Intro to Health Assessment
Health History
General Survey
Skin
Vital Signs
100

Name the 5 steps of the nursing process in the correct order

Assessment, Analysis, Planning, Implementation, Evaluation

100
What is the difference between objective and subjective data? 

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.

100

A client weighs 321 lbs. What is the client's weight in kg? Round to the tenths. 

145.9 kg

100

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

100

This is the name of the route for taking a client's temperature in their ear? 

Tympanic

200

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.

200
Who is a primary source? Who could be a secondary source?

Primary = patient

Secondary = family, friends

200

What are 5 questions a nurse could ask if a patient reports they are having pain?

OLDCARTS, PQRST
200

This is the location on the body where it is best to assess skin turgor?

Clavicle

200

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

300

Identify a tool used to perform inspection, palpation, auscultation and percussion. 

Many possible answers! Inspection = penlight, Palpation = hands, Auscultation = stethoscope, Percussion = hands

300

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. 

300

What unexpected findings during a general survey could cause the nurse to delay taking a health history?

Multiple answers!

300

What does ABCDE stand for when assessing a lesion?

Asymmetry, Border, Color, Diameter, Evolving

300

________ 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.

400

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

400

These items are included in a past medical history?

illnesses, injuries, hospitalizations, immunizations, medications, allergies

400

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

400

This is the surface of the hand used to assess skin temperature?

Posterior

400

a weak, thready, diminished pulse would receive this rating?

+1 = a weak, thready, diminished pulse

500

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. 

500

What occurs during a review of systems?

Structured method for reviewing each of the body systems for unexpected findings that warrant further assessment

500

A client is 6 feet 4 inches tall, how many inches tall is the client?

76 inches

500

Stage the ulcer: Full-thickness skin loss with subcutaneous fat visible

Stage 3

500

________ is an oxygen saturation level less than 90%.

Hypoxia is an oxygen saturation level less than 90%.