Introduction to Health Assessment
General Survey
Health History
Skin
Clinical Skills
100

What are the steps of the Nursing Process?

Assessment

Analysis

Planning

Implementation

Evaluation

100
Name Eight Pulse Points in the body.

Temporal

Carotid

Radial

Brachial

Femoral

Popliteal

Dorsalis Pedis

Posterior Tibial

100

What are the three stages of the interview process?

Opening-introduction & reason for the interview

Information gathering stage-use therapeutic communication techniques to collect and document client data

Closing stage-thank the client and summarize the collected information. 


100

Name two examples of a macule; a nonpalpable, skin color change, smaller than 1 cm.

Freckle

Petechiae

100

What is a pulse deficit and how would you assess for a Pulse Deficit?

Pulse deficit:  The difference between the apical rate and the radial rate.

200

What are the types of Assessments?

Comprehensive

Focused

200

Identifying data includes what is in the demographic information of the health history.

● Name, address, contact information 

● Birth date, age 

● Gender 

● Race, ethnicity  

● Relationship status  

● Occupation, employment status 

● Insurance 

● Emergency contact information 

● Family, others living at home 

● Advance directives

200

Using effective skills and techniques in therapeutic communication describes one clarifying technique that a nurse uses to determine whether the message the client received is accurate.

Restating: Uses the client’s exact words 

Reflecting: Directs the focus back to the client for them to examine their feelings 

Paraphrasing: Restates the client’s feelings and thoughts for them to confirm what they have communicated  

Exploring: Allows the nurse to gather more information about important topics the client mentioned

200

What is an example of a Nodule; palpable, circumscribed, deep, firm, 1 to 2 cm.

Wart

200

During the Analyze Cues (Analysis) what is the expected response and behavior of the nurse?

Analyze expected and unexpected findings in health data.

Identify client problems and related health alternatives.

Analyze client needs. 

Identify potential complications.

Identify how pathophysiology relates to clinical presentation.

Identify data that is of immediate concern.

300

Past Health History and Current Health Status includes what?

● Childhood illnesses, both communicable and chronic

● Medical, surgical, obstetrical, gynecological, psychiatric history, including time frames, diagnoses, hospitalizations, treatments 

● Current immunization status, dates and results of any screening tests 

● Allergies to medication, environment, food 

● Current medications including prescription, over-the-counter, vitamins, supplements, herbal remedies, time of last dose(s)  

● Habits and lifestyle patterns (interests and social activities) 

● Substance use (alcohol, tobacco, caffeine, recreational drugs)

300

The general survey is a written summary or appraisal of overall health. What information is Assessed (5) for the General Survey?

PHYSICAL APPEARANCE 

BODY STRUCTURE 

MOBILITY 

BEHAVIOR 

VITAL SIGNS  

300

What does PQRST mean for a pain assessment?

P-Pattern or precipitating factors

Q-Quality 

R-Radiates

S-Severity

T-Time and Treatment

300

Name three types of vesicle; serious fluid filled, smaller than 1 cm lesion.

Blister

Herpes Simplex

Varicella

300

Older Adults should follow these 7 age-related guidelines for screening.  

Hearing

Fecal occult blood test

Digital rectal and prostate-specific antigen (males)

Dual-energy x-ray absorptiometry (DXA) scanning for osteoporosis

Eye examination for glaucoma

Mental Health Screening for depression

Cholesterol and diabetes screening

400

What are four nursing techniques used in Objective Data Collection?

Inspection

Palpation

Percussion

Auscultation

400

Name three nursing interventions for Hyperthermia an abnormally elevated body temperature.

● Obtain specimens for blood, urine, sputum, or wound cultures as needed. 

● Assess/monitor white blood cell counts, sedimentation rates, and electrolytes. 

● Ensure prescribed cultures are obtained before administering prescribed antibiotics, to promote test accuracy. 

● Provide fluids and rest. Minimize activity. Use a cooling blanket. 

● Children and older adults are at particular risk for fluid volume deficit. 

● Provide antipyretics (aspirin, acetaminophen, ibuprofen). Do not give aspirin to manage fever for children and adolescents who have a viral illness (influenza, chickenpox) due to the risk of Reye’s syndrome. 

● Prevent shivering, as this increases energy demand. 

● Offer blankets during chills and remove them when the client feels warm. 

● Provide oral hygiene and dry clothing and linens. 

● Keep environmental temperature between 21° and 27° C (70° to 80° F).

400

What is the meaning of an open-ended question and give one example. 

Open ended questions allow the client to relay information that is important to them and give you an opportunity to actively listen and observe the client. They convey caring and interest by the nurse. 

Describe how you are feeling. 

What symptoms brought you to the hospital today?

400

What does the ABCDE system to detect possible skin cancer mean?

A-Asymmetry of shape

B-border irregularity

C-color variation within one lesion

D-diameter greater than 6 mm

E-evolving or chang in color, elevation, shape, size, or development of itching, crusting, or bleeding

400

During the Generate Solutions (Planning) what is the expected response and behavior of the nurse?

Collaborate with members of the interprofessional healthcare team and the client to establish client outcomes and the plan of care. 

Identify optimal client outcomes. 

Prioritize plan of care to achieve optimal client outcomes. 

Prioritize nursing care when caring for multiple clients. 

Modify a plan of care to ensure the achievement of optimal client outcomes when indicated. 

Determine the potential impact of selected interventions.


500

During the Recognize Cues (Assessment) what is the expected response and behavior of the nurse?

Identify and recognize relevant subjective/objective client data related to the client's condition.


500

Name 7 assessment skills that are part of the General Survey

Appearance

Behavior

Body Structure

Mobility

Height & Weight

Vital Signs

Pain Assessment

500

What are the Key Elements of the health interview using the acronym PLEASE

P-Past medical history

L-Last oral intake

E-Events leading to illness

A-Allergies and reactions

S-Symptoms of chief complaint

E-Each prescribed medication; OTC; & herbal

500

Edema is an accumulation of fluid in the tissues.  The depth of pitting edema reflects the degree of edema.  How is this graded?

1+ Trace 2mm rapid skin response

2+ Mild 4 mm 10-15 second skin response

3+ Moderate 6 mm prolonged skin response

4+ Severe 8 mm prolonged skin response

500

For most body systems, follow the sequence of first inspecting, then palpating, followed by percussion, and finally auscultation. What focused system assessment is a different sequence used?

The exception is the abdomen; inspect, auscultate, percuss, and palpate in that order to avoid altering bowel sounds.