health assessment final exam study guide
Week 1: Introduction to health assessment: - ANS
how do health professionals protect the clients private information when using a hard copy
medical record? (SATA)
a.) allow the clients children to review the medical record
b.) return the medical record to the designated storage area
c.) shield identifying information from view by visitors
d.) lock records in your desk drawer when not in use
e.) close the medical record when entering the clients room - ANS b.) return the medical record
to the designated storage area
c.) shield identifying information from view by visitors
e.) close the medical record when entering the clients room
The major components of the complete health history assessment - ANS health history
physical assessment
Interpretation of data
social determinants of health - ANS The conditions in which people are born, grow, live, work,
and age, the broader set of forces and systems shaping the needs of daily life
Health History Questions - ANS what prompted you to see care today?
how long have you been feeling unwell?
what prescribed and over the counter medications/supplements are you currently taking?
are you having any challenges obtaining your medications or other items needed to care for
yourself?
do any chronic illnesses run in your family?
do you have specific dietary practices we can support while you are here?
are you able to purchase healthy food near your home>
do you have any concerns or challenges caring for yourself at home?
Physical Assessment - ANS are you having any chest pain or tightness?
how is your vision?
have you noticed any changes in your level of energy?
how often do you normally have a bowel movement?
would you like another person to be present while I complete your physical examination?
In which situations does the nurse collect data as part of an assessment? - ANS during the
complete health assessment
when administering medications
when asking questions from the clients partner
,while reading the nurse practitioners admission note
as they pass the individual walking in the hallway
rapid screening assessment - ANS determines the urgency of the client's condition
when used: each time the client is seen
includes: LOC, ease of breathing, and body positon
ex: examiner finds a person in a hospital gown sitting on the floor gasping for fair
complete (total) health assessment - ANS establishes the medical database for episode of care
when used: at the first interaction between a person seeking care and the professional providing
care
includes: detailed health history and physical examination of all body systems
ex: the first visit to a new healthcare provider or new admission to a long term care facility
focused (problem-centered) assessment - ANS to obtain more data about specific concerns or
abnormal findings related to a body system
when used: after abnormal findings are identified during any assessment
includes: the collection of data related to findings of concern
ex: after nothing a clients productive cough and SOB when entering the room, the examiner
begins the assessment by listening to lung sounds, measuring O2, checking for cyanosis
follow up assessment - ANS to determine effectiveness during or after treatment
when used: timing depends on the situation
includes: a focused assessment used to evaluate how the client is responding to treatment
ex: checking on a client 30 mins after administering medication or a follow up office visit with a
primary care provider to determine the effectiveness of BP medications
emergency assessment - ANS collection of key data during an urgent or emergent medical
situation
when used: an individual is facing a life-threatening situation
includes: assessment of the airway, breathing, circulation, disabilities, and exposure
ex: the ABCs of CPR specify that if a person is found and appears unresponsive, first step is to
take and shout to check the LOC, open the airway, check for breathing, and palpate for a carotid
pulse
The nurse enters the room of a client sitting in a reclining chair with their eyes closed. When the
individual does not respond to their name, the nurse speaks louder while gently shaking the
client's arm before assessing their breathing and pulse, which are both normal.
What type of assessment was completed? - ANS rapid
Maslow's Hierarchy of Needs - ANS (listed bottom to top)
physiological: breathing, water, food, sex, sleep, homeostasis, excretion
, safety: security of body. employment, of resources, of mortality , of the family, of health and
property
love/belonging: family, friendship, sexual intimacy
esteem: self esteem, confidence, achievement, respect for others, respect by others
self actualization: morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance
of facts
Steps of the health history - ANS biographic data
reason for seeking care
present health history or history of present illness
past medical history
medication reconciliation
family history
ROV
functional assessment or ADLs
During the review of systems, the nurse primarily uses which clinical judgment skills? Select all
that apply.
a.) Assesses areas overlooked in the present illness information.
b.) Evaluates health of each body system.
c.) Plans care to address the client's primary concern.
d.) Implements strategies to resolve health issues.
e.) Recognizes health risks. - ANS a.) Assesses areas overlooked in the present illness
information.
b.) Evaluates health of each body system.
e.) Recognizes health risks.
What steps can the examiner take to ensure a new client understands their rights and
responsibilities related to receiving healthcare? (SATA)
a.) Refer the client to the charge nurse for further information.
b.) Provide a copy of the Patient's Bill of Rights written in the client's primary language.
c.) Secure the Patient's Bill of Rights to the wall next to the bed.
d.) Ask the client if they have questions about their healthcare-related rights.
e.) Require the client to acknowledge receipt of the Patient's Bill of Rights in writing. - ANS b.)
Provide a copy of the Patient's Bill of Rights written in the client's primary language.
d.) Ask the client if they have questions about their healthcare-related rights.
ights in writing.
