Exam 4 Flashcards
(57 cards)
What is an ongoing partial assessment ?
An ongoing partial assessment is one that is conducted a regular intervals during care of the patient. This type of assessment concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions
What is a comprehensive assessment?
Comprehensive assessment with a health history and complete physical examination is usually conducted when the patient first enters a healthcare setting, with information providing a baseline for comparing later assessment
What is a focused assessment?
A focused assessment is conducted to assess a specific problem. For example if a woman is having abdominal pain the nurse asked questions about urinary problems, bowel problems, and menstrual history.
How does the nursing health assessment differ from one performed by a physician?
The nursing health assessment differs from other types of health assessments in that it is a holistic collection of information about factors that affect or affected by one’s level of help
True or false
A health history is a collection of subjective data that provides a detailed profile of the patient’s health status
True
What is a physical assessment?
Physical assessment is the systematic collection of a objective information
When assessing the patient eyes, which instrument with the nurse used to visualize the retina?
Ophthalmoscope, only the ophthalmoscope is used to assess the internal eye
Which of the following would be most important for a nurse to do to ensure the accuracy of inspection during assessment?
A. Compare bilateral body parts
B. have 2020 vision
C. Focus on selected body system
D. Use touch judiciously
A, with inspection, a comparison of bilateral body parts is necessary for recognizing abnormal findings
Percussion over the stomach reveals a loud, drum like sound. The nurse would document this finding as which of the following?
Tympany , is a loud drum like sound heard over an air filled organ
While conducting a physical assessment, the nurse uses the bell of the stethoscope to hear which type of sounds?
Heart sounds, the bell of the stethoscope is used to hear low pitch sounds, such as those produced by the heart and vascular system
The patient’s visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets the signing is which of the following?
The patient has less than normal vision
When using an otoscope to assess the Tympanic membrane of an adult, the nurse straightens the ear canal by gently pulling the pinna in which direction?
Up and back
In children younger than three years of age, the ear canal is straightened by pulling the pinna gently down and back
Percussion of the thorax reveals a dull sound. The nurse interprets this indicate which of the following?
Fluid or solid mass
The nurse auscultates the thorax and lungs and hears coarse gurgling sounds on expiration. The nurse would describe the sounds As, what?
Adventitious breath sounds, sounds not normally heard in the lungs
When assessing heart sounds the nurse understands that the sounds heard reflect which of the following?
Closure of the heart valves
When palpating the breast of a woman during an assessment, the nurse would divide the breast into which of the following?
Quadrants, the breast is divided into four quadrants outer upper quadrant, outer lower quadrant, inner upper quadrant, and inner lower quadrant
After inspecting the patient’s abdomen, which technique with the nurse do next?
Auscultation, when assessing the abdomen the sequence is inspection, auscultation , percussion, and palpation
When assessing a patient’s mental status, which of the following with the nurse the least likely to include when evaluating level of awareness?
A. Orientation to time
B. Ability to state where he is
C. Ability to state name
D. Level of consciousness
D. Level of consciousness
Assessing consciousness is a separate assessment and is not included in assessing the patient’s level of awareness
A nurse is conducting an assessment of a patient cranial nerves. The nurse asked the patient to raise eyebrows, smile, and show the teeth tooth process which cranial nerve?
The facial nerve
What is an ophthalmoscope?
An ophthalmoscope is a lighted instrument used to visualize the interior structure of eye
What is an otoscope?
An otoscope is alighted instrument used to examine the external ear canal and the tympanic membrane
What is a tuning fork?
A tuning fork is a two-pronged metal instrument used to test auditory function and vibratory perception
What are the four primary assessment techniques?
Inspection, palpation, percussion, auscultation
What is inspection?
Inspection is the process of performing deliberate, purposeful observations in a systematic manner
