NSG 121 Exam I | Health
Assessment Exam Study Guide |
Download to Score A+ | Herzing
The Physical Examination - Correct Answer - Inspection, Palpation,
Percussion, and Auscultation
Physical Examination - Inspection - Correct Answer - First - Start with
overall general survey.
Note physical characteristics and behaviors.
Note any odors. For focused inspection, assure adequate covering.
Intentional and deliberate
Physical Examination - Palpation - Correct Answer - Second - Use of
touch to assess temperature, texture, moisture, size, shape, location,
position, vibration, crepitus, tenderness, pain, and edema.
Physical Examination - Percussion - Correct Answer - Third - Produce
sound or elicit tenderness.
Physical Examination - Auscultation - Correct Answer - Listening for
sounds of movement from organs and tissues. A stethoscope is used to
transmit normally unheard sounds. Auscultation requires a quiet
environment with minimal to no distractions.
Comparison of auscultation sounds - Correct Answer -
,Direct Percussion - Correct Answer - To tap with your fingers directly on
the patient's skin.
ex. Sinuses - tap over periorbital area
Indirect Percussion - Correct Answer - Position nondominant hand
between patient and
dominant hand. Tap with dominant hand.
Percussion Tones - Correct Answer - Flat, dull, tympanic, resonant and
hyperresonant
PERCUSSION SOUNDS - Correct Answer -
Purpose of Documentation - Correct Answer - ▪Sentinel Event -
unexpected occurrence involving death or serious, physiological or
psychological injury
▪Verbal Communication - SBAR- situation, background, assessment,
recommendations
▪Written Communication - documenting in EHR
IF ITS NOT DOCUMENTED IT DIDN'T HAPPEN!!!
Stethoscope - Correct Answer - Conducts sound from patient to listener
and blocks
environmental noise. Does not amplify!!!!!
Bell of Stethoscope - Correct Answer - low frequency sounds, light skin
pressure
, Diaphragm of Stethoscope - Correct Answer - High frequency sounds,
firm skin contact
Principles of Documentation - Correct Answer - ▪Confidentiality- HIPAA
(Health Insurance Portability and Accountability Act) Keeping private any
information pertaining to health status or care received.
▪Accuracy and Completeness - Descriptions should be as clear and
precise as possible.
▪Organization - Entries made chronologically
▪Timeliness - Point of care documentation reduces errors that can occur
with Batch charting.
▪Conciseness - Be complete with documentation, but avoid unnecessary
words.
Documentation Formats - Narrative Notes - Correct Answer -
Unstructured paragraph. Nurses record relevant
assessments and nursing activities during a shift
Documentation Formats - S.O.A.P.I.E - Correct Answer - S - Subjective
O - Objective
A - Analysis
P - Plan
I - Intervention
E -Evaluation
Documentation Formats - P.I.E - Correct Answer - P - Problem
I - Intervention
E - Evaluation
Assessment Exam Study Guide |
Download to Score A+ | Herzing
The Physical Examination - Correct Answer - Inspection, Palpation,
Percussion, and Auscultation
Physical Examination - Inspection - Correct Answer - First - Start with
overall general survey.
Note physical characteristics and behaviors.
Note any odors. For focused inspection, assure adequate covering.
Intentional and deliberate
Physical Examination - Palpation - Correct Answer - Second - Use of
touch to assess temperature, texture, moisture, size, shape, location,
position, vibration, crepitus, tenderness, pain, and edema.
Physical Examination - Percussion - Correct Answer - Third - Produce
sound or elicit tenderness.
Physical Examination - Auscultation - Correct Answer - Listening for
sounds of movement from organs and tissues. A stethoscope is used to
transmit normally unheard sounds. Auscultation requires a quiet
environment with minimal to no distractions.
Comparison of auscultation sounds - Correct Answer -
,Direct Percussion - Correct Answer - To tap with your fingers directly on
the patient's skin.
ex. Sinuses - tap over periorbital area
Indirect Percussion - Correct Answer - Position nondominant hand
between patient and
dominant hand. Tap with dominant hand.
Percussion Tones - Correct Answer - Flat, dull, tympanic, resonant and
hyperresonant
PERCUSSION SOUNDS - Correct Answer -
Purpose of Documentation - Correct Answer - ▪Sentinel Event -
unexpected occurrence involving death or serious, physiological or
psychological injury
▪Verbal Communication - SBAR- situation, background, assessment,
recommendations
▪Written Communication - documenting in EHR
IF ITS NOT DOCUMENTED IT DIDN'T HAPPEN!!!
Stethoscope - Correct Answer - Conducts sound from patient to listener
and blocks
environmental noise. Does not amplify!!!!!
Bell of Stethoscope - Correct Answer - low frequency sounds, light skin
pressure
, Diaphragm of Stethoscope - Correct Answer - High frequency sounds,
firm skin contact
Principles of Documentation - Correct Answer - ▪Confidentiality- HIPAA
(Health Insurance Portability and Accountability Act) Keeping private any
information pertaining to health status or care received.
▪Accuracy and Completeness - Descriptions should be as clear and
precise as possible.
▪Organization - Entries made chronologically
▪Timeliness - Point of care documentation reduces errors that can occur
with Batch charting.
▪Conciseness - Be complete with documentation, but avoid unnecessary
words.
Documentation Formats - Narrative Notes - Correct Answer -
Unstructured paragraph. Nurses record relevant
assessments and nursing activities during a shift
Documentation Formats - S.O.A.P.I.E - Correct Answer - S - Subjective
O - Objective
A - Analysis
P - Plan
I - Intervention
E -Evaluation
Documentation Formats - P.I.E - Correct Answer - P - Problem
I - Intervention
E - Evaluation
