Documente Academic
Documente Profesional
Documente Cultură
SCORE _______
RATING ______
Instruction: NO ERASURES!
Part I IDENTIFICATION: Answer what is being asked. (10pts)
1. __________________________________ Is a systematic rational method of planning in
providing individualized quality nursing care NJURSING PROCESS
2. __________________________________ Are problem identified by the nurse that are
already in existence. ACTUAL PROBLEM
3. _______________________________________ Are situation in problem might occur
but are not currently in existence. RISK/POSSIBLE
4. _______________________________________ Are those sanctioned by professional
practice acts and they do not require direction or an order from another health care
professional. INDEPENDENT NURSING INTERVENTION
5. _______________________________________ Are those that require an order from
health care providers DEPENDENT NURSING INTERVENTION
6. _______________________________________ Focus on the etiology of a problem and
cover a short period of time within hours or days. SHORT TERM GOAL
7. ___________________________________ Focus on the problem and cover a longer
time frame within a week or months. LONG TERM GOAL
8. ___________________________________ Address human responses to a health state,
problem or condition and is a three part statement. NURSING DIAGNOSIS
9. ___________________________________ Are used by physicians to identify or
determine a specific disease condition of pathologic state. MEDICAL DIAGNOSIS
10. ________________________________________ An evaluation of the health status of an
individual by performing physical examination after obtaining a health history. HEALTH
ASSESSMENT
PART II MULTIPLE-CHOICE: Read the following questions and choose the best answer.
Encircle the letter of the correct answer. (15pts)
1. When the client states that my head hurts and my vision is blurry, is what type of
source data?
a. Primary and objective
b. Secondary and subjective
2. A patients chart is what type of data?
a. Primary
b. Secondary
c. Tertiary
d. A and B
3. The major and only concern during this type of assessment is to determine the status of
the clients life sustaining physical functions:
a. Initial comprehensive assessment
b. Ongoing or partial assessment
c. Focused or problem oriented assessment
d. Emergency assessment
4. Major areas of subjective data include the following except:
a. Physical symptoms related to each body part or system
b. Biographical information
c. Physical characteristics
d. Family history
5. The following data are objective data except:
a. Bodily function
b. Past health history
c. Appearance
d. Behavior
6. An important step of assessment because it forms the database for entire nursing process
and provides data for all other members of the health care team:
a. Documenting data
b. Validating data
10. Consider the following nursing diagnosis: Chronic pain related to pain from stiff joints.
What is the error in this diagnosis?
a. It should have written as one part nursing diagnosis
b. It includes medical diagnosis
c. It says the same thing twice
d. It is judgmental
11. Which of the following wellness diagnosis is written correctly?
a. Readiness for Enhanced Health-Seeking Behaviors (low sodium diet)
b. Readiness for Enhanced Health-Seeking Behaviors r/t making clinic visit
c. Readiness for Health-Seeking Behavior (low sodium diet
d. Enhanced Health-Seeking Behavior
12. Which of the following correctly written diagnosis that the nurse should add to the
clients care plan?
a. Altered Nutrition: Less than body requirements
b. Pneumonia related to infectious process
c. Impaired Physical Mobility related to weakness in lower extremities
d. Acute pain related to abdominal incision
13. Which of the following is stated in the format of a collaborative problem?
a. Potential for Complication of Immobility: Decubitus Ulcer
b. Risk for decubitus ulcer related to immobility
c. Complication of immobility: Decubitus ulcer
d. Decubitus ulcer related to immobility
14. Which of the following nursing diagnoses uses the PES format?
a. Fluid volume deficit related to prolonged vomiting
b. Risk for impaired skin integrity as manifested by poor skin turgor and old age
c. Ineffective airway clearance related to infectious process as manifested by
excessive mucous and retained secretions
d. Ineffective airway clearance as manifested by secretions in the bronchi, presence
of allergies and airway spasm
15. Consider the following nursing diagnosis for client who in on bed rest: Risk for Impaired
Skin Integrity related to bed rest. Which of following nursing interventions was derived
from etiological portion of the nursing diagnosis?
a. Select high-protein foods each meal
b. Complete bed bath every morning
c. Offer a back rub as necessary
d. Turn and reposition every 2h
16. PART III LABELING Write S in the blank is the data is Subjective and O is the data
is Objective
______ 1
______ 2
______ 3
______ 4
______ 5
______ 6
______ 5 Weakness f
______ 6
______ 7
______ 8
______ 9
23. COLUMN B
a. Not working
b. Signs and symptoms (defining
characteristics)
c. Problem is resolved
d. Patient will maintain a pain level of 3
or less during remaining of hospital
stay.
e. Problem is still present but plan is still
working
f. Etiology
g. Utilizes resources wisely
h. Problem statement
i. Promotes client satisfaction and
progress
j. Patient will have pain at less than a 3
within thirty minutes.
