TEST 1: Health Asssessment Review1.

How should you respond to sensitive topics such as sexuality or

alcohol use?A nurse would respond without communicating any biases toward the client’s sexuality or
abuse of chemicals. Yet, the nurse would be able to speak of the complications and dangers associated
with these topics.
2. What are the phases of the nursing process?
A. Introducing the Interview
-keep the introductions short
-address person with title and last name
B. The Working Phase (data gathering phase)
-start with open-ended questions
-before a new topic is brought up ask “Is there anything else?”
-ask only one question at a time
-keep the language understandable-don’t use medical terms or regional phrases
-Use of the nine verbal responses
Facilitation-continue with the story
Silence-silence is golden after open-ended questions
Reflection-repeating part of what a person has just said
Empathy-recognizes a feeling and puts it into words
Clarification-used to summarize the person’s words, simplify the words to make them clearer, then ask
if you are on the right track.
Confrontation-use the last four responses only when merited by the situation
Interpretation-based on your inference or conclusion
Explanation-you share factual and objective information
Summary-final review of what you understand the person has said
3. What is a health history?
A health history is a complete picture of a person’s past and present health. The purpose of the health
history is to collect subjective data. The history is combined with objective data from the physical
examination and laboratory studies to form a data base.
4. What is included in a health history and what is not included in a health history?
A health history includes:
-Biographical data-name, address, age, birth date, sex, marital status, race, ethnic origin, and past
and present occupation
-Source of history-record who furnishes the information, judge how reliable, and note any special
circumstances.
-Reasons for seeking care-statement in the person’s own words. It states one or possible two symptoms
(a subjective sensation that the person feels from the disorder)or signs (an objective abnormality that
you as the examiner could detect on physical examination or in the laboratory reports). Use quotation
marks for the exact statement of client. Reason for seeking care is not a diagnostic statement.
-Present health or history of present illness-For the well person , this is a short statement about
general state of health. For the ill person this is a chronological record or reason for seeking care from
start of symptoms to date. After the client’s narrative, make sure these eight critical characteristics
are included: (PQRSTU)
-location-be specific
-character or quality-specific descriptive terms
-quantity or severity-attempt to quantify the sign or symptom
-timing-onset, duration and frequency
-setting-where and what was the client doing when symptoms appear
-aggravating or relieving factors-what makes the pain worse or less
-associated factors-is the primary symptom related to any other symptoms
-patient’s perception-how does the symptoms affects daily activities
-Past health-childhood illnesses, accidents or injuries, serious or chronic illnesses, hospitalizations,
operations, obstetric history, immunizations, last examination date, allergies, and current medications
-Family history-genetic significance for the client
-Review of systems-the order of the examination of the body systems is roughly head to toe. Evaluate
the past and present health state of each body system. Double-check in case any significant data were
omitted in the present illness section. Evaluate health promotion practices.
-Functional assessment- activities of daily living
-Perception of health-clients interpretation of what health is
A health history does not include the following:
-your opinions or biases
-self-diagnoses made by client based on similar signs and symptoms of others
-avoid writing “negative”, use “presence” or “absence”
5. What is subjective and objective data? Give examples of each.
Subjective data is what the client says about himself or herself during history-taking. An example
would be “I feel tired all the time.”
Objective data is what the health professional observes by inspection, percussing, palpating, and
auscultating during the physical examination. Objective data also includes the person’s record and
laboratory studies. An example would be blood pressure 120/80. Subjective and objective data form
the client’s data base.
6. How do you obtain subjective and objective data?
The interview is the place you would collect subjective data. It is the first and really the most
important part of data collection. You would obtain detailed subjective data from taking a health
history. Objective data would be obtained from laboratory reports and physical examination.
7. When interviewing the environment needs to be inducive to what?
The interview environment should glean all the necessary information as well as build rapport for a
successful working relationship. It should be inducive to open communication.
8. What should be included in the interview environment?
The interview should ensure privacy, refuse interruptions, room temperature should be a comfortable
level, lighting should enable both parties to see clearly, reduce noise, and remove distracting objects
or equipment.
Distance between client and nurse should be 4-5 feet, or twice arm’s length. Seating should be an
equal-status setting, and a face-to face position.
