Week 1 Introduction

Question 1

What are the three types of health assessments?

Answer 1

1. comprehensive/admission assessment
2. focused assessment
3. emergency assessment

Question 2

When do nurses perform a health assessment

Answer 2

ideally on introduction/ admission

Question 3

If a critically ill patient comes into the ER, when should you perform the health assessment

Answer 3

wait until the patient is stable to complete

Question 4

A nurse is caring for the same patient as he/she did yesterday, what do you need for your health assessment

Answer 4

just need updates

Question 5

What are the 4 overall goals of the nursing process and what acronym is used for the nursing process

Answer 5

• extrapolate the findings
• prioritize the findings
• formulate the plan of care
• implement the plan of care

We use ADPIE

Question 6

What is the key difference between a medical diagnosis and a nursing diagnosis

Answer 6

Medical: diagnosis and treatment of the disease

Nursing diagnosis: diagnosis and treatment of the actual or potential human responses. Ex: how does this contribute to your ability to perform ADLs

Question 7

What are the three levels of preventative care? Briefly describe each of them

Answer 7

Primary prevention: improving overall wellness and protecting from disease

Secondary prevention: early detection and treatment (Ex: mammograms, paps)

Tertiary prevention: preventing complication or loss when defect is permanent. These patients have specific needs or something that makes them more prone to something else (Ex: physical therapy)

Question 8

What are some examples of primary prevention

Answer 8

immunizations, environmental measures (air quality), accident prevention measures, reducing risk factors, occupational measures, health education, provision of adequate housing, periodic selective exams, diet and exercise

Question 9

What are some examples of secondary prevention

Answer 9

Screenings (paps, colonoscopies, mammos), early treatment of diseases, self-examination

Question 10

What are some examples of tertiary prevention

Answer 10

Rehab programs, provision of hospital and community facilities, promotion of employing rehabilitated individuals in the workplace, sheltered communities, prevention of skin breakdown in immobile patients, physical therapy

Question 11

What are some sequence and positioning techniques for the examination?

Answer 11

Minimize how often you ask the patient to change position

Examine patient from RIGHT side, moving to the opposite side as needed

Question 12

What does IPPA stand for when discussing techniques of examination? Give a brief description of each

Answer 12

Inspection - close observations

Palpation - tactile pressure

Percussion - evoke sound wave

Auscultation - listening with stethoscope

Question 13

What is the most reliable source for taking a temperature and why?

Answer 13

tympanic; it shares the same blood flow as the hypothalamus

Question 14

What is considered a normal temperature in degrees F and Celsius

Answer 14

98.6 degrees F and 37 degrees C

Question 15

What does obliterating a pulse mean

Answer 15

means you have pushed too hard and can no longer feel the pulse

Question 16

Why is checking a pulse for 15 seconds not accurate

Answer 16

you could miss an irregularity

Question 17

What is a normal heart rate for an adult patient

Answer 17

60-100 bpm

Question 18

what is the systolic

Answer 18

its the squeeze of the heart

Question 19

what is the diastolic

Answer 19

its the ventricles relaxing

Question 20

what is proper positioning of a patient for blood pressure

Answer 20

both feet firmly on the floor, not crossed, sitting up straight, and arm elevated to about heart level, ensured they are relaxed

Question 21

What can affect a blood pressure

Answer 21

caffeination, crossing legs which could put pressure on the lower arteries

Question 22

What are some contraindications when selecting an arm for blood pressure

Answer 22

fistulas, can’t use arm on the same arm as a mastectomy (because they take lymphatic tissue which usually cause lymphedema), peripheral IVs that are currently running, central lines (PICC), disease or illness to that arm

Question 23

What sounds would the bell of the stethoscope be used to hear and how should you hold it

Answer 23

low pitched sounds and lightly

Question 24

What sounds would the diaphragm of the stethoscope be used to hear

Answer 24

high pitched sounds

Question 25

What is the difference between a health belief and a health practice

Answer 25

Belief = a person’s ideas and attitudes about health

Practices = activities that individuals do to care for themselves

Question 26

What are the 5 social determinants of health

Answer 26

Social and community context 
Health and Health care 
Education 
Economic Stability 
Neighborhood and built environment

Question 27

What is Healthy People 2030

Answer 27

Framework that identifies risk factors, health issues, and diseases of concern in the US

Question 28

What is the overall goal of healthy people 2030

Answer 28

to increase quality of life

Question 29

What are the goals and objectives of healthy people 2030

Answer 29

improve the health of individuals and communities

it promotes health and prevents disease

Question 30

According to Health Assessment powerpoint slides, what is the duration of time needed for illness to be considered acute or chronic

Answer 30

acute <6 months

chronic >6 months

Question 31

What data is collected in the health history

Answer 31

assess validity 
PMH
past physical issues 
past psychological issues 
social history 
cultural history 
spiritual beliefs

Question 32

What does ADPIE stand for

Answer 32

Assessment 
Diagnosis 
Planning 
Implementation 
Evaluation