Health Assessment Quiz 1

Front 1

The registered nurse collects comprehensive data pertinent to the patient's health or the situation.

Back 1

Assessment

Front 2

The RN analyzes the assessment data to determine the diagnoses or issues.

Back 2

Diagnosis

Front 3

The RN identifies expected outcomes for a plan individualized to the patient or the situation.

Back 3

Outcome Identification

Front 4

The RN develops a plan that prescribes strategies and alternatives to attain expected outcomes.

Back 4

Planning

Front 5

The RN implements the identified plan through coordination of care, health teaching and health promotion, consultation, and prescriptive authority and treatment.

Back 5

Implementation

Front 6

The RN evaluates progress toward attainment of outcomes.

Back 6

Evaluation

Front 7

Information provided by clients when asked to describe their current state of health, previous illnesses and surgeries, and their family background.

Back 7

History (subjective data)

Front 8

Subjective data acquired by another individual (such as a family member)

Back 8

Secondary source of history data

Front 9

Collection of observable data by the nurse. Data obtained using techniques of inspection, palpation, percussion, and auscultation.

Back 9

Objective Data - Examination

Front 10

Data observed, felt, heard, or measured by the nurse. Include fever, rash, enlarged lymph nodes, and swelling.

Back 10

Signs

Front 11

Data that the client or family tells the nurse. Pain, itching, nausea.

Back 11

Symptoms

Front 12

Detailed history and physical examination performed at the onset of care. Encompasses health problems of the client as well as health promotion, disease prevention, and assessment for problems with known risk factors.

Back 12

Comprehensive assessment

Front 13

History and examination that is limited in scope to a specific problem or complaint (ie sprained ankle).

Back 13

Problem based/focused assessment.

Front 14

Usually done when client is seeking additional care with a provider after a previous visit. 2 weeks after antibiotics, etc.

Back 14

Follow-up/Episodic assessment

Front 15

Short, usually inexpensive exam focused on disease detection.

Back 15

Screening assessment

Front 16

5 data sources

Back 16

Client, Significant Others, Records, Consultations, Lab/Diagnostic studies

Front 17

Data collection methods

Back 17

observation
health history interview
physical exam

Front 18

Health History Interview 4 components

Back 18

Purpose, Preparation, Plan-Skills, Parts

Front 19

Health History Purpose

Back 19

I - involve client
C - collect subjective data
E - establish a baseline

Front 20

Health History Preparation

Back 20

S - self (build trust, skills, knowledge, appearance)
S - setting (privacy, quiet, comfort)

Front 21

Health History Plan

Back 21

Interpersonal
Communication

Front 22

Health History Parts

Back 22

Bio
Reason
Present
Past
Family Hx
Psycho/Social
ROS

Front 23

Health History Physical Examination

Back 23

Purpose
Preparation
Plan-Skills

Front 24

Physical Exam Purpose

Back 24

V - validate subjective data
C - collect objective data
E - establish a baseline

Front 25

Physical Exam Preparation

Back 25

Hands, equipment, client positioning

Front 26

Physical Exam Plan - Skill

Back 26

KNOW IN ORDER:
Inspection
Palpation
Percussion
Auscultation

Except abdominal exam, out of order - auscultation before palpation/percussion

Front 27

Diagnosis - Purpose

Back 27

Direct plan of care
PPM - predict, prevent, manage
decrease costs, increase efficiency

Front 28

Diagnosis - Process

Back 28

Analyze - normal, risk, impaired
Synthesize - signs/symp, evidence

Front 29

Normal Temperature

Back 29

96.4-99.1

Front 30

Normal Oral Temperature

Back 30

97.6-99.6

Front 31

Normal axillary temperature

Back 31

96.6-98.6

Front 32

Normal rectal temperature

Back 32

98.6-100.6

Front 33

Normal Heart rate

Back 33

60-100 BPM

Front 34

Normal respirations

Back 34

12-20 RPM

Front 35

Normal Blood Pressure

Back 35

Systolic 110-140/
Diastolic 60-90

Front 36

Risk potential diagnosis

Back 36

2 parts -
Risk of "x"
r/t "x"

Front 37

Actual diagnosis

Back 37

3 parts -
diagnosis
r/t "x"
AEB (as evidenced by) "x"

Front 38

Symptom Analysis

Back 38

O - onset
L - location
D - duration
C - characteristics
A - aggravating and alleviating factors
R - related symptoms
T - treatment
S - severity

Front 39

Onset

Back 39

When did symptoms begin?

Front 40

Location

Back 40

Where are the symptoms?

Front 41

Duration

Back 41

How long do the symptoms last?

Front 42

Characteristics

Back 42

Describe the characteristics of the symptom

Front 43

Aggravating and Alleviating Factors

Back 43

What affects the symptoms?

Front 44

Related Symptoms

Back 44

What other symptoms are present?

Front 45

Treatment

Back 45

Describe self treatment tried before seeking care

Front 46

Severity

Back 46

Describe the severity of the symptom

Front 47

older adult vital sign changes

Back 47

97.2 F average temp
arteriosclerosis - higher BP