EXAM 1 NURS 3325 QUESTIONS WITH h h h h h
CORRECT ANSWERS h h
Components of health assessment - CORRECT ANSWERV-Health History (subjective data) h h h h h h h h h
Physical Examination (objective data)
h h h h
Documentation of Data (complete, concise, factual) h h h h h
Why we Learn about health assessments - CORRECT ANSWERV-
h h h h h h h h
Systematic way of collecting and analyzing
h h h h h h
Used to start patient plan of care First
h h h h h h h
step in the health assessment
h h h h h
The types of health assessments depends on - CORRECT ANSWERV-Context of Care Patient
h h h h h h h h h h h h
Need
h
Nurse Expertise h
Type of health assessments - CORRECT ANSWER -Comprehensive Assessment
h h h h h h h h
Focused Assessment
h h
Follow-up Assessment h
Shift Assessment
h h
Screening Assessment
h h
Clinical reasoning and judgment - CORRECT ANSWER -Collect, organize, analyze, and
h h h h h h h h h h
interpret data
h h
Create plan of care using clinical judgmenth h h h h h
CLINICAL JUDGMENT - CORRECT ANSWER - h h h h h
"interpretation or conclusion about a patient's needs, concerns, or health programs and/or the decision t o h h h h h h h h h h h h h h h
take action (or not), use or modify standard approaches, or improvise new ones as deemed by the pat ient
h h h h h h h h h h h h h h h h h h h
response."
h
health promotion - CORRECT ANSWERV-increase well-being and actualize human health potential
h h h h h h h h h h
primary health promotion - CORRECT ANSWER -
h h h h h h h
prevent disease development through healthy lifestyle choices
h h h h h h
secondary health promotion - CORRECT ANSWERV- h h h h h
screening efforts to promote early detection of disease
h h h h h h h h
tertiary health promotion - CORRECT ANSWER -minimizing disability from acute or chronic disease
h h h h h h h h h h h h
health protection - CORRECT ANSWER -
h h h h h h
actively avoid illness, early detection, maintain function with illness
h h h h h h h h
Healthy people 2030 - CORRECT ANSWERV- h h h h h
goal of reducing most significant preventable health threats and reducing preventable health threats
h h h h h h h h h h h h
Skin assessment- when documenting a skin assessment, the nurse should: - CORRECT ANSWER -
h h h h h h h h h h h h h
Use standardized terminology to report findings
h h h h h h h
, • Use standardized terminology to record findings
h h h h h
• Perform assessment when risk factors identified h h h h h
• Allow information from the history to help direct the assessment
h h h h h h h h h
• Document both normal and abnormal skin strategies from the assessment h h h h h h h h h
OLD CARTS - CORRECT ANSWER -h h h h h
Onset, Location, Duration, Characteristics, Aggravating Factors, Related Symptoms, Treatment, and Se
h h h h h h h h h h
verity
h
• Example:
• When did the rash start (onset) h h h h h
• What makes the rash worse (aggravating factors)
h h h h h h
• What do you do to make the rash better (treatment)
h h h h h h h h h
• Describe the sensation from the burn, does it burn or itch (related symptoms)
h h h h h h h h h h h h
• Describe what the rash looked like initially (duration/characteristics) h h h h h h h
stage 1 pressure injury - CORRECT ANSWER -intact skin, non- blanchable
h h h h h h h h h h
redness over coccyx, tender, warm
h h h h h
stage 2 pressure injury - CORRECT ANSWER -
h h h h h h h
partial thickness loss of dermis, pink wound bed, no slough or bruising
h h h h h h h h h h h
stage 3 pressure injury - CORRECT ANSWER -
h h h h h h h
full thickness skin loss, subcutaneous fat visible, no visible bone
h h h h h h h h h
stage 4 pressure injury - CORRECT ANSWER -
h h h h h h h
full thickness tissue loss, tendon exposed, tunneling, slough present
h h h h h h h h
Nail Assessment - CORRECT ANSWERV-
h h h h
Nail surface should be smooth and flat in the center and slightly curved downward at the edges. The s
h h h h h h h h h h h h h h h h h h
kin adjacent to the nail should be intact, the same color as adjacent skin and without edema. The expec ted
h h h h h h h h h h h h h h h h h h h h
angle of the nail base is 160 degrees. The nail should have uniform thickness and the base should f eel firm
h h h h h h h h h h h h h h h h h h h h h
and adhere to the nail bed.
