Health Assessment Exam 1 Study Questions
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Differentiate between a holistic nursing assessment and a physical medical assessment
- Correct Answer Holistic→ the nurse collects physiologic, psychological, sociocultural,
developmental, and spiritual data ABOUT the client
Physical→ Less focus may be placed on psychological, sociocultural, or spiritual well-
being. Also focus primarily on patient's musculoskeletal system and the effects on ability
to perform activities of daily living.
Explain how assessment skills are needed for every situation the nurse encounters. -
Correct Answer If data collection is inadequate or inaccurate, incorrect nursing
judgments may be made that adversely affect the remaining phases of the process
Describe how assessment fits into the total nursing process - Correct Answer
Assessment is the first and most critical phase of the nursing process. If data collection
is inaccurate or inadequate, incorrect judgments might be made that affect the
remaining phases of the process. Assessment is ongoing and continuous throughout all
the phases of the nursing process.
List and describe the steps of the nursing process - Correct Answer • Assessment→
collecting subjective data and objective data
• Diagnosis→ analyzing subjective and objective data to make a professional nursing
judgment (nursing diagnosis, collaborative problem, or referral)
• Planning→ determining outcome criteria and developing a plan
• Implementation→ carrying out the plan
• Evaluation→ assessing whether outcome criteria have been met and revising the plan
as necessary
Describe how critical thinking relates to diagnostic reasoning - Correct Answer critical
thinking is the way on which the nurse processes information using knowledge, past
experiences, intuition, and cognitive abilities to formulate conclusions or diagnosis.
Determine your own ability to think critically. - Correct Answer Have you collected all of
the information?
Can you support your opinion or comments with data, rationale, and literature?
Have you explored or considered alternatives?
Can you distinguish better fact, opinion, cur or inference.
Can you validate your information and judgements with experts in the field?
Do you use past knowledge/experiences to analyze data?
Do you try to avoid basis
Could you be wrong
What are the steps of health assessment - Correct Answer Subjective data
Objective data
,Validation of data
Documentation of data
subjective data collection - Correct Answer sensations or symptoms, feelings,
perceptions, desires, preferences, beliefs, ideas, values, and personal information that
can be elicited and verified only by the client
objective data collection - Correct Answer - Objective data collection: physical
characteristics, body functions, appearance, behavior, measurements, and results of lab
testing
General observation and health documents
Define validation of data - Correct Answer process of confirming or verifying that the
subjective and objective data you have collected are reliable and accurate.
Describe the steps of the validation process. - Correct Answer decide if the data
requires validation
determine ways to validate
Identify gaps/missing data
documentation of data - Correct Answer forms the database of for the entire nursing
process and provides data for all other members of the health care team
Ensures that valid conclusions are made when the data are analyzed in the second
step of the nursing process
analysis of data - Correct Answer Second stage of the nursing process.
analyze and synthesize data to determine whether the data reveal a nursing concern, a
collaborative concern, or a concern that needs to be referred to another discipline
Requires diagnostic reasoning skills (critical thinking)
Purpose is to reach conclusions regarding the client's health
4 basic types of nursing assessment - Correct Answer initial comprehensive
ongoing or partial,
focused/problem-oriented
emergency
initial comprehensive assessment - Correct Answer o Involves collection of subjective
data about the client's perception of his or her health of all body parts or systems, past
health history, family history, and lifestyle and health practices, as well as objective data
gathered during a step-by-step physical examination
o Needed when the client first enters a health care system and periodically thereafter to
establish baseline data against which future health status changes can be measured
and compared
ongoing or partial assessment - Correct Answer o Consists of data collection that
occurs after the comprehensive database is established; this consists of a mini-
,overview of the client's body systems and holistic health patterns as a follow-up on
health status
o Any problems are reassessed to determine any changes or to detect any new
problems
o Usually performed whenever the nurse or another health care professional has an
encounter with the client
focused/problem-oriented assessment - Correct Answer o Does not replace the
comprehensive exam!
o Performed when a comprehensive database exists for a client who comes to the
health care agency with a specific health concern
o Focused assessment consists of a thorough assessment of a particular client problem
and does not cover areas not related to the problem
Emergency assessment - Correct Answer o Very rapid assessment performed in life-
threatening situations
o The major and only concern of this assessment is to determine the status of the
client's life-sustaining physical functions
Describe the ways to prepare the physical environment and make it conducive to a
physical examination - Correct Answer o Comfortable, warm room temperature: provide
a warm blanket if the room temperature cannot be adjusted
o Private area free of interruptions from others: close the door or pull the curtains if
possible
o Quiet area free of distractions: turn off the radio, television, or other noisy equipment
-Adequate lighting
-firm examination table or bed at height that prevents stooping.
-Bedside table
Equipment needed for examination - Correct Answer pg 32
Explain the ways to prepare a client for a physical examination. - Correct Answer o
Establish the nurse-client relationship during interview before exam
o Explain that the physical assessment will follow and describe what the exam will
involve
o Respect the client's desires and requests related to the physical exam
o If a urine specimen is necessary, explain to the client the purpose of a urine sample
and the procedure for giving a sample; provide them with a container (if not necessary,
have the client urinate before exam)
o Begin exam with less intrusive behaviors (temperature, etc.)
o Approach client from right-hand side of exam bed
Standard Precautions - Correct Answer pg 34-35
Describe the various positions used to perform a physical examination - Correct Answer
o Sitting position→ the client should sit upright on the side of the exam table (allows full
, expansion of the lungs, the nurse to access upper extremities and see symmetry). Good
for evaluating the head, neck, lungs, chest, back, breasts, axillae, heart, vital signs and
upper extremities
o Supine position→ ask the client to lie down with the legs together on the exam table
(allows abdominal muscles to relax and provides easy access to peripheral pulse sights.
Head, neck, chest, breast, axillae, abdomen, heart lungs, and all extremities
o Dorsal recumbent position→ the client lies down on the exam table or bed with the
knees bent, the legs separated, and the feet flat on the table. Better for patients with
pain in back or abdomen. May assess head, neck, chest, axillae, lungs, heart,
extremities
o SIMS' position→ the client lies on right or left side with the lower arm placed behind
the body and the upper arm flexed at the shoulder and elbow; the lower leg is slightly
flexed at the knee while the upper leg is at a sharper angle and pulled forward. Useful
for assessing the rectal and vaginal area.
o Standing position→ the client stands still in normal, comfortable, resting posture.
Assessing posture, balance and gait. And male genitalia.
o Prone position→ the client lies down on the abdomen with the head to the side
(mainly to access hip joint). Assess hip joint and back.
o Knee-chest position→ the client kneels on the exam table with the weight of the body
supported by the chest and knees; a 90 degree angle should exist between body and
the hips. Examine the rectum.
o Lithotomy position→ the client lies on the back with the hips at the edge of the
examination table and feet supported by stirrups. Assessing female genitalia,
reproductive tracts and rectum.
Demonstrate the correct method used for inspection during a physical examination -
Correct Answer o Make sure room is a comfortable temperature
o Use good lighting, preferably sunlight
o Look and observe before touching
o Completely expose the body part you are inspecting while draping the rest of the
client as appropriate
o Note the following characteristics while inspecting the client: color, size, patterns,
location, consistency, symmetry, movement, behaviors, odors, or sounds
What is inspection - Correct Answer involves using the sense of vision, smell and
hearing to observe and detect any normal or abnormal findings.
What is the correct order of physical examination - Correct Answer Inspect, palpitate,
percussion, auscultation
except for abdomen
What is palpitation? - Correct Answer consist of using parts of the hand to touch and
feel for the following:
Texture
Temp
