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Health Assessment

CHAPTER QUIZ Nurses Role in Health Assessment


NAME __________________________________________
DATE _____________________

SCORE _______
RATING ______

Instruction: NO ERASURES!
Part I IDENTIFICATION: Answer what is being asked. (10pts)
1. __________________________________ Is a systematic rational method of planning in
providing individualized quality nursing care NJURSING PROCESS
2. __________________________________ Are problem identified by the nurse that are
already in existence. ACTUAL PROBLEM
3. _______________________________________ Are situation in problem might occur
but are not currently in existence. RISK/POSSIBLE
4. _______________________________________ Are those sanctioned by professional
practice acts and they do not require direction or an order from another health care
professional. INDEPENDENT NURSING INTERVENTION
5. _______________________________________ Are those that require an order from
health care providers DEPENDENT NURSING INTERVENTION
6. _______________________________________ Focus on the etiology of a problem and
cover a short period of time within hours or days. SHORT TERM GOAL
7. ___________________________________ Focus on the problem and cover a longer
time frame within a week or months. LONG TERM GOAL
8. ___________________________________ Address human responses to a health state,
problem or condition and is a three part statement. NURSING DIAGNOSIS
9. ___________________________________ Are used by physicians to identify or
determine a specific disease condition of pathologic state. MEDICAL DIAGNOSIS
10. ________________________________________ An evaluation of the health status of an
individual by performing physical examination after obtaining a health history. HEALTH
ASSESSMENT
PART II MULTIPLE-CHOICE: Read the following questions and choose the best answer.
Encircle the letter of the correct answer. (15pts)
1. When the client states that my head hurts and my vision is blurry, is what type of
source data?
a. Primary and objective
b. Secondary and subjective
2. A patients chart is what type of data?

c. Primary and subjective


d. Secondary and objective

a. Primary
b. Secondary

c. Tertiary
d. A and B

3. The major and only concern during this type of assessment is to determine the status of
the clients life sustaining physical functions:
a. Initial comprehensive assessment
b. Ongoing or partial assessment
c. Focused or problem oriented assessment
d. Emergency assessment
4. Major areas of subjective data include the following except:
a. Physical symptoms related to each body part or system
b. Biographical information
c. Physical characteristics
d. Family history
5. The following data are objective data except:
a. Bodily function
b. Past health history

c. Appearance
d. Behavior

6. An important step of assessment because it forms the database for entire nursing process
and provides data for all other members of the health care team:
a. Documenting data
b. Validating data

c. Collecting objective data


d. Collecting subjective data

7. Which of the following is an example of objective data?


a. The client complains nausea
b. The clients abdomen is soft and round
c. The physician says the client is experiencing chest pain
d. The clients spouse asks the he be returned to be bed because he is tired
8. Which of the following data the nurse should validate?
a. The clients pulse is 104
b. The chart says the client is allergic to penicillin
c. The clients says, I feel like my blood sugar is high
d. The clients temperature is 101.2 degree Farenheit
9. Consider the following nursing diagnosis: Ineffective breathing pattern related to
respiratory muscle fatigue as evidenced by use of accessory muscles. Which part
represents the etiology for this diagnosis?
a. Ineffective breathing pattern
b. Respiratory muscle fatigue

