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Health assessment

A detailed illustration of a nursing professional assessing a patient in a clinical environment, with visual elements representing nursing assessments, charts, and medical tools, emphasizing care and attention in a healthcare setting.

Nursing Assessment Quiz

Test your knowledge on the essential components of the nursing process with this comprehensive Health Assessment Quiz. Designed for nursing students and professionals alike, this quiz will help you evaluate your understanding of nursing assessments, diagnoses, planning, interventions, and evaluations.

Key Features:

Multiple-choice questions covering all aspects of health assessment.
Perfect for preparation for exams or to brush up on your nursing knowledge.
Instant feedback on your answers.

107 Questions27 MinutesCreated by CaringNurse42

Is a systematic, rational method of planning, and providing quality and individualized nursing care. • Series of phases describing the practice of nursing

Nursing Process

Health Process

Nursing education

Health Education Process

A statement or conclusion regarding the nature of phenomena • Analyzing subjective and objective data to make a professional judgement • Provides basis for the selection of nursing intervention

Assessment

Diagnosis

Planning

Intervention

Evaluation

Collection, organization, validation and documentation of data. The most important step.Continuous process carried out during all phases of the nursing process. Identifies the patient’s strengths and limitations.

Assessment

Diagnosis

Planning

Intervention

Evaluation

To carry out planned nursing interventions to help the client attain goals and achieve optimal health. The “doing” phase

Assessment

Diagnosis

Planning

Intervention

Evaluation

It should be S.M.A.R.T or Specific, Measurable, Attainable, Realistic, Time-bound

Assessment

Diagnosis

Planning

Intervention

Evaluation

Assessing client’s response to nursing progress toward health care and effectiveness of nursing care plan. Crucial to determine if the patient’s condition improved or worsen after application of the first four steps of nursing process.

Assessment

Diagnosis

Planning

Intervention

Evaluation

Deliberative, systematic phase of nursing process that involves decision making and problem solving

Assessment

Diagnosis

Planning

Intervention

Evaluation

First time to see the patient o Completing data base

Initial comprehensive assessment

Emergency assessment

Focused or problem-oriented assessment

Time lapsed

Occurs during physiologic or psychological crisis of the patient

Initial comprehensive assessment

Emergency assessment

Focused or problem-oriented assessment

Time lapsed

Life threatening situation o Rapid identification and intervention of client’s need

Initial comprehensive assessment

Time-lapsed reassessment

Focused or problem-oriented assessment

Time lapsed

After initial assessment o Compare current status to baseline data

Initial comprehensive assessment

Emergency assessment

Focused or problem-oriented assessment

Time lapsed

Choose the right order of assessment steps

Validating, organizing, collecting, documentation of data

Collecting, organizing, validating, documentation of data

Documentation, collecting, organizing, validation of data

What are the two source of data in assessment?

Family of patient & Medical background

Patient & Family

Primary & secondary

Patient & Family/important someone

Data directly/indirectly observed through measurement

Subjective Data

Objective Data

Primary Data

Secondary Data

Data elicited and verified by the client

Subjective Data

Objective Data

Primary Data

Secondary Data

- “I can’t breathe” - “I have a stomach pain” - “I can’t sleep”

Subjective Data

Objective Data

Primary Data

Secondary Data

- Heart rate of 110bpm - UTZ reveals the client is pregnant for 18weeks - X-ray film reveals PTB

Subjective Data

Objective Data

Primary Data

Secondary Data

Disease process of the patient. Is the process of determining which disease or condition explains a person's symptoms and signs.

Medical diagnosis

Nursing diagnosis

Clinical judgement about individuals, family, or community responses to actual and potential health problems and life process. The client response on actual or potential health problem (reaction of patient to illness)

Medical diagnosis

Nursing diagnosis

Describes human response to level of wellness in an individual, family, or community that have a readiness for enhancement

Wellness Diagnosis

Actual Diagnosis

Risk Diagnosis

Possible Diagnosis

Syndrome Diagnosis

Problem does not exist, but the present of risk factors indicate a problem is likely to develop unless nurses intervene

Wellness Diagnosis

Actual Diagnosis

Risk Diagnosis

Possible Diagnosis

Syndrome Diagnosis

Problem is present (+) signs and symptoms

Wellness Diagnosis

Actual Diagnosis

Risk Diagnosis

Possible Diagnosis

Syndrome Diagnosis

Associated with a cluster of other diagnosis

Wellness Diagnosis

Actual Diagnosis

Risk Diagnosis

Possible Diagnosis

Syndrome Diagnosis

Health problem is incomplete or unclear

Wellness Diagnosis

Actual Diagnosis

Risk Diagnosis

Possible Diagnosis

Syndrome Diagnosis

What is NANDA?

North american nurses diagnosis association

North american nursing diagnosis association

National American Nursing Diagnosis Association

Client response to a problem

Problem

Etiology

Defining characteristic/ Sign & symptoms

evidence of the problem

Problem

Etiology

Defining characteristic/ Sign & symptoms

What's causing to the clients problem/ causative factor for diagnosis

Problem

Etiology

Defining characteristic/ Sign & symptoms

Interventions are treatments performed through interaction with patient.

Direct Care

Indirect Care

Intervention are treatments performed away from a patient but on behalf of the group of / patient.

