- develop interventions based on identified needs
- educate and counsel patient
- collaborate with others in health care team
What are the two types of data? - ANSWER>>>subjective and objectice
What is subjective data? - ANSWER>>>- what the patient says
- obtained from the patient and/or family
,- includes past medical history, chief complaint (reason for seeking care) & review of systems
- ex. "shortness of breath," "my head hurts"
Always open the chief complaint interview with what type of question? - ANSWER>>>open ended
What are examples of an open ended question you can ask when beginning the chief complaint
interview? - ANSWER>>>- "what brought you here today"
- "tell me about the chest pressure, from when it begin until now"
- "what problems are you experiencing"
What is objective data? - ANSWER>>>- what you observe
- physical examination findings
- ex. BP, pulse, height, weight, etc.
What is a symptom? - ANSWER>>>subjective sensation described by the client
What is a sign? - ANSWER>>>objective abnormality that the examiner detects on physical examination
Symptom is the same as what type of data? - ANSWER>>>subjective
Sign is the same as what type of data? - ANSWER>>>objective
What are the three steps in exploring symptoms? - ANSWER>>>1) ask open-ended questions to hear
"the story of the symptom" in the patients own words
2) ask more specific questions to elicit "the seven features of every symptom" ( OLD CART)
3) ask yes or no questions or "pertinent positives and negatives" from the relevant section of the review
of systems
What are the 7 features of every symptom? (history of present illness) - ANSWER>>>OLD CART
- onset
- location
- duration
- character
- associated manifestations
- relieving/exacerbating factors
- treatment
What is onset? - ANSWER>>>when the sign or symptom began
What is location? - ANSWER>>>where the sign or symptom is located
What is duration? - ANSWER>>>how long the sign or symptom has been going on
, What is character? - ANSWER>>>What it feels like, how it is described, the severity/pain
- ex. "describe on a scale of 1 to 10"
What is associated manifestations? - ANSWER>>>what else is going on when the sign or symptom is
occurring (headache, vomit, sweating)
What is relieving/exacerbating factors? - ANSWER>>>what makes it better/worse, anything the patient
has tried to make to relieve the sign/symptom
What are treatments? - ANSWER>>>what treatments might the patient try, any interventions
What is health history? - ANSWER>>>-home medications (and how they take them)
-biographic data
-source of history
-reason for seeking care
-history of health
-family health history
-review of systems
-functional assessment (ADL's)
What are topics of data pertaining to lifestyle and health practices? - ANSWER>>>- description of typical
day
- nutrition and weight management
- activity and exercise
- sleep and rest patterns
- medication and substance use
- self concept
- social activities
- relationships
- values/beliefs
- education/work
- stress and coping styles
- environment
What are the different types of health histories? - ANSWER>>>1) comprehensive
2) focused of problem oriented
