NURS 252 Assessment Review
Questions and Correct Answers
Joey has has just been transferred to your unit after having surgery 3 days ago. What
type of assessment should be done:
A. Focussed assessment
B. Emergency assessment
C. Comprehensive assessment ✅A. Focussed assessment
What is the purpose of a Health assessment? ✅Provides information of patient's past
and current health, including strengths and coping skills
What are the components of Biographical data in the health history? ✅Name
Address and phone number
Age and birth date
Birthplace
Gender
Marital status
Ethnocultural background
Occupation
Primary language
Source of information
Which of the following would be considered a primary source of information?
A Patient's chart
B Patient's physician
C Patient's family
D Patient him/herself ✅D
Which is important to remember about Reason for Seeking care?
A. A medical diagnosis
B. The patient's chronic state
C. Using the patient's own words ✅C
What does PQRST Stand for? ✅P- provokes
Q- quality or quantity
R- Region/ radiation
S- Severity/ setting
T- Timing (onset, duration, frequency)
U- Understanding
Why is it important to assess human violence?
A. Because of the high prevalence of physical abuse in children and women
,B. Because all women are abused during pregnancy
C. Because all women are abused at sometime in their life
D. Because nurses are nosy and want to know ✅A
Which is a reason for seeking care:
A Exacerbation of COPD
B "My leg pain is alleviated by rest"
C R/O MI
D "I feel shaky" ✅D
Acute assessment of the Head, Neck, and Regional lymphatics would need to be done
when? ✅Head injuries, nero injuries, head trauma, neck pain, paralysis, headache,
lacerations, hyperthyroidism,
What is included in subjective assessment? (theres an acronym) ✅SAMPLE:
Signs and symptoms
Allergies
Medications
Personal (and family) medical history
Last visit to health care provider
Evaluation of functional assessment
What could be included in health promotion for the head, neck, and regional
lymphatics? ✅- Injury prevention: helmets, spinal cord injury, elderly patients fall
- Thyroid health: minimize disease process
- Examine lymph nodes
What should be included in the functional assessment of the head, neck, and regional
lymphatics? ✅Headache, neck pain, limited neck movement, facial pain, lumps and
masses, hypo/hyperthyroidism
Joe comes into your clinic with the symptoms of cold intolerance, fatigue, weight gain,
and periorbital edema. What does he likely have? What other symptoms could support
this finding ✅Hypothyroidism:
- hair loss/ brittle, decreased libido, menstral irregularity (females)
Sam comes into your clinic with the symptoms of fatigue, weight loss, clammy skin, and
palpations. What does she likely have? What other symptoms may support this?
✅Hyperthyroidism:
- heat intolerance, hair limp/fine, sweating, rapid pulse, buldging eyes, goiter
What kind of objective assessments are done during a head, neck, and regional
lymphatic exam? ✅Inspection
Palpation: temporal arteries, thyroid, lymph nodes
Auscultation: thyroid for bruits
, Which of these is irregular:
1. Anterior fontanel in a 12 month old
2. Anterior fontanel in a 25 month old
3. Posterior fontanel in a 1 month old
4. Posterior fontalel in a 2 month old ✅2. Anterior fontanel in a 25 month old
- Anterior fontanels disapear between 9 months and 2 years old
- Posterior fontanels disapear between 1-2 months old
Fontanels should normally be ____, if they are _____ the fontanel would be dipped, if
they are ___ the fontanel would be raised ✅- Normal= flat
- Dipped= dehydrated
- Raised= increased intracranial pressure
Which would be an abnormal finding:
1. lymph node soft
2. lymph node more than 1cm
3. Lymph not tender
4. Lymph node moves ✅2. Lymph node more than 1 cm
Which is abnormal:
1. Emma is 3 months pregnant and has an enlarged thyroid
2. Sam, a 2 month old, has a soft spot on top of his head
3. Joe is 85 years old and has hyperthyroid symptoms
4. Jane is 92 years old and has hypothyroid symptoms ✅3. Hypothyroidism is common
in the elderly, hyperthyroidism is not
What are some unexpected findings that you may come across while doing a head,
neck, and lymph node assessment? ✅- enlarged lymph nodes
- Bruit over thyroid
- Tracheal deviation
- Mastoiditis
Where does the lacrimal gland drain? ✅The medial lower part of the eye
The right eye moves dirrectly to the right and then to the bottom right. What muscles
and Cranial nerves control these? ✅Right eye:
- Medial right- Lateral rectus CN 6
- Right bottom- Inferior rectus CN 3
The right eye moves to the look to the middle top and then to the middle bottom. What
muscles and Cranial nerves control these? ✅Right eye:
- Medial top- Inferior oblique CN 3
- Medial bottom- Superior oblique CN 4