h h h h h h
jaundice - CORRECT ANSWERV-which is a yellowish-green color in light and dark skinned patients
h h h h h h h h h h h h h
Jaundice can best be assessed in - CORRECT ANSWER -Sclera of the eye
h h h h h h h h h h h h h
Palms of the hands h h h
Soles of the feet h h h
The appearance of the normal tympanic membrane is - CORRECT ANSWERV-
h h h h h h h h h h
Translucent and pearly gray h h h
tympanic membrane - CORRECT ANSWER - h h h h h
Redness of the tympanic membrane may indicate infection h h h h h h h
A brown sticky discharge is cerumen which is a normal finding, but may cause the tympanic membran e
h h h h h h h h h h h h h h h h h
to be obscured
h h h
Pink may indicate possible otitis externa or impending infection
h h h h h h h h
CORRECT ANSWERS h h
Components of health assessment - CORRECT ANSWERV-Health History (subjective data) h h h h h h h h h
Physical Examination (objective data)
h h h h
Documentation of Data (complete, concise, factual) h h h h h
Why we Learn about health assessments - CORRECT ANSWERV-
h h h h h h h h
Systematic way of collecting and analyzing
h h h h h h
Used to start patient plan of care First
h h h h h h h
step in the health assessment
h h h h h
The types of health assessments depends on - CORRECT ANSWERV-Context of Care Patient
h h h h h h h h h h h h
Need
h
Nurse Expertise h
Type of health assessments - CORRECT ANSWER -Comprehensive Assessment
h h h h h h h h
Focused Assessment
h h
Follow-up Assessment h
Shift Assessment
h h
Screening Assessment
h h
Clinical reasoning and judgment - CORRECT ANSWER -Collect, organize, analyze, and
h h h h h h h h h h
interpret data
h h
Create plan of care using clinical judgmenth h h h h h
CLINICAL JUDGMENT - CORRECT ANSWER - h h h h h
"interpretation or conclusion about a patient's needs, concerns, or health programs and/or the decision t o h h h h h h h h h h h h h h h
take action (or not), use or modify standard approaches, or improvise new ones as deemed by the pat ient
h h h h h h h h h h h h h h h h h h h
response."
h
health promotion - CORRECT ANSWERV-increase well-being and actualize human health potential
h h h h h h h h h h
primary health promotion - CORRECT ANSWER -
h h h h h h h
prevent disease development through healthy lifestyle choices
h h h h h h
secondary health promotion - CORRECT ANSWERV- h h h h h
screening efforts to promote early detection of disease
h h h h h h h h
tertiary health promotion - CORRECT ANSWER -minimizing disability from acute or chronic disease
h h h h h h h h h h h h
health protection - CORRECT ANSWER -
h h h h h h
actively avoid illness, early detection, maintain function with illness
h h h h h h h h
Healthy people 2030 - CORRECT ANSWERV- h h h h h
goal of reducing most significant preventable health threats and reducing preventable health threats
h h h h h h h h h h h h
Skin assessment- when documenting a skin assessment, the nurse should: - CORRECT ANSWER -
h h h h h h h h h h h h h
Use standardized terminology to report findings
h h h h h h h
, • Use standardized terminology to record findings
h h h h h
• Perform assessment when risk factors identified h h h h h
• Allow information from the history to help direct the assessment
h h h h h h h h h
• Document both normal and abnormal skin strategies from the assessment h h h h h h h h h
OLD CARTS - CORRECT ANSWER -h h h h h
Onset, Location, Duration, Characteristics, Aggravating Factors, Related Symptoms, Treatment, and Se
h h h h h h h h h h
verity
h
• Example:
• When did the rash start (onset) h h h h h
• What makes the rash worse (aggravating factors)
h h h h h h
• What do you do to make the rash better (treatment)
h h h h h h h h h
• Describe the sensation from the burn, does it burn or itch (related symptoms)
h h h h h h h h h h h h
• Describe what the rash looked like initially (duration/characteristics) h h h h h h h
stage 1 pressure injury - CORRECT ANSWER -intact skin, non- blanchable
h h h h h h h h h h
redness over coccyx, tender, warm
h h h h h
stage 2 pressure injury - CORRECT ANSWER -
h h h h h h h
partial thickness loss of dermis, pink wound bed, no slough or bruising
h h h h h h h h h h h
stage 3 pressure injury - CORRECT ANSWER -
h h h h h h h
full thickness skin loss, subcutaneous fat visible, no visible bone
h h h h h h h h h
stage 4 pressure injury - CORRECT ANSWER -
h h h h h h h
full thickness tissue loss, tendon exposed, tunneling, slough present
h h h h h h h h
Nail Assessment - CORRECT ANSWERV-
h h h h
Nail surface should be smooth and flat in the center and slightly curved downward at the edges. The s
h h h h h h h h h h h h h h h h h h
kin adjacent to the nail should be intact, the same color as adjacent skin and without edema. The expec ted
h h h h h h h h h h h h h h h h h h h h
angle of the nail base is 160 degrees. The nail should have uniform thickness and the base should f eel firm
h h h h h h h h h h h h h h h h h h h h h
and adhere to the nail bed.
h h h h h h
jaundice - CORRECT ANSWERV-which is a yellowish-green color in light and dark skinned patients
h h h h h h h h h h h h h
Jaundice can best be assessed in - CORRECT ANSWER -Sclera of the eye
h h h h h h h h h h h h h
Palms of the hands h h h
Soles of the feet h h h
The appearance of the normal tympanic membrane is - CORRECT ANSWERV-
h h h h h h h h h h
Translucent and pearly gray h h h
tympanic membrane - CORRECT ANSWER - h h h h h
Redness of the tympanic membrane may indicate infection h h h h h h h
A brown sticky discharge is cerumen which is a normal finding, but may cause the tympanic membran e
h h h h h h h h h h h h h h h h h
to be obscured
h h h
Pink may indicate possible otitis externa or impending infection
h h h h h h h h