The steps to overcome implicit bias - ANS acknowledge biases
be aware
be proactive
have discussions
Week 1: Introduction to health assessment: - ANS
how do health professionals protect the clients private information when using a hard copy
medical record? (SATA)
a.) allow the clients children to review the medical record
b.) return the medical record to the designated storage area
c.) shield identifying information from view by visitors
d.) lock records in your desk drawer when not in use
e.) close the medical record when entering the clients room - ANS b.) return the medical record
to the designated storage area
c.) shield identifying information from view by visitors
e.) close the medical record when entering the clients room
The major components of the complete health history assessment - ANS health history
physical assessment
Interpretation of data
social determinants of health - ANS The conditions in which people are born, grow, live, work,
and age, the broader set of forces and systems shaping the needs of daily life
Health History Questions - ANS what prompted you to see care today?
how long have you been feeling unwell?
what prescribed and over the counter medications/supplements are you currently taking?
are you having any challenges obtaining your medications or other items needed to care for
yourself?
do any chronic illnesses run in your family?
do you have specific dietary practices we can support while you are here?
are you able to purchase healthy food near your home>
do you have any concerns or challenges caring for yourself at home?
Physical Assessment - ANS are you having any chest pain or tightness?
how is your vision?
have you noticed any changes in your level of energy?
how often do you normally have a bowel movement?
would you like another person to be present while I complete your physical examination?
In which situations does the nurse collect data as part of an assessment? - ANS during the
complete health assessment
when administering medications
when asking questions from the clients partner
,while reading the nurse practitioners admission note
as they pass the individual walking in the hallway
rapid screening assessment - ANS determines the urgency of the client's condition
when used: each time the client is seen
includes: LOC, ease of breathing, and body positon
ex: examiner finds a person in a hospital gown sitting on the floor gasping for fair
complete (total) health assessment - ANS establishes the medical database for episode of care
when used: at the first interaction between a person seeking care and the professional providing
care
includes: detailed health history and physical examination of all body systems
ex: the first visit to a new healthcare provider or new admission to a long term care facility
focused (problem-centered) assessment - ANS to obtain more data about specific concerns or
abnormal findings related to a body system
when used: after abnormal findings are identified during any assessment
includes: the collection of data related to findings of concern
ex: after nothing a clients productive cough and SOB when entering the room, the examiner
begins the assessment by listening to lung sounds, measuring O2, checking for cyanosis
follow up assessment - ANS to determine effectiveness during or after treatment
when used: timing depends on the situation
includes: a focused assessment used to evaluate how the client is responding to treatment
ex: checking on a client 30 mins after administering medication or a follow up office visit with a
primary care provider to determine the effectiveness of BP medications
emergency assessment - ANS collection of key data during an urgent or emergent medical
situation
when used: an individual is facing a life-threatening situation
includes: assessment of the airway, breathing, circulation, disabilities, and exposure
ex: the ABCs of CPR specify that if a person is found and appears unresponsive, first step is to
take and shout to check the LOC, open the airway, check for breathing, and palpate for a carotid
pulse
The nurse enters the room of a client sitting in a reclining chair with their eyes closed. When the
individual does not respond to their name, the nurse speaks louder while gently shaking the
client's arm before assessing their breathing and pulse, which are both normal.
What type of assessment was completed? - ANS rapid
Maslow's Hierarchy of Needs - ANS (listed bottom to top)
physiological: breathing, water, food, sex, sleep, homeostasis, excretion
, safety: security of body. employment, of resources, of mortality , of the family, of health and
property
love/belonging: family, friendship, sexual intimacy
esteem: self esteem, confidence, achievement, respect for others, respect by others
self actualization: morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance
of facts
Steps of the health history - ANS biographic data
reason for seeking care
present health history or history of present illness
past medical history
medication reconciliation
family history
ROV
functional assessment or ADLs
During the review of systems, the nurse primarily uses which clinical judgment skills? Select all
that apply.
a.) Assesses areas overlooked in the present illness information.
b.) Evaluates health of each body system.
c.) Plans care to address the client's primary concern.
d.) Implements strategies to resolve health issues.
e.) Recognizes health risks. - ANS a.) Assesses areas overlooked in the present illness
information.
b.) Evaluates health of each body system.
e.) Recognizes health risks.
What steps can the examiner take to ensure a new client understands their rights and
responsibilities related to receiving healthcare? (SATA)
a.) Refer the client to the charge nurse for further information.
b.) Provide a copy of the Patient's Bill of Rights written in the client's primary language.
c.) Secure the Patient's Bill of Rights to the wall next to the bed.
d.) Ask the client if they have questions about their healthcare-related rights.
e.) Require the client to acknowledge receipt of the Patient's Bill of Rights in writing. - ANS b.)
Provide a copy of the Patient's Bill of Rights written in the client's primary language.
d.) Ask the client if they have questions about their healthcare-related rights.
ights in writing.
The steps to overcome implicit bias - ANS acknowledge biases
be aware
be proactive
have discussions
