Health Assessment Test 1. 1

Front 1

What makes up the health assessment?

Back 1

Physical Examination & Health History

Front 2

Is it ok to push for details even if you feel like you're intruding on a patient's personal business?

Back 2

Yes. You need details in order to understand their situation entirely. This is why they need to feel comfortable around you to speak to you about things they may be embarrassed about admitting.

Front 3

What are the three types of abuse discussed in class and which of the three is an RN mandated to report if he/she suspects anything?

Back 3

Child Abuse
Elder Abuse
Domestic Abuse

The RN is required to report child abuse***

Front 4

What is the fifth vital sign?

Back 4

Pain. (it effects all other vital signs)

Front 5

Why is a health assessment essential?

Back 5

It aids in diagnosing medical and nursing problems

Front 6

What does the RN do with data collected during the health assessment?

Back 6

Analyze it

Front 7

What are important aspects of the health assessment?

Back 7

-A thorough health history
-Investigating details
-Evaluation of social environment
-Economic status
-Addictive behaviors

Front 8

When palpating, which area do you touch last? Why?

Back 8

Touch Pain will radiate to other areas so that you cannot distinguish where the pain is specifically.

Front 9

Health Assessment

Back 9

-Utilizes the nursing process
-Provides insight into beliefs and perceptions
-Incorporates critical thinking
-Requires knowledge of developmental stages
-Includes physical & mental assessment along with assessment for domestic violence, elderly, and child abuse
-Requires proficient communication skills and interviewing techniques
-Considers cultural aspects

Front 10

What is critical thinking?

Back 10

Thinking things through...looking at the big picture... look beyond...what could result as a result of those actions...think outside the box

Front 11

Erikson

Back 11

Tasks that need to be accomplished...which can effect health...ie...adolescence ego identity vs identity confusion-- concerned with how they look and body image...may lose weight and become anorexic...may take steroids to develop more muscle mass, etc

Front 12

Why is it important to consider cultural aspects during the health assessment?

Back 12

-To learn how patient expects to heal from illness (medicine, scientific folk healers, etc)
-Expression of pain (verbal, stoic, not expressed for various reasons...)

Front 13

What does the health assessment begin with?

Back 13

The reason for seeking care (chief complaint) & health history

Front 14

What does a legal document consist of?

Back 14

-using quotes to document patients response ie "my boyfriend pushed me through the door"
-quote the pts exact words

Front 15

Adequate vs Inadequate Documentation

Back 15

Inadequate
nausea and vomiting

Adequate
Began 12 hrs ago, vomited small amount of yellow fluid, then had dry heaves 3 times

*always document duration of complaint

**Remember to ask specific questions to achieve optimal level of details
ie What aggravates condition?... What may alleviate it?

Front 16

What are the three types of health histories?

Back 16

Complete, Interval, & Problem Focused (chief complaint)

Complete- when care provided will be comprehensive or continuous (complete physical)
Interval- follow-up visit, whats new since I saw you last?
Problem focused- when a specific problem exists, ER nurse

Front 17

What is important to consider when taking a patients history?

Back 17

-Set up an environment conducive to privacy and comfort
-Well developed interview skills and careful documentation
-Think to yourself, is the client a good historian?
-Listen more than you speak
-Don't interrupt
Don't talk down to pt. / or give false reassurance
-Use interpretor or translator if needed

Front 18

What are the three phases of the interview?

Back 18

Introduction
Working Phase
Termination Phase

Front 19

What 2 age groups would be considered bad historians?

Back 19

The elderly & young Children

Front 20

What is therapeutic communication?

Back 20

open ended questions, verbalized implied ideas, seeking clarification, using silence. Street clothes ok, sit with client, open body language

Front 21

What are the aspects of a complete health history?

Back 21

-Biographical
-Reason for seeking health care
-Present health/illness
-Past health
-Family Health
-Review of Systems
-Psychological
-Functional assessment
-Perception of health

Front 22

What is the biographical component of health history?

Back 22

name, address, etc

Front 23

What is done when asking client their reason for seeking health care?

Back 23

document why they're here in their own words, quote it

Front 24

Aggravating vs alleviating factors

Back 24

what makes it feel better/ what makes it feel worse

Front 25

What is important to ask about the client's present health/illness?

Back 25

-Onset, duration, precipitating factors
-Frequency, duration...
-Associated symptoms i.e. N/V
-Alleviating/aggravating factors

Front 26

What information should be obtained in the past health history?

Back 26

-past general health
-childhood illnesses
-accidents/injuries
-hospitalizations/surgeries
-acute and chronic illnesses
-allergies, medications, transfusions?
-immunizations

Document fully and carefully. This can give you a good idea of the patient's condition.

Front 27

What information is essential about the patient's current health?

Back 27

-Allergies
-Habits
-Meds (including OTC/Herbal/Vitamins)
-Exercise
-Sleep

Front 28

What is significant about the family history?

Back 28

-Important to know to determine individual's risks
-Spouse/significant other
-Children
-Cultural considerations
-Many diseases are genetic or culture familial
-If loved ones are ill, huge stressor
-Remember to consider cultural differences in terms of treatment and beliefs

Front 29

What is cultural ethnocentrism?