9. What should not be included in the interview environment?
The following should not be included in the interview environment:
-other people
-televisions, radios and unnecessary equipment
-clutter, stacks of mail, files of other patients, and your lunch
10. What are the phases of the interview?
-Introduction of the interview
-The working phase (data-gathering)
a. Use active listening
b. Adaptive questioning (open/closed questions)
c. Pay attention to non-verbal communication
d. Facilitation-by using silence, pause or nod, the client continues narration
e. Echoing or reflection-repeating words or phrases to the client
f. Empathic responses- recognizes a feeling and puts it into words
g. Clarification-summarize, simplify, ask if your on the right track
h. Confrontation-honest feedback of what you have seen or heard
i. Interpretation- based on your inference or conclusion
j. Explanation-share your factual and objective information.
k. Summary-final review of what you understand the person has said
11. What happens in the phases of the interview?
The following will be accomplished in a successful interview:
-gather complete and accurate data
-establish rapport and trust
-teach the person about the health state
-build rapport fr a continuing therapeutic relationship
-begin teaching for health promotion
The following happens during the interview:
-nonverbal communication occurs through posture, gestures, facial expressions, eye contact, touch
even where you place your chair.
-patient must that he or she is accepted unconditionally
-patient receives empathy without criticism
-complete attention is given to the client
-complete privacy is given to the client
-rapport is established
12. Discuss vital signs.
Temperature: Cellular metabolism requires a stable core, or deep body temperature of a mean of 37.2
C (99 F)
-oral/tympanic = 37.0 C or 98.6 F (range ¦ 1 F)
-rectal = 37.6 C or 99.6 F (range ¦ 1 F)
-axillary = 36.4 C or 97.6 F (range ¦ 1 F)
Pulse: infants- palpate or auscultate an apical rate with infants and toddlers.
children over 2- use the radial site, count the pulse for a full minute.
-60 to 100 beats/min strong and regular for an adult = average 74-76 beats/min
-50 to 100 beats/min for an athlete
-70 to 190 beats/min for an newborn
-80 to 130 beats/min for a 2 year old
-70 to 110 beats/min for a 10 year old
Respirations: infants- watch the infant’s abdomen for movement, more diaphragmatic than thoracic,
count one full minute.
-10-20 breaths/min, deep and regular for an adult
-12-20 breaths/min for an 18 year old
-20-26 breaths/min for a 10 year old
-25-32 breaths/min for a 2 year old
-30-40 breaths/min for a neonate
Blood Pressure: use correct cuff size, must cover 2/3 of the upper arm, cuff bladder must completely
encircle.
In children, height is more strongly correlated with BP than is age.
-less than 120/80 mm Hg optimal BP for the young adult
-less than 130/85 mm Hg normal BP
-a gradual rise from childhood to adulthood
-BP rises to a high in late afternoon or early evenings
-BP is higher in obese people
-BP is higher with increase activity
-BP is higher is presence of fear, anger or pain
-BP is raises during times of stress
-BP is hypotensive (low) in adults when less than 95/60
-BP is hypertensive (high) in adults
Stage One 140-159/90-99
Stage Two 160-179/100-109
Stage Three 180/110
13. What are the three ways of taking a temperature?
a. The normal oral temperature in a resting person is 37 C (98.6 F)
The normal range is 35.8 to 37.3 C (96.4 to 99.1 F)
Temperature registers in 3 to 5 minutes.
b. The normal rectal temperature measures 0.4 to 0.5 C (0.7 to 1 F) higher.
Do not insert thermometer farther than 2.5 cm (1 inch).
Temperature registers in 3 minutes.
c. The axillary temperature (taken under the arm) or inguinal (infant’s leg & femoral pulse).
Temperature registers in 5 + minutes-under the arm and 3-5 minutes with leg).
14. How would you assess heart rate and the radial pulse?
Bradycardia-heart rate less than 60 beats/minute
Tachycardia-heart rate over 100 beats/minute
Rhythm-normally has an even tempo
-sinus arrhythmia-heart rate varies with the respiration cycle, speeding up at the peak of inspiration
and slowing to normal with expiration.
Force-weak or thready reflects a decreased stroke volume.
-full or bounding reflects a increased stroke volume.
Elasticity-normal elasticity, the artery feels springy, straight and resilient.
