CH 27/26 Health Assessment

Question 1

Data Collection includes obtaining

Answer 1

subjective and objective data

Question 2

Subjective Data

Answer 2

Things only the client can tell

Question 3

Objective Data

Answer 3

Things the nurse can observe

Question 4

The health history

Answer 4

provides subjective data

Question 5

The physical exam and diagnostic test

Answer 5

provide objective data

Question 6

Interviewing techniques

Answer 6

standardized formats and therapeutic techniques

Question 7

Standardized formats

Answer 7

framework for obtaining information about clients, physical, developmental, emotional, intellectual, social, and spiritual demensions

Question 8

Therapeutic technique

Answer 8

foster communication and create an environment that promotes an optimal health assessment/data collection experience

Question 9

Health history components

Answer 9

demographic, history, chief concern, history of present illness, past history, family history, psychosocial history, health promotion behaviors

Question 10

Demographic Info

Answer 10

name, age, race, family, relationship status, insurance, etc

Question 11

Source of history

Answer 11

client, family member, friend, record

Question 12

chief concern

Answer 12

reason for client seeking care

Question 13

history of present illness

Answer 13

location, timing, onset, duration, predicating factos, things that make better or worse

Question 14

past and current health history

Answer 14

childhood illnesses, medical, surgical, ob, immunizations status, medications, habits, substance use

Question 15

Family history includes

Answer 15

grandparents, parents, siblings, children and grandchildren , chronic disorders, ages, ages at death,

Question 16

Psycho social history

Answer 16

relationships, support systems, living and work situations, financial status, all spitural wellness

Question 17

Health promotion beahviors of client

Answer 17

excerisce activity, diet, stress prevention, risk of heart diseases or other chronic disease, prevention of substances, sunlight

Question 18

Review of systems

Answer 18

An extensive review of systems ascertains info about the functions of all body systems and health problems

Question 19

integumentary system

Answer 19

skin disease? itching? hair loss? nail changes? allergies? sunscreen? etc

Question 20

head and neck?

Answer 20

headaches? how often? relieve of pain? can you move? facial movements? thyroid disease? etc

Question 21

eyes?

Answer 21

vision? eyeglasses? diabetes? etc

Question 22

Ear nose throat and mouth

Answer 22

hearing? changes? hearing aids? buzzing? ear infections? dizziness? nose bleeds? difficulty breathing though nose? changes in smell or taste? dentures? dentist?? etc

Question 23

breast

Answer 23

self exams? Family hx of breast cancer? over 40? mammogram?

Question 24

respiratory system

Answer 24

breathing problems? flu vaccine? void vaccine? allergies? hx o flung cancer? etc?

Question 25

cardiovascular system

Answer 25

heart problems? heart med? chest or jaw pain? cough? etc?

Question 26

gastrointestinal system?

Answer 26

stomach? heartburn? last bowel movement? laxatives? weight changes? difficulty swallowing? drink alcohol?? food intolerances? etc

Question 27

genitourinary system?

Answer 27

diff urinating? color of urine? pain during sex? scrotum pain? etc

Question 28

Musculoskeletal system

Answer 28

pain in joint or muscles? vitamin d or calcium supplements? exercise? sports? falls? etc

Question 29

Neurologic system

Answer 29

vision changes or speech? dizziness or headaches? weakness? seizures? tremors? etc

Question 30

Mental health

Answer 30

recent losses? stress? depression? concentration? etc?

Question 31

Endocrine system

Answer 31

urination patters? every level? weight or appetite change? visual disturbances? palpitations?

Question 32

Allergic/immunologic system?

Answer 32

allergies to meds or foods? blood transfusion? reactions?

Question 33

physical exam

Answer 33

look and observe before touching

Question 34

Do not feel or listen

Answer 34

through clothing

Question 35

use standard precautions

Answer 35

when in contact with body fluids wound drainage or open lesions

Question 36

For most body systems follow the sequence of (except abdomen)

Answer 36

1.inspect 2.palpate 3.percussion 4.ausculate except abdomen

Question 37

For abdomen follow the sequence

Answer 37

1.inspect 2.ausculate 3.percuss 4.palpate

Question 38

Use light palpation for most body surfaces

Answer 38

0.4 in less than

Question 39

Use deeper palpation to evaluate abdominal organs or masses

Answer 39

1.6 in

Question 40

dorsal surface of hands

Answer 40

detect temperature

Question 41

palmar surface of hand or finger base

Answer 41

sensitive to vibration

Question 42

fingertips

Answer 42

sensitive to pulsation, position,texture, turgor, sizefi

Question 43

fingers and thumb

Answer 43

useful for grasping an organ or mass

Question 44

Use the diagram of the stethoscope to listen to

Answer 44

high pitched sounds such as hear sounds bowel sounds or lung sounds

Question 45

use the bell of the stethoscope to listen to

Answer 45

low pitched sounds such as unexpected heart sound so bruits