WGU Health Assessment
Subjective data correct answersSaid by the client (S)
Obejective data correct answersObserved by the nurse (O)
Assessment Techniques is as follows correct answersInspect-Palpation-
Percussion- Auscultation
Order of Abdomen Assessment correct answersInspect-Auscultation-Percuss-
Palapate Inspection correct 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 correct answersTo assess skin temperature
use Deep Palpation correct answers5-8cm or (2-3") deep
is considered Light Paplpation correct answers1cm deep is
considered
Percussion correct answerssounds produced by striking body
surface sounds are dull resonant flat tympanic
action is performed in the wrist
Ausculation correct answerslistening to sounds produced by
the body Bell correct answerspicks up low pitched sounds such
as heart murmurs
General Survey correct answersis an overall review or first impression a
nurse has of person's well being.
Appearance correct answersappears to be
reported age sexual development appropriate
alert and oriented
facial features
symmetric no signs of
acute distress
,Body Structure/mobilty correct answersweight 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 correct answersmaintains 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 correct answerswhich 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 correct answersAre completed across three
generations looking specifically for patterns in genetic issues that
negatively impact quality of life
Health Hx correct answersgives 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 correct answersObtain
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 correct answers3. 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: correct answers1. 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 correct answers3. 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
minima
l
clothin
g.
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 correct answersObtain 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 correct answersThis 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 correct answersgenerally 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 correct answersoral usually
98.6 axillary 97.6 litter lower
rectal and aural (ear) 99.6 slightly
higher
Subjective data correct answersSaid by the client (S)
Obejective data correct answersObserved by the nurse (O)
Assessment Techniques is as follows correct answersInspect-Palpation-
Percussion- Auscultation
Order of Abdomen Assessment correct answersInspect-Auscultation-Percuss-
Palapate Inspection correct 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 correct answersTo assess skin temperature
use Deep Palpation correct answers5-8cm or (2-3") deep
is considered Light Paplpation correct answers1cm deep is
considered
Percussion correct answerssounds produced by striking body
surface sounds are dull resonant flat tympanic
action is performed in the wrist
Ausculation correct answerslistening to sounds produced by
the body Bell correct answerspicks up low pitched sounds such
as heart murmurs
General Survey correct answersis an overall review or first impression a
nurse has of person's well being.
Appearance correct answersappears to be
reported age sexual development appropriate
alert and oriented
facial features
symmetric no signs of
acute distress
,Body Structure/mobilty correct answersweight 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 correct answersmaintains 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 correct answerswhich 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 correct answersAre completed across three
generations looking specifically for patterns in genetic issues that
negatively impact quality of life
Health Hx correct answersgives 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 correct answersObtain
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 correct answers3. 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: correct answers1. 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 correct answers3. 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
minima
l
clothin
g.
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 correct answersObtain 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 correct answersThis 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 correct answersgenerally 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 correct answersoral usually
98.6 axillary 97.6 litter lower
rectal and aural (ear) 99.6 slightly
higher