15. Where would you check for the heart rate and the radial pulse?
You would check for a heart rate with a stethoscope placed on the chest wall adjacent to the cardiac
apex. The apical or brachial pulse is the site for routine pulse assessment in infants. The apical pulse
would be taken in adults if the radial pulse was abnormal. The apical pulse is the most accurate
measure of heart rate and rhythm. Place the diaphragm of the stethoscope over the point of maximum
impulse at the fifth inter-coastal space on the left mid-clavicular line. You would check for the radial
pulse by palpating at the wrist. This is usually taken for vital signs. Using the pads of your first three
fingers, palpate the radial pulse at the flexor aspect of the wrist laterally along the radius bone. Push
until you feel the strongest pulsation. If the rhythm is regular count the number of beats for 30 seconds
and multiply by 2.. If irregular count for a full minute. Start your count with “zero” for the first pulse
felt. The pulse is assessed by rate, rhythm, force and elasticity.
16. What is a tympanic thermometer?
The tympanic thermometer is the newest development in temperature monitoring. It senses the
infrared emissions of the tympanic membrane (eardrum). The tympanic thermometer is a noninvasive,
non-traumatic device that is extremely quick and efficient. It can read a temperature in 2 to 3
seconds. This thermometer is very successful in use with unconscious patients or with those who are
unable or unwilling to cooperate with traditional techniques, those in critical care units, emergency
departments, recovery areas, labor and delivery units, and pediatric care settings.
17. How would you communicate with a client with hearing or sight disabilities?
Ask the deaf person his or her preferred way to communicate – by signing, lip reading, or writing. A
complete health history requires a sign language interpreter. If the person prefers lip reading be sure
to face him or her squarely and have good lighting on your face. Speak slowly and supplement your
voice with appropriate hand gestures or pantomime. Be sure the person understands your questions.
Written communications is efficient in sections such as past health history or review of systems. A
client with a sight disability would need your voice as a guide to tell them exactly what you are doing
and where you are. This person would need assistant in filling out paperwork, remember confidentiality
is utmost important, a family member may not be the best choice.
18. What is a health history and what is the purpose?
A health history is a collection of information obtained from the patient and from other sources,
concerning the patient’s physical status and psychologic, social, and sexual function. The history
provides a data base on which a diagnosis, a plan for management of the diagnosis, treatment, care,
and follow-up observation of the patient may be made. The first part of the history describes the chief
complaint, the present illness, including its signs and symptoms, onset and character, and any factors
or behaviors that aggravate or ameliorate the symptoms. The patient’s own words often serve as the
best description and may be quoted. The second part of the history comprises an account of previous
illnesses and health-promotion behaviors, allergies, transfusions, immunizations, screening tests, and
hospitalizations. An occupational history, describing the patient’s work and exposure to stress, toxins,
radiation, or other occupational hazards, may be included. The effect of the current illness on the
patient’s work is also noted. A social history is taken in which the patient’s social, cultural,
environmental, and familial milieu are outlined, focusing on aspects that might have an effect on the
current illness. In some instances a sexual history may be relevant. A review of systems may follow or
be incorporated into the health history.
19. How would you assess reliability?
You would assess reliability by judging how reliable the informant seems and how willing he or she is to
communicate. A reliable person always gives the same answers, even when questions are rephrased or
are repeated later in the interview. Never state your biases by stating “client appears reliable” instead
state “client answers questions appropriately and effectively.”
20. What is a review of systems?
A review of systems in a health history is a system-by-system review of the body functions. The review
of systems is begun during the initial interview with the patient and completed during the physical
examination, as physical findings prompt further questions. Questions about family or personal history
are included in each section.
21. What information would you find in a review of systems?
Remember that the history should be limited to patient statements, or subjective data.
One outline of the systems that might be noted or reported are as follows:
-skin -hematopoietic -head and face
-ears -eyes -mouth and throat
-nose and sinuses -breasts -respiratory tract
-cardiovascular system -gastrointestinal system
-urinary tract -genital tract (female) -genital tract (male)
-skeletal system -nervous system -endocrine system
-psychologic status
22. What is the difference between open and closed questions?
Open questions are questions that ask for narrative information. The open-ended question is unbiased;
it leaves the person free to answer in any way. This question encourages the person to respond in
paragraphs and to give a spontaneous account in any order chosen.. It lets the person express himself
or herself fully.
Closed questions or direct questions ask for specific information. They elicit a short, one- or two-word
answer, a yes or no, or a forced choice.
23. What is a normal and abnormal vital signs?
See vital sign discussion for normal signs.
