WGU Health Assessment Test Questions With Correct Answers

WGU Health Assessment Test Questions With Correct Answers Subjective data - ANSWER- Said by the client (S) Objective data - ANSWER- Observed by the nurse (O) Assessment Techniques is as follows - ANSWER- Inspect-Palpation-PercussionAuscultation Order of Abdomen Assessment - ANSWER- Inspect-Auscultation-Percuss-Palpate Inspection - ANSWER- *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 techniques Back of hand - ANSWER- To assess skin temperature use Deep Palpation - ANSWER- 5-8cm or (2-3") deep is considered Light Palpations - ANSWER- 1cm deep is considered Percussion - ANSWER- sounds produced by striking body surface Sounds are dull resonant flat tympanic action is performed in the wrist Auscultation - ANSWER- listening to sounds produced by the body Bell - ANSWER- picks up low pitched sounds such as heart murmurs General Survey - ANSWER- is an overall review or first impression a nurse has of person's wellbeing. Appearance - ANSWER- appears to be reported age Sexual development appropriate Alert and oriented Facial features symmetric No signs of acute distress Body Structure/mobility - ANSWER- weight 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 - ANSWER- maintains 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 - ANSWER- which 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 - ANSWER- Are completed across three generations looking specifically for patterns in genetic issues that negatively impact quality of life Health Hx - ANSWER- gives 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 - ANSWER- Obtain 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 - ANSWER- 3 obtain a standing height on children greater than 2 to 3 years of age, adolescents, and adults, using a portable audiometer. 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 audiometer 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: - ANSWER- 1. 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 - ANSWER- 3 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 minimal Clothing 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 - ANSWER- Obtain 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