NURS 204_ Assessment exam with correct answers 2024
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Course
Nursing 204
Institution
Nursing 204
The 4 basic types of Nursing Health Assessment are:
• Initial comprehensive assessment
• Ongoing or partial assessment
• Focused or problem-oriented assessment
• Emergency assessment
Health assessment can be divided into four steps:
collecting subjective data
collecting objecti...
NURS 204: Assessment exam with correct
answers 2024
The 4 basic types of Nursing Health Assessment are: - ANSWER- • Initial
comprehensive assessment
• Ongoing or partial assessment
• Focused or problem-oriented assessment
• Emergency assessment
Health assessment can be divided into four steps: - ANSWER- collecting
subjective data
collecting objective data
validation of data
documentation of data
The complete health history is performed to collect as much subjective data
about a client as possible. It consists of eight sections: - ANSWER- 1. Biographic
data (name, address, phone, gender, who provided the info—the client or
significant others. birth date, Social Security, medical record number, or similar
identifying data may be included) NOT occupation.
2. Reasons for seeking health care ("What is your major health problem or
concerns at this time?" & "How do you feel about having to seek health care?")
3. History of present health concern (use COLDSPA)
4. Personal health history (illnesses, immunizations, allergies, etc)
5. Family health history,
6. Review of body systems (ROS) for current health problems (skin, hair nails,
head, neck, etc)
7. Lifestyle and health practices (social history: Description of Typical Day,
Nutrition and Weight Management, Activity Level and Exercise, Sleep and Rest,
Substance Use)
8. Developmental level.
Inspection involves - ANSWER- using the senses of vision, smell, & hearing
to observe & detect any normal or abnormal findings.
Precedes palpation, percussion, & auscultation because the latter techniques can
potentially alter the appearance of what is being inspected.
Palpation consists of - ANSWER- Palpation consists of using parts of the hand to
touch and feel for the following characteristics:
• Texture (rough/smooth)
• Temperature (warm/cold)
• Moisture (dry/wet)
• Mobility (fixed/movable/still/vibrating)
• Consistency (soft/hard/fluid filled)
• Strength of pulses (strong/weak/thready/bounding)
• Size (small/medium/large)
• Shape (well defined/irregular)
• Degree of tenderness
Light palpation - ANSWER- There should be very little or no depression (less than
1 cm). Feel the surface structure using a circular motion.
Use this technique to feel for pulses, tenderness, surface skin texture,
temperature, and moisture.
Moderate palpation - ANSWER- Depress the skin surface 1 to 2 cm (0.5 to 0.75
inch) with your dominant hand, and use a circular motion to feel for easily
palpable body organs and masses.
Note the size, consistency, and mobility of structures you palpate.
Deep palpation: - ANSWER- Place your dominant hand on the skin surface & your
nondominant hand on top of your dominant hand to apply pressure between 2.5
& 5 cm (1 and 2 inches).
This allows you to feel very deep organs or structures that are covered by thick
muscle.
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