24.
25. Part VI ENUMERATION: List what is being asked. (15pts)
26. FOUR MAJOR STEPS OF NURSING HEALTH ASSESSMENT
1. ______________________________________ Collecting Subjective Data
2. ______________________________________ Collecting Objective Data
3. ______________________________________ Validating Data
32.
33. Doing whats right today means no regrets tomorrow
34. Prepared by
35. Annalisa A Telles, MAN
36. Instructor
37. Health Assessment
38. CHAPTER QUIZ Collecting Objective Data
39.
SCORE
RATING
______________________________
______________________________
______________________________
______________________________
_______________________________
_______________________________
_______________________________
_______________________________
7. A type of percussion used to detect tenderness over organs by placing one hand-flat on
the body surface, using the fist of the other hand to strike back of the hand flat on the
body surface.
8. A type of auscultation when the listens to sounds produced from within the body by use
of the stethoscope.
9. A type of palpation used to feel for pulses, tenderness, surface skin texture, temperature
and moisture.
10. A loud low pitched hollow sound of a long duration typically over the normal lung
tissues.
11. A soft high pitched dead stop of a sound absolute dullness sound of short duration
typically found over muscle and bone.
12. It is the frequency of the vibration of an auscultated sound (high/low).
13. This refers to loudness or softness of an auscultated sound (loud or soft).
14. It is done before equipment preparation and examination to reduce transfer of
microorganisms.
15. A data the examiner directly or indirectly observed.
50. TRUE OR FALSE
1. Begin with the non-threatening procedures to allow client feel more comfortable and ease
client anxiety about the examination.
2. The highest priority before the examination is to established rapport because clients are
easily embarrassed when body parts are exposed or sensitive questions are asked.
3. Approach client from whichever part of the table or bed to begin the examination.
4. Prior to palpation the examiner should warm hands before placing them on the patient.
5. During palpation instruct the client to hold his breathe.
6. Performing percussion the nurse uses quick taps by quickly flexing the hands, not the
forearm.
7. Auscultate by placing the stethoscope through the clients clothing or gown.
8. The bell of the stethoscope is used to listen for low pitched sounds.
9. The diaphragm of the stethoscope is used to listen for high pitched sounds.
10. During inspection the client is asked to remove all clothing to view all body parts.
51. MATCHING TYPE
52. COLUMN A
1. _____ Penlight
2. _____ Opthalmoscope
3. _____ Otoscope
4. _____ Gloves
5. _____ Stethoscope
6. _____ Sitting
53. COLUMN B
a. To determine the reactions of the pupils
of the eye
b. Client lies on abdomen with head
turned to side
c. Position used to examine male genitalia
d. To visualize the interior of the eye
e. Position used during much of the
physical examination
f. To visualize external auditory canal
54.
55. MULTIPLE -CHOICE
1. The examiner directly observed the following as objective data except:
a. Physical characteristics
b. Appearance
c. Behavior
d. Preference
2. To become proficient with physical assessment skills the nurse must have basic
knowledge in three areas except:
a. Observe the principles on transmission of infectious agents while performing a
physical assessment
b. Types and operation of equipment needed for particular examination
c. Preparation of setting, oneself and the client for physical assessment
d. Performance of the four assessment techniques
3. Before beginning the physical assessment the nurse psychologically prepare the client.
Select that all apply.
a. Reduce clients anxiety
b. Ask the client to wear gown
c. Established rapport
d. Explain to the client after interview that physical assessment will follow
e. Explain what procedure you are performing and why you are performing it
4. Following are clients physical preparation before beginning physical assessment. Select
that all apply.
a. Established rapport to alleviate clients anxiety
b. Ask client to wear gown
c. Asks the client if he has the need to use the toilet
d. Approach client from the right side of the examination table
5. To inspect body part the nurse observes the following principles or guideline except:
a. Make the room in a comfortable temperature
b. Make sure good lighting is available
c. Touch the body parts you are to examine and then look and observe
d. Compare the appearance with the same area of the opposite side of the body
6. Part of the hand sensitive to vibrations, thrills and fremitus:
a. Fingerpads
b. Palmar surface
c. Dorsal surface
d. Fingers
7. Percussion has several different assessment use during physical assessment except:
a. Eliciting pain
b. Determining consistency
c. Determining density
d. Detecting abnormal masses
8. The most commonly used method of percussion:
a. Direct percussion
b. Blunt percussion
c. Indirect percussion
d. Bimanual percussion
9. A sound elicited by percussion described as a loud, high pitched musical sound of
moderate duration typically over the stomach filled with gas:
a. Flatness
b. Dullness
c. Hyperresonance
d. Tympany
10. All of the following are correct descriptions of auscultated sounds. Select that all apply.
a. Pitch
b. Severity
c. Intensity
d. Duration
e. Quality
f. Location
56.
57.
58.