c. Use of accessory muscle


d. Related to

10. Consider the following nursing diagnosis: Chronic pain related to pain from stiff joints.
What is the error in this diagnosis?
a. It should have written as one part nursing diagnosis
b. It includes medical diagnosis
c. It says the same thing twice
d. It is judgmental
11. Which of the following wellness diagnosis is written correctly?
a. Readiness for Enhanced Health-Seeking Behaviors (low sodium diet)
b. Readiness for Enhanced Health-Seeking Behaviors r/t making clinic visit
c. Readiness for Health-Seeking Behavior (low sodium diet
d. Enhanced Health-Seeking Behavior
12. Which of the following correctly written diagnosis that the nurse should add to the
clients care plan?
a. Altered Nutrition: Less than body requirements
b. Pneumonia related to infectious process
c. Impaired Physical Mobility related to weakness in lower extremities
d. Acute pain related to abdominal incision
13. Which of the following is stated in the format of a collaborative problem?
a. Potential for Complication of Immobility: Decubitus Ulcer
b. Risk for decubitus ulcer related to immobility
c. Complication of immobility: Decubitus ulcer
d. Decubitus ulcer related to immobility
14. Which of the following nursing diagnoses uses the PES format?
a. Fluid volume deficit related to prolonged vomiting
b. Risk for impaired skin integrity as manifested by poor skin turgor and old age
c. Ineffective airway clearance related to infectious process as manifested by
excessive mucous and retained secretions
d. Ineffective airway clearance as manifested by secretions in the bronchi, presence
of allergies and airway spasm
15. Consider the following nursing diagnosis for client who in on bed rest: Risk for Impaired
Skin Integrity related to bed rest. Which of following nursing interventions was derived
from etiological portion of the nursing diagnosis?
a. Select high-protein foods each meal
b. Complete bed bath every morning
c. Offer a back rub as necessary
d. Turn and reposition every 2h
16. PART III LABELING Write S in the blank is the data is Subjective and O is the data
is Objective
______ 1
______ 2
______ 3
______ 4
______ 5
______ 6

T=103.3 degree farenheit O


Dizziness S
Hematocrit 33% O
Right upper quadrant pain S
Itching S
Feeling tired S

______ 7 Feeling warm skin S


______ 8 Seeing spots S
______ 9 A fever O
______ 10 Needing to cough S
17. Identify the following statement by writing MD for medical diagnosis and ND for
nursing diagnosis on the space provided.
______ 1 Pneumonia MD
______ 2 Impaired gas Exchange ND
______ 3 Ineffective Breathing Pattern ND
______ 4 Acute Renal Failure MD
______ 5 Diarrhea ND
______ 6 Altered mobility ND
______ 7 Myocardial infarction MD
______ 8 Insomnia ND
______ 9 Readiness for enhance nutrition ND
______ 10 Risk for infection ND
18. Label each of the following nursing intervention as DEP (dependent), IND
(independent), or INT (interdependent). Write the correct answer on the space provided.
______ 1 Applying a heating pad to a shoulder for 20 minutes IND
______ 2 Sending an order for diagnostic laboratory test INT
______ 3 Turning client with impaired mobility every 2 hours IND
______ 4 Teaching client about side effects of medication IND
______ 5 Reviewing and conveying abnormal laboratory results INT
______ 6 Giving medications as necessary DEP
______ 7 Position client on a high-Fowlers IND
______ 8 Collecting specimen for urine analysis DEP
______ 9 Administering oxygenation DEP
______ 10 Administering TSB to client with fever IND
19. Identify the following diagnosis as Correct by putting a mark and Incorrect by putting
X mark on the space before the number.
______ 1 Self-care deficit related to stroke X
______ 2 Ineffective airway clearance related to general weakness and immobility CHECK
______ 3 Urinary retention related perianal swelling CHECK
______ 4 Constipation related to nutritional intake X
______ 5 Constipation related to inadequate dietary bulk and fluid intake CHECK
______ 6 Fear related to separation from parents X
______ 7 Anxiety related to change in environment and unmet needs CHECK
______ 8 Ineffective airway clearance related to bad habit X
______ 9 Risk for altered parenting related to inexperience X
______ 10 Impaired skin integrity related to pressure CHECK

20. Part IV DEFINITION: Define the following terms. (10pts)


1.
2.
3.
4.
5.

Nursing Assessment is the collecting of subjective and objective data


Diagnostic Phase analysis of the subjective and objective data
Planning developing a plan of nursing care and outcome criteria
Implementation carrying out the plan of care
Evaluation assessing whether the outcome criteria have been met an and revising the
plan of care if necessary
6. Subjective data sensations or symptoms that can be verified only by the client
7. Objective data findings directly or indirectly observed through measurements
8. Collaborative problem physiologic complications that nurses monitor to detect their
onset of changes in status
9. Referral problem problem that requires attention or assistance of other health care
professionals
10. Medical diagnosis are used by the physicians to determine or identify specific disease
condition or pathologic condition
21. Part V MATCHING TYPE: Match Column A with Column B
22. COLUMN A
______ 1 Efficient i
______ 2 Effective g
______ 3 Inability to walk b
______ 4 Altered mobility h

______ 5 Weakness f
______ 6
______ 7
______ 8
______ 9

Short term objective j


Long term objective d
Continue plan e
Revise plan a

______ 10 Discontinue plan c

23. COLUMN B
a. Not working
b. Signs and symptoms (defining
characteristics)
c. Problem is resolved
d. Patient will maintain a pain level of 3
or less during remaining of hospital
stay.
e. Problem is still present but plan is still
working
f. Etiology
g. Utilizes resources wisely
h. Problem statement
i. Promotes client satisfaction and
progress
j. Patient will have pain at less than a 3
within thirty minutes.