Direct Care

Indirect Care

Normal Temperature

36.5 – 37.2 °C

37.5 – 37.9 °C

35.5 – 36 °C

37.5 – 38.2 °C

Normal Adult pulse rate

60 – 100 bpm

55 – 110 bpm

80 – 100 bpm

Normal Respiratory rate

16-20

16-24

18-20

Is a small region located at the base of the brain that plays a vitals role such as releasing of hormones • Temperature regulatory center found in the brain

Thymus

Muscle

Hypothalamus

Cerebrum

A response to prolonged exposure to cold or need for oxygen of the body, hypoglycemia, hypothyroidism, starvation

Pyrexia / Hyperthermia / Febrile

Hyperpyrexia

Hypothermia

Body temperature above the usual range

Pyrexia / Hyperthermia / Febrile

Hyperpyrexia

Hypothermia

A response to prolonged exposure to cold or need for oxygen in the body

Pyrexia / Hyperthermia / Febrile

Hyperpyrexia

Hypothermia

Wide range of temperature fluctuations all of which are above normal (pyrexia) throughout the day over 24-hour period

Intermittent fever

Remittent fever

Relapsing fever

Constant fever

Alternates at regular interval where temperature is elevated for several hours or periods of fever and followed by an interval of normal temperature

Intermittent fever

Remittent fever

Relapsing fever

Constant fever

Fluctuates minimally but always remain above normal o Temperature does not touch the baseline and remain above normal throughout the day

Intermittent fever

Remittent fever

Relapsing fever

Constant fever

Short periods of high fever (40oC) with periods of 1 or 2 days of normal temperature

Intermittent fever

Remittent fever

Relapsing fever

Constant fever

Occurs when the cause of fever is suddenly removed, patient’s body temperature returns to normal. This event is known as crisis, the flush defervesce stage of pyrexia

Onset / Chill

Course / Plateau

Defervescence

After the core temperature has reach a new set point, the person neither feels warm nor cold

Onset / Chill

Course / Plateau

Defervescence

Set point increases from normal to higher than normal

Onset / Chill

Course / Plateau

Defervescence

Pressure of blood as result of contraction of the ventricles

Systolic pressure

Diastolic pressure

Lower pressure as result of ventricular relaxation

Systolic pressure

Diastolic pressure

The difference between systolic and diastolic pressure

Pulse pressure

Stroke volume

The volume of blood ejected with each heartbeat

Pulse pressure

Stroke volume

Abnormally high blood pressure over 140/90, o confirmed by a minimum of 2 consecutive visits.

Hypertension

Hypotension

Orthostatic hypotension

Abnormally low blood pressure below 100 mmHg systolic. o Between 85-100 mmHg systolic.

Hypertension

Hypotension

Orthostatic hypotension

Is a sudden drop in blood pressure when you stand from seated or lying down position.

Hypertension

Hypotension

Orthostatic hypotension

It is located on the apex of the heart on the left side of the chest that is monitored using a stethoscope. o The apex is usually found at the 5th intercostal space just inside the midclavicular line

Central or Apical pulse

Peripheral

Pulses that can be felt on the periphery of the body by palpating an artery over a bony prominence.

Central or Apical pulse

Peripheral

Located in front of the ear and lateral to eyebrow

Temporal

Carotid

Brachial

Radial

Located beside the larynx

Temporal

Carotid

Brachial

Radial

Located in the medial antecubital fossa (hollow in front of the elbow)

Temporal

Carotid

Brachial

Radial

Located on the thumb side of the forearm at wrist

Temporal

Carotid

Brachial

Radial

Located halfway between the anterior superior iliac spine and the symphysis pubis, below the inguinal ligament.

Femoral

Popliteal

Dorsalis pedis

Posterior tibial

Located on the dorsum of the foot with the foot plantar flexed.

Femoral

Popliteal

Dorsalis pedis

Posterior tibial

Located behind the knee in the popliteal fossa with the patient’s knee flexed

Femoral

Popliteal

Dorsalis pedis

Posterior tibial

Located on the inner side of the ankle slightly below

Femoral

Popliteal

Dorsalis pedis

Posterior tibial

May be a random, irregular beats or predictable pattern of irregular beats

Dysrhythmia or arrhythmia

Erythema

Cardicthmia

Describes as breaths per minute. (slow respiration)

Eupnea

Bradypnea

Tachypnea

Apnea

Describes as breaths per minute. (normal)

Eupnea

Bradypnea

Tachypnea

Apnea

Describes as breaths per minute. (absence of breathing)

Eupnea

Bradypnea

Tachypnea

Apnea

Describes as breaths per minute. (fast / rapid respiration)

Eupnea

Bradypnea

Tachypnea

Apnea

Increased amount of air in the lungs characterized by prolonged deep breaths. o It is a condition in which you start to breathe very fast

Hyperventilation

Hypoventilation

Decreased in amount of air in lungs caused by shallow breaths (hypopnea) or too slow (bradypnea) or may be caused by diminished lung function

Hyperventilation

Hypoventilation

To document the responses of the client and actual and potential concerns. • To obtain information about the client’s health.

Health history

Purpose

Interviewing

Focuses of Interview

Obtaining a valid nursing health history requires professional, interpersonal and interviewing skills

Health history

Purpose

Interviewing

Focuses of Interