NURS 525 EXAM 1 HEALTH ASSESSMENT
Holistic Nursing - Answer -Mind/Emotions, Body, Spirit, and Environment
SOAP - Answer -Subjective, Objective, Assessment, Plan of Care
Primary Data Source - Answer -Patient
Secondary Data Source - Answer -Chart, Family members
Subjective Data - Answer -CC, HPI (OLDCARTS), PMH (Medications, Allergies,
Surgical History) FMH, Social/Behavioral (Diet, Sleep, Occupation), ROS
OLDCARTS - Answer -Onset
Location
Duration
Characteristics
Aggravating Factors
Relieving Factors
Treatments
Severity (1-10)
Review of Systems (ROS) - Answer -HEENT, Thorax & Lungs, Heart & Neck vessels,
Peripheral Vascular, Breasts, Abdominal-GI, Abdominal-Urinary, Musculoskeletal,
Neurological, Genitalia, Anus/Rectum/Prostate, Endocrine and Hematologic
Objective Data - Answer -Physical Exam, Vitals
Assessment - Answer -Nursing diagnoses or problem based on subjective and
objective data
Plan - Answer -Interventions related to a diagnosis or problem
(diagnostic, therapeutic, and patient education needs)
General Survey - Answer -Overall first impression of the patient's well-being
(physical appearance, body structure, mobility, behavior)
Infection Prevention Precautions - Answer -Hand hygiene, clean paper on exam table,
gloves (when contacting mucous membrane, blood, and body fluids), Clean & organized
work surface
Physical Assessment - Answer -Begin with Vitals, Ht. & Wt.
General Survey
1.) Inspection
, 2.) Palpation
3.) Percussion
4.) Auscultation
*same for every system except abdominal
Types of Sounds - Answer -Resonance (loud, low, hollow)
Hyper-resonance (very loud, low, booming)
Tympany (loud, high, drum-like)
Dullness (soft, moderate, thud-like)
Flatness (soft, high, dull)
Auscultation - Answer -Listening for sounds produced by the body
(note intensity, pitch, duration, and quality)
Identify appropriate landmark
Bell- lower pitch
Diaphragm- higher pitch
Preparing for the Physical Exam - Answer -Introduce, Verify correct patient (name and
DOB), Subjective Data, Client in gown, Gather equipment, Provide privacy, Clean
hands, Explain procedure, Opportunities for teaching
Body Mass Index (BMI) - Answer -<18 = underweight
18-25 = normal
25-30 = overweight
>30 = obese
Temperature - Answer -Rectal- gold standard
Oral- slightly lower reading
Tympanic- accurate, used in pediatrics
Temporal- accurate
Axillary- not as accurate, thermometer in place 5-10 minutes
Rectal/Tympanic/Temporal>Oral>Axillary
Document: time, measurement, & route
*wider variations in infants and children
Pulse - Answer -Beats per minute (bpm)
Evaluate- rate (tachycardia, bradycardia), rhythm (regular or irregular), force (0-absent,
4+-bounding), elasticity (springy, straight, resilient)
Locations- carotid, brachial, radial, dorsalis pedis
*trends down with age
Respiratory Rate - Answer -Check for 30 sec., 60 sec. if irregular
Descriptors- regular, relaxed, automatic, silent
*trends down with age
Blood Pressure - Answer -Digital- 10-20 mmHG off
Holistic Nursing - Answer -Mind/Emotions, Body, Spirit, and Environment
SOAP - Answer -Subjective, Objective, Assessment, Plan of Care
Primary Data Source - Answer -Patient
Secondary Data Source - Answer -Chart, Family members
Subjective Data - Answer -CC, HPI (OLDCARTS), PMH (Medications, Allergies,
Surgical History) FMH, Social/Behavioral (Diet, Sleep, Occupation), ROS
OLDCARTS - Answer -Onset
Location
Duration
Characteristics
Aggravating Factors
Relieving Factors
Treatments
Severity (1-10)
Review of Systems (ROS) - Answer -HEENT, Thorax & Lungs, Heart & Neck vessels,
Peripheral Vascular, Breasts, Abdominal-GI, Abdominal-Urinary, Musculoskeletal,
Neurological, Genitalia, Anus/Rectum/Prostate, Endocrine and Hematologic
Objective Data - Answer -Physical Exam, Vitals
Assessment - Answer -Nursing diagnoses or problem based on subjective and
objective data
Plan - Answer -Interventions related to a diagnosis or problem
(diagnostic, therapeutic, and patient education needs)
General Survey - Answer -Overall first impression of the patient's well-being
(physical appearance, body structure, mobility, behavior)
Infection Prevention Precautions - Answer -Hand hygiene, clean paper on exam table,
gloves (when contacting mucous membrane, blood, and body fluids), Clean & organized
work surface
Physical Assessment - Answer -Begin with Vitals, Ht. & Wt.
General Survey
1.) Inspection
, 2.) Palpation
3.) Percussion
4.) Auscultation
*same for every system except abdominal
Types of Sounds - Answer -Resonance (loud, low, hollow)
Hyper-resonance (very loud, low, booming)
Tympany (loud, high, drum-like)
Dullness (soft, moderate, thud-like)
Flatness (soft, high, dull)
Auscultation - Answer -Listening for sounds produced by the body
(note intensity, pitch, duration, and quality)
Identify appropriate landmark
Bell- lower pitch
Diaphragm- higher pitch
Preparing for the Physical Exam - Answer -Introduce, Verify correct patient (name and
DOB), Subjective Data, Client in gown, Gather equipment, Provide privacy, Clean
hands, Explain procedure, Opportunities for teaching
Body Mass Index (BMI) - Answer -<18 = underweight
18-25 = normal
25-30 = overweight
>30 = obese
Temperature - Answer -Rectal- gold standard
Oral- slightly lower reading
Tympanic- accurate, used in pediatrics
Temporal- accurate
Axillary- not as accurate, thermometer in place 5-10 minutes
Rectal/Tympanic/Temporal>Oral>Axillary
Document: time, measurement, & route
*wider variations in infants and children
Pulse - Answer -Beats per minute (bpm)
Evaluate- rate (tachycardia, bradycardia), rhythm (regular or irregular), force (0-absent,
4+-bounding), elasticity (springy, straight, resilient)
Locations- carotid, brachial, radial, dorsalis pedis
*trends down with age
Respiratory Rate - Answer -Check for 30 sec., 60 sec. if irregular
Descriptors- regular, relaxed, automatic, silent
*trends down with age
Blood Pressure - Answer -Digital- 10-20 mmHG off