24.
25. Part VI ENUMERATION: List what is being asked. (15pts)
26. FOUR MAJOR STEPS OF NURSING HEALTH ASSESSMENT
1. ______________________________________ Collecting Subjective Data
2. ______________________________________ Collecting Objective Data
3. ______________________________________ Validating Data

4. ______________________________________ Documenting Data


27. THREE METHODS OF DATA COLLECTION
5. ______________________________________ Interview
6. ______________________________________ Observation
7. ______________________________________ Physical Examination
28. ELEMENTS/COMPONENTS OF A THREE PART NURSING DIAGNOSIS
8. ______________________________________ Problem
9. ______________________________________ Etiology
10. ______________________________________ Signs and Symptoms
29. FIVE CHARACTERISTICS OF NURSING PROCESS
11. ______________________________________ Goal-oriented
12. ______________________________________ Organized and systematic
13. ______________________________________ Humanistic care
14. ______________________________________ Involves decision making
15. _______________________________________ Cyclical and dynamic and Uses critical
thinking
30. Part VII ESSAY (10pts)
1. Outcome must always be SMART. What does this mean? Explain in 5 to 10 sentences.
31. SMART stands

for SPECIFIC, MEASURABLE, ATTAINABLE, REALISTIC, AND


TIME BOUND. This means that in formulating the desired outcome it should be specific
meaning precise and definite based on the clients identified needs and problems (Who is
the subject?). It has a criteria specific to meet the desired outcome. Attainable within a
specified time frame. EXPECTED OUTCOMES are part of the planning process. Is
stated as (1) the SUBJECT or CLIENT (2) a TASK statement of the hoped-for client
behavior and function (3) the CRITERIA by which the nurse will determine whether
the expected outcomes is met (4) the CONDITIONS or QUALIFYING statements or
condition for meeting the expected outcome (5) the TIME FRAME with in which the
outcomes is expected to be reached.

32.
33. Doing whats right today means no regrets tomorrow
34. Prepared by
35. Annalisa A Telles, MAN
36. Instructor
37. Health Assessment
38. CHAPTER QUIZ Collecting Objective Data
39.

40. NAME __________________________________________


_______
41. DATE _____________________
______
42.

SCORE
RATING

43. Instruction: NO ERASURES!


44. ENUMERATION
45. Four Physical Examination Techniques
1.
2.
3.
4.

______________________________
______________________________
______________________________
______________________________

46. Four Principles on preventing transmission of infectious agents


5.
6.
7.
8.

_______________________________
_______________________________
_______________________________
_______________________________

47. Equipment used in examining the skin, hair, and nails


9. ________________________________
10. ________________________________
11. ________________________________
12. ________________________________
48. Conditions in preparing the physical setting before beginning the examination
13. _________________________________
14. _________________________________
15. _________________________________
49. IDENTIFICATION
1. A technique used from the moment that you meet the client and continues throughout the
examination.
2. A process of listening to sound created in body organs to detect variations from normal.
3. An assessment technique in which the examiner feels the body by application of the
hands.
4. An examination by striking the bodys surface with a finger, vibration and sound are
produced.
5. A part of the hands used to feel texture, shape, size, consistency, shape and crepitus.
6. A part of the hands used to feel clients temperature.