24. Discuss techniques when performing a physical exam.
The technical skills are the tools to gather data. You will use your senses– sight, smell, touch, and
hearing– to gather data during the physical examination. The skills requisite for the physical
examination are:
– inspection – concentrated watching, it is a close , careful scrutiny, first of the individual as a whole
than of each body system.
– palpation – follows and often confirms points you noted during inspection. Assess these factors:
texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation,
rigidity or spasticity, crepitation, presence of any limps or masses, and presence of tenderness or pain.
Use fingertips, best for fine tactile discrimination. Use a grasping action to detect position, shape and
consistency of an organ or mass. The dorsa (backs) of the hands and fingers are best for the
determining temperature. Base of the fingers or ulnar surface of the hand to determine vibration. Your
palpation technique should be slow and systematic, start with a light palpation.
– percussion – is tapping a person’s skin with short, sharp strokes to assess underlying structures. Map
out the location and size of the organ by exploring where the percussion note changes. Signaling the
density (air, fluid, or solid) of the structure, detecting a superficial mass (5cm deep). Eliciting pain if
the underlying structure is inflamed, as with a sinus area or are over the kidney. Eliciting a deep
tendon reflex using the percussion hammer. Two methods are used in percussion: The direct and
indirect method. Direct uses a hand striking the body. The indirect uses both hands.
– auscultation. – is listening to sounds produced by the body, such as the heart and blood vessels and
the lungs and abdomen. (use of the stethoscope).
25. What comes first, second, and third?
First is inspection, then palpation, percussion and last technical skill is auscultation.
26. What senses do you use for these?
You will use your senses-sight, smell, and hearing.
27. What is a stethoscope, parts and purpose?
An instrument for evaluating soft body sounds. A stethoscope does not magnify sound, it blocks out
extraneous room sounds. The slope of the earpiece should slant forward. Consists of two end pieces-a
diaphragm and a bell. Flat edge of diaphragm is best for high pitched sounds-breath, bowel, and
normal heart sounds. The bell end piece has a deep, hollow cup like shape. It is best for soft, low-
pitched sounds such as extra heart sounds or murmurs.
28. Know what crepitus is?
Crepitus is flatulence or the noisy discharge of fetid gas from the intestine through the anus. A sound
or feel that resembles the crackling noise heard when rubbing hair between the fingers or throwing salt
on an open fire. Crepitus is also associated with gas gangrene, rubbing of bone fragments, air in
superficial tissues, or crackles of a consolidated area of the lung in pneumonia. Also called crepitation,
a clicking sound often heard in movement of joints, for example in tempromandibular joint resulting
from joint irregularities.
29. What do you do before you preform a physical exam?
-consider your emotional state and that of the person being examined.
-reduce anxiety by being confident, self-assured, as well as considerate and unhurried.
-introduce yourself and shake hands.
-measure height, weight, blood pressure, temperature, pulse and respirations.
-ask the client to change into a gown, leaving underpants on, leave the room
-re-enter the room and wash hands in presence of the client.
-explain the steps of the examination and how the client can cooperate.
-encourage the client to ask questions
-keep movements slow, methodical, and deliberate.
30. What are the priorities? Give examples.
-be formal, respectful, and polite
-be considerate of cultural, gender and sexual orientations
-listen to the client and watch for nonverbal communications
31. What do you do with a blood pressure on an agitated person?
Taking a blood pressure reading on a person that is agitated will result in a falsely high reading. Allow a
5-10 minute rest before taking the blood pressure.
32. Why is proper cuff size important?
The cuff size is important, using a cuff that is too narrow yields a falsely high BP because it takes extra
pressure to compress the artery. The same results for a cuff that is too large.
33. What happens when using a standard cuff on an obese patient?
The cuff size that is too narrow for the extremity will result in a falsely high reading due to the need
for excessive pressure to occlude the brachial artery.
34. What would you hear with a standard cuff?
You would hear the phases of Korotkoff sounds:
-Cuff correctly inflated– no sound, compresses brachial artery.
-Phase One– Tapping, soft clear tapping , increasing in intensity. This is the systolic pressure
-Auscultatory Gap– no sound, silence for 30-40 mm Hg.
-Phase Two– Swooshing, softer murmur follows tapping.
-Phase Three– Knocking, crisp, high-pitched sounds. Artery closes just briefly during late diastole.
-Phase Four– Abrupt muffling, sound mutes to a low-pitched, cushioned murmur, a blowing quality.
-Phase Five– Silence, the last audible sound is the diastolic pressure.