Health Assessment NUR 102 Final Exam with Best Solutions
100% Verified and Graded A+ 2024
What are the four goals of the ANA, American Nurses Association? - Correct Answer
Promote health, prevent illness, treat human responses to health or illness, advocate for
individuals, families, communities and populations.
What are the four levels of care? - Correct Answer Primary, secondary, tertiary and
hospice.
What is primary care? - Correct Answer Prevent health problems. Example: Vaccines
What is secondary care? - Correct Answer Early diagnosis of health problems.
Example: Mammograms
What is tertiary care? - Correct Answer Treat complications of disease. Example: Using
a cane to ambulate.
What is hospice care? - Correct Answer Provide for client at death.
What does a health assessment include? - Correct Answer Health history, physical
assessment, psychological, sociocultural, spiritual, economic and lifestyle factors.
What are primary preventions? - Correct Answer Strategies aimed at preventing
problems.
What are secondary preventions? - Correct Answer Early diagnoses, prompt treatment.
What are tertiary preventions? - Correct Answer Preventing complications of existing
disease, promoting highest health level possible.
Assess - Correct Answer History and physical examination
Diagnose - Correct Answer Data clustering
Plan goals, outcomes - Correct Answer Formulation of measurable, realistic, patient-
centered goals.
Plan of Care - Correct Answer Determining resources; targeting nursing interventions;
writing plan of care.
Implement - Correct Answer Any treatment, based upon clinical judgement and
knowledge.
Evaluate - Correct Answer Judgment of nursing care efficacy in meeting patient goals
and outcomes based on response to interventions.
,True or false. A health assessment includes both a health history and a physical
assessment. - Correct Answer True.
What are the three types of assessments? - Correct Answer Emergency,
comprehensive and focused.
What are the three major health assessment frameworks? - Correct Answer Functional
assessment, head-to-toe assessment, body systems approach.
Which physical assessment framework promotes critical thinking? - Correct Answer
Body systems.
What is restatement? - Correct Answer Relates to content of communication. Purpose:
Ask patients to elaborate.
What is reflection? - Correct Answer Summarizing main themes of communication.
What is elaboration? - Correct Answer Assists patients to more completely describe
difficulties.
What is silence? - Correct Answer Purposefully allows patients time to gather thoughts,
provide accurate answers.
What is focusing? - Correct Answer Redirecting patients to pertinent topic being
discussed.
What is clarification? - Correct Answer Questions to ascertain patient's meaning when
word choice or ideas are unclear.
What is summarizing? - Correct Answer Reviewing and condensing important
information into two or three most important findings.
What are the phases of the interview process? - Correct Answer Preinteraction phase,
beginning phase, working phase and closing phase.
What is the preinteraction phase? - Correct Answer Compiling existing data, preparing
for patient interview from existing medical records.
What is the beginning phase? - Correct Answer Introduction, state purpose for
interview.
What is the working phase? - Correct Answer Closed-ended or direct questions, specific
information, open-ended questions, broad answers in patient's own words.
What is the closing phase? - Correct Answer Summarizing, stating most important two
to three problems or patterns.
, Which phase of the interviewing process includes the summation step? - Correct
Answer Closing phase.
OLDCARTS - Correct Answer Onset, location, duration, character,
aggravating/alleviating factors, relieving factors, timing, severity.
In what phase of the interview are open-ended questions used? - Correct Answer
Working phase.
SBAR - Correct Answer Situation, background, assessment and recommendations.
SOAPIE - Correct Answer Subjective, objective, analysis, plan, interventions and
evaluation.
PIE - Correct Answer Problem, interventions, evaluation
DAR - Correct Answer Data, action, response
CBE - Correct Answer Charting by exception. Outside normal limits, assessment data
requires additional documentation.
What are the four physical assessment techniques? - Correct Answer Inspection,
palpation, percussion and auscultation.
What are the five steps of patient-to-patient spread microbes? - Correct Answer
Organisms present on skin or environment, transferred to nurse's hands, survive on
hands for several minutes, nurse omits hand hygiene, contaminated hands contact
another patient or environment that directly contacts the patient.
What are the respiratory precautions? - Correct Answer Airborne, droplet, contact,
contact plus.
Why should you palpate with the finger pads? - Correct Answer For fine discrimination.
Pulses, small lumps, skin texture, edema.
Why should you palpate with the finger palmar surfaces? - Correct Answer For
firmness, contour, position, size, pain, tenderness.
Moderate to deep palpation. - Correct Answer Pressure 2-4 cm. Assess size, shape,
consistency of abdominal organs.
Light palpation. - Correct Answer 1 cm
Direct percussion - Correct Answer Tap fingers directly on skin.