7. A type of percussion used to detect tenderness over organs by placing one hand-flat on
the body surface, using the fist of the other hand to strike back of the hand flat on the
body surface.
8. A type of auscultation when the listens to sounds produced from within the body by use
of the stethoscope.
9. A type of palpation used to feel for pulses, tenderness, surface skin texture, temperature
and moisture.
10. A loud low pitched hollow sound of a long duration typically over the normal lung
tissues.
11. A soft high pitched dead stop of a sound absolute dullness sound of short duration
typically found over muscle and bone.
12. It is the frequency of the vibration of an auscultated sound (high/low).
13. This refers to loudness or softness of an auscultated sound (loud or soft).
14. It is done before equipment preparation and examination to reduce transfer of
microorganisms.
15. A data the examiner directly or indirectly observed.
50. TRUE OR FALSE
1. Begin with the non-threatening procedures to allow client feel more comfortable and ease
client anxiety about the examination.
2. The highest priority before the examination is to established rapport because clients are
easily embarrassed when body parts are exposed or sensitive questions are asked.
3. Approach client from whichever part of the table or bed to begin the examination.
4. Prior to palpation the examiner should warm hands before placing them on the patient.
5. During palpation instruct the client to hold his breathe.
6. Performing percussion the nurse uses quick taps by quickly flexing the hands, not the
forearm.
7. Auscultate by placing the stethoscope through the clients clothing or gown.
8. The bell of the stethoscope is used to listen for low pitched sounds.
9. The diaphragm of the stethoscope is used to listen for high pitched sounds.
10. During inspection the client is asked to remove all clothing to view all body parts.
51. MATCHING TYPE
52. COLUMN A
1. _____ Penlight
2. _____ Opthalmoscope
3. _____ Otoscope
4. _____ Gloves
5. _____ Stethoscope
6. _____ Sitting

53. COLUMN B
a. To determine the reactions of the pupils
of the eye
b. Client lies on abdomen with head
turned to side
c. Position used to examine male genitalia
d. To visualize the interior of the eye
e. Position used during much of the
physical examination
f. To visualize external auditory canal

7. _____ Sims position


8. _____ Standing position
9. _____ Supine position
10. _____ Prone position
11. _____ Lithotomy position
12. _____ Bell of stethoscope
13. _____ Diaphragm of stethoscope
14. _____ Dorsal surface
15. _____ Ulnar surface

g. Side-lying used during rectal


examination
h. This position also allows easy access
for palpation of peripheral pulses
i. To prevent contamination
j. To auscultate heart, lung, abdominal
sound
k. Used to examine female genitalia
l. Used to detect normal breath sounds
m. Used to feel for temperature
n. Used to detect abnormal heart sounds
o. Used to feel vibrations, thrills or
fremitus

54.
55. MULTIPLE -CHOICE
1. The examiner directly observed the following as objective data except:
a. Physical characteristics
b. Appearance
c. Behavior
d. Preference
2. To become proficient with physical assessment skills the nurse must have basic
knowledge in three areas except:
a. Observe the principles on transmission of infectious agents while performing a
physical assessment
b. Types and operation of equipment needed for particular examination
c. Preparation of setting, oneself and the client for physical assessment
d. Performance of the four assessment techniques
3. Before beginning the physical assessment the nurse psychologically prepare the client.
Select that all apply.
a. Reduce clients anxiety
b. Ask the client to wear gown
c. Established rapport
d. Explain to the client after interview that physical assessment will follow
e. Explain what procedure you are performing and why you are performing it
4. Following are clients physical preparation before beginning physical assessment. Select
that all apply.
a. Established rapport to alleviate clients anxiety
b. Ask client to wear gown
c. Asks the client if he has the need to use the toilet
d. Approach client from the right side of the examination table
5. To inspect body part the nurse observes the following principles or guideline except:
a. Make the room in a comfortable temperature
b. Make sure good lighting is available

c. Touch the body parts you are to examine and then look and observe
d. Compare the appearance with the same area of the opposite side of the body
6. Part of the hand sensitive to vibrations, thrills and fremitus:
a. Fingerpads
b. Palmar surface
c. Dorsal surface
d. Fingers
7. Percussion has several different assessment use during physical assessment except:
a. Eliciting pain
b. Determining consistency
c. Determining density
d. Detecting abnormal masses
8. The most commonly used method of percussion:
a. Direct percussion
b. Blunt percussion
c. Indirect percussion
d. Bimanual percussion
9. A sound elicited by percussion described as a loud, high pitched musical sound of
moderate duration typically over the stomach filled with gas:
a. Flatness
b. Dullness
c. Hyperresonance
d. Tympany
10. All of the following are correct descriptions of auscultated sounds. Select that all apply.
a. Pitch
b. Severity
c. Intensity
d. Duration
e. Quality
f. Location
56.
57.
58.