Exam (elaborations)
Nursing Health Assessment Questions with Solutions
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Nursing Health Assessment
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Nursing Health AssessmentWhat is the purpose of nursing health assessment? - answer1) determine clients health
status
2) identify risk factors
3) identify need for education as a basis for developing a nursing plan of care
What are the components of the nursing health assessment? - answer health history
and physical exam
The extent of the nursing assessment is determined by what? - answer the acuity of the
clients condition and the site of care
During the health history, what does the nurse do? - answer asks pertinent questions to
gather data from the client and/or family
When can past medical records be used to collect data during the health history? -
answerif the patient is unreliable or has no family or support system available
Physical exam is a structured _____ to _____ examination. - answer head to toe
What is the role of the nurse in assessment? - answer- collect data
- assess client needs
- formulate a nursing plan of care
- develop interventions based on identified needs
- educate and counsel patient
- collaborate with others in health care team
What are the two types of data? - answersubjective and objectice
What is subjective data? - answer- what the patient says
- obtained from the patient and/or family
- includes past medical history, chief complaint (reason for seeking care) & review of
systems
- ex. "shortness of breath," "my head hurts"
Always open the chief complaint interview with what type of question? - answeropen
ended
What are examples of an open ended question you can ask when beginning the chief
complaint interview? - answer- "what brought you here today"
,- "tell me about the chest pressure, from when it begin until now"
- "what problems are you experiencing"
What is objective data? - answer- what you observe
- physical examination findings
- ex. BP, pulse, height, weight, etc.
What is a symptom? - answersubjective sensation described by the client
What is a sign? - answerobjective abnormality that the examiner detects on physical
examination
Symptom is the same as what type of data? - answersubjective
Sign is the same as what type of data? - answerobjective
What are the three steps in exploring symptoms? - answer1) ask open-ended questions
to hear "the story of the symptom" in the patients own words
2) ask more specific questions to elicit "the seven features of every symptom" ( OLD
CART)
3) ask yes or no questions or "pertinent positives and negatives" from the relevant
section of the review of systems
What are the 7 features of every symptom? (history of present illness) - answerOLD
CART
- onset
- location
- duration
- character
- associated manifestations
- relieving/exacerbating factors
- treatment
What is onset? - answerwhen the sign or symptom began
What is location? - answerwhere the sign or symptom is located
What is duration? - answerhow long the sign or symptom has been going on
What is character? - answerWhat it feels like, how it is described, the severity/pain
- ex. "describe on a scale of 1 to 10"
What is associated manifestations? - answerwhat else is going on when the sign or
symptom is occurring (headache, vomit, sweating)
, What is relieving/exacerbating factors? - answerwhat makes it better/worse, anything
the patient has tried to make to relieve the sign/symptom
What are treatments? - answerwhat treatments might the patient try, any interventions
What is health history? - answer-home medications (and how they take them)
-biographic data
-source of history
-reason for seeking care
-history of health
-family health history
-review of systems
-functional assessment (ADL's)
What are topics of data pertaining to lifestyle and health practices? - answer-
description of typical day
- nutrition and weight management
- activity and exercise
- sleep and rest patterns
- medication and substance use
- self concept
- social activities
- relationships
- values/beliefs
- education/work
- stress and coping styles
- environment
What are the different types of health histories? - answer1) comprehensive
2) focused of problem oriented
3) follow up history
4) emergency history
What is a comprehensive health history? - answerfull picture of the client's health status,
health promotion, and risk reduction needs
What is a focused of problem oriented health history? - answerfocuses on gathering
information on the clients current problem
What is a follow up health history? - answerclient is retuning to have a problem
evaluated after treatment
What is an emergency health history? - answerfocused on clients emergent problem
with a systematic prioritization of need based on clients presentation
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