Back 29

The tendency to view ones own way of life as the most desirable, acceptable, or best and to act in a superior manner toward another culture's ways

Front 30

ROS-review of systems

Back 30

-Review past and present health status of each body system
-Reviews health maintenance
-Head to toe inspection
-May elicit new information

Front 31

What to assess in the psychological function?

Back 31

-Cognitive--memory, comprehension
-Response to illness and health
-Psych history? meds? anxiety?
-Cultural considerations

Front 32

Important aspects to cover during functional assessment?

Back 32

-ADLs
-Sleep/rest
-Nutrition/problems with diet, weight
-Alcohol problems/substance abuse
-Coping difficulties
-Domestic/child abuse

Front 33

Coping

Back 33

ability to cope often comes from support groupd and networks. Always best to find ways to deal with stress that are not harmful to yourself or others

Front 34

Perception of health

Back 34

-How one defines health
-View's on one's health status
-What are one's expectations pertaining to health and health care?

*Everyone views health differently
*you could be physically healthy but extremely OCD to the extent that it effects your life drastically

Front 35

Physical Examination

Back 35

-Goal is to identift variations from normal
-Explain procedure first
-Head to toe
-Unaffected areas before affected

Front 36

What are the four techniques used in the physical assessment? what is the specific order they must be done in? What is the exception to this?

Back 36

Inspection
Palpation
Percussion
Auscultation

* When examining abdomen, auscultate prior to palpating

Front 37

Inspection

Back 37

First techniques used. What examiner sees, hears, and smells. Observe symmetry. Make sure you have adequate lighting and exposure

Front 38

Palpation

Back 38

Second technique using fingers and hands to touch. Light palpation first then deep palpation. Warm hands, short nails. Palpation may detect pulse, temp, textures, position, size, mass, vibration, crepitus, tenderness

Front 39

Percussion

Back 39

Third technique... tapping on skin surface which creates a vibration of underlying structures. The vibration produces a sound, may aid in diagnosis.

Front 40

What is resonance? Where is it heard?

Back 40

Resonance is a hollow sound produced when percussing over normal lungs

Front 41

What is hyperresonance? Where is it heard?

Back 41

A booming sound heard over a child's lung or an adult's lung who has emphysema

Front 42

What is tympany? Where is it heard?

Back 42

A musical and drumlike sound heard over air filled organs such as the stomach or intestines

Front 43

What is dullness? Where is it heard?

Back 43

A muffled thud heard over dense organs like the liver or the spleen

Front 44

What is a flat sound? Where is it heard?

Back 44

A dead stop of sound, absolute dullness that is heard in places with no air present like bone

Front 45

Why do we percuss?

Back 45

To determine the density of what's lying underneath

Front 46

What are the three methods of percussion?

Back 46

Direct, Indirect, & fist percussion

Front 47

What is direct percussion? Where is it done?

Back 47

Directly tap the skin
Used over the sinuses

Front 48

What is indirect percussion?
Where is it done?

Back 48

Finger used to strike (usually dominant hand) finger on other hand placed on skin
Used over thorax and abdomen

Front 49

What is fist percussion? Where is it done?

Back 49

Fist of one hand strikes open hand placed on skin
Done over the kidney to test for inflammation and pain, only done if pt complains of pain

Front 50

Auscultation

Back 50

Usually last technique during physical assessment (exception-abdomen, it's the 2nd technique after inspection)
Use stethoscope to block sounds not magnify
Diaphragm-firmly against skin
Bell-lightly against skin

Front 51

True or false
The stethoscope aids to magnify sounds.

Back 51

False. It aids to block out sounds but does not magnify sounds

Front 52

What are the uses for percussion?

Back 52

-Mapping out location and size of an organ
-Determining density (air, fluid, solid) of a structure
-Detecting superficial mass (up to 5 cm deep)

Front 53

What is pitch?

Back 53

frequency of sound vibrations, low or high

Front 54

What is intensity?

Back 54

loudness of a sound: loud or soft (amplitude)

Front 55

What is duration?

Back 55

length of sound: short, long

Front 56

What is quality?

Back 56

subjective terms- harsh, tingling, etc

Front 57

What are the 4 things used to describe sounds heard while auscultating?

Back 57

Pitch
Intensity
Duration
Quality

Front 58

What to remember when performing a physical exam:

Back 58

-Utilize 4 techniques
-Proper setting
-Equipment
-Clean/safe environment
-Remember client comfort

Front 59

The reason for Ms. K to seek care is "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headache worse?" With this question, the nurse is seeking information about:
A. Ms. K's perception of pain
B. The nature or character of the headache
C. Aggravating factors
D. Relieving factors

Back 59

C is correct

Front 60

You question the reliability of the history provided by the patient. One method to verify information within the context of the interview is to:
A. review the previous medical records
B. rephrase the same questions later in the interview
C. ask the patient if there is someone that could verify information
D. call a family member to confirm information

Back 60

B is correct