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Health Assessment
NUR 216 EXAM 1 Spring-Summer 2025
Arizona College Of Nursing (Modules 1 - 3)
Complete Question And Answer
What is an assessment?
- A data collection process
- A continuous process
- A method to establish a baseline What is the "P" in the nursing process? Plan - develop SMART goals, desired outcomes, and action plans What is the "I" in the nursing process? Implementation - perform nursing actions What is the "E" in the nursing process? Evaluate - were desired outcomes and goals achieved?
Health Assessment List 5 'Communication' skills nurses must implement at all times.
- Eye Contact
- Eye Level
- Personal Space
- Active Listening
- LISTEN to them!!! List 4 'Cognitive' skills you must implement in the assessment process.
- Critical Thinking Skills
- Inductive & Deductive Reasoning Skills
- Clinical Decision Making Skills
- Problem Solving Skills What are 'Psychomotor' skills? Skills needed to perform the 4 techniques of physical assessment. What are 'Interpersonal/Affective' skills? Affective skills needed to develop caring, therapeutic nurse-patient relationships.
Health Assessment What is the 'Introductory Phase' of the interview process?
- Introduce self
- Put patient at ease
- Explain purpose of interview
- Explain time frame What is the 'Working Phase' of the interview process?
- Data collection, structured
- Longest phase What is the 'Termination Phase' of the interview process?
- End of interview
- Summarize and restate findings What is an assessment?
- A data collection process
- A continuous process
Health Assessment
- A method to establish a baseline What is a comprehensive assessment? Consists of a complete nursing history and physical examination. What is a focused assessment? Based around the patients immediate problems. What is the nursing process? Assessment Diagnosis Planning Implementation Evaluation (ADPIE) What is the "A" in the nursing process? Assessment - gather information and review the patients history
Health Assessment Anyone, other than the nurse, reports seeing, feeling, smelling, or hearing. (DO NOT taste). Ex. AP states, "Her urine smells odorous." Observation
- Use your senses
- Look at patient and environment What are the steps to a 'Physical Assessment' in order of performance?
- Inspection
- Palpation
- Percussion
- Auscultation When does the order to a 'Physical Assessment' change? When assessing the abdomen. What are the steps to a 'Physical Assessment' in order of performance for the abdomen?
Health Assessment
- Inspection
- Auscultation
- Percussion
- Palpation What is Inspection? Sight/Smell; observe symmetry, abnormalities, distress, unusual odors, direct vs. indirect What is Palpation? Touch; texture, temperature, swelling, pain presence, organ location, etc. Can be light (less than 1/2 inch), deep (greater than 1/2 inch), or ballottement (used to assess partially free-floating objects). What is the dorsal aspect of your hand used to palpate? Best for temperature What is the ulnar surface of your hand used to palpate?
Health Assessment What side of the stethoscope would you use if you wanted to hear high pitched sounds? Diaphragm What is 'Primary' or 'Top' Priority data? Life-threatening problems What is 'Secondary' Priority data? Require prompt attention to prevent further progression or deterioration. What is 'Tertiary' Priority data? Important, but do not require immediate attention. List 6 components of the Health History.
- Biographical Data
- Current Health Status
- Past Health History
- Family History
Health Assessment
- Review of Systems
- Psychosocial History What is a 'General Survey'? Begins the moment you first encounter a patient. Includes Physical Appearance, Behavior, Body Structure, and Mobility. What 6 characteristics do you assess when looking at a patients 'Physical Appearance'?
- Age
- Sex
- Level of Consciousness (x1, x2, x3, x4)
- Skin Color
- Facial Features
- Overall any signs of distress? What 5 characteristics do you assess when looking at a patients 'Behavior'?
- Facial Expressions
Health Assessment How do you obtain a proper weight? Instruct the patient to remove any heavy clothing and to record their weight at the same time and on the same scale device everyday. How do you obtain a proper height? Instruct the patient remove their shoes and to stand straight, with their feet shoulder width apart. What is BMI? Body Mass Index; indicator of obesity or malnutrition. What is the BMI formula? Weight(lbs)/Height(in)^2x BMI Table Underweight <18. Normal Weight 18.5-24. Overweight 25-29.
Health Assessment Obese > What is the normal temperature range? 96.8-100.4 (F) 36 - 38 (C) What is considered a treatable fever? 102.2 (F) 39 (C) What tools do you need to measure a temperature? Thermometer What different locations can you obtain a temperature on a patient?
Health Assessment
- Rate
- Rhythm
- Quality
- Strength What tools do you need to measure a pulse? Index & Middle Fingers List the different pulse sites.
- Temporal
- Carotid
- Brachial
- Radial
- Femoral
- Popliteal
- Posterior Tibial
- Dorsalis Pedis
Health Assessment List 3 factors that can increase your heart rate.
- Stress
- Pain
- Exercise List 3 factors that can decrease your heart rate.
- Being a runner
- Beta Blockers
- Sedating Medications What is the normal oxygen range? 95 - 100 % What tools do you need to measure oxygen saturation's? Pulse Oximeter What different locations can you obtain an oxygen saturation?
Health Assessment List 3 factors that can increase your respiration rate.
- Pain
- Asthma
- COPD List 2 factors that can decrease your respiration rate.
- Opioids
- Anesthesia What is a normal blood pressure? 120/80 mmHg What tools do you need to measure a blood pressure?
- Sphygmomanometer
- Stethoscope
Health Assessment What 2 locations can you obtain a blood pressure?
- Either arm
- Either thigh Prehypertension Range 120 - 129/< Stage 1 Hypertension Range 130 - 139/80- 89 Stage 2 Hypertension Range
140/> Hypertension Crisis Range 180/>
