Intro to Health Assessment
Name the 5 steps of the nursing process in the correct order
Assessment, Analysis, Planning, Implementation, Evaluation
Objective data is obtained through direct assessment of a client (inspection, percussion, palpation, and auscultation). Subjective data is information that the client tells you in response to assessment questions.
A client weighs 321 lbs. What is the client's weight in kg? Round to the tenths.
145.9 kg
This condition is caused by lack of oxygen to the tissues. It causes bluish skin tones and can be seen in the oral mucosa.
Cyanosis
This is the name of the route for taking a client's temperature in their ear?
Tympanic
Identify 3 opportunities for hand hygiene
It should be done before and after all client contact; before and after invasive procedures such as inserting a urinary catheter; before and after the removal of gloves; and after contact with client items or surfaces in the client's room. The use of alcohol-based rubs is an appropriate hand hygiene method if the hands are not visibly soiled.
Primary = patient
Secondary = family, friends
What are 5 questions a nurse could ask if a patient reports they are having pain?
This is the location on the body where it is best to assess skin turgor?
Clavicle
Is a radial pulse on the thumb side or pinky side? How many seconds should a pulse be counted for?
Thumb side, count for 30 seconds and multiply by 2
Identify a tool used to perform inspection, palpation, auscultation and percussion.
Many possible answers! Inspection = penlight, Palpation = hands, Auscultation = stethoscope, Percussion = hands
True or False: Nurses when documenting allergies only need to document allergies to medications
False: food, medications, or environmental or contact triggers, such as latex.
What unexpected findings during a general survey could cause the nurse to delay taking a health history?
Multiple answers!
What does ABCDE stand for when assessing a lesion?
Asymmetry, Border, Color, Diameter, Evolving
________ is systolic blood pressure of less than 90 mm Hg or a diastolic pressure less than 60 mm Hg.
Hypotension is systolic blood pressure of less than 90 mm Hg or a diastolic pressure less than 60 mm Hg.
Give an example of how a nurse can provide physical and personal privacy when conducting an assessment?
Physical privacy = closing the door, private room
Personal privacy = maintaining confidentiality
These items are included in a past medical history?
illnesses, injuries, hospitalizations, immunizations, medications, allergies
Upon entering a client's room, how would the nurse expect the client to appear?
A relaxed posture, smiling, and responsiveness to communication
sitting upright with ease with the arms relaxed at sides
This is the surface of the hand used to assess skin temperature?
Posterior
a weak, thready, diminished pulse would receive this rating?
+1 = a weak, thready, diminished pulse
Describe the ethical principle of autonomy and how it applies to health assessment?
Autonomy is the client's right to make decisions. They can refuse if they desire.
What occurs during a review of systems?
Structured method for reviewing each of the body systems for unexpected findings that warrant further assessment
A client is 6 feet 4 inches tall, how many inches tall is the client?
76 inches
Stage the ulcer: Full-thickness skin loss with subcutaneous fat visible
Stage 3
________ is an oxygen saturation level less than 90%.
Hypoxia is an oxygen saturation level less than 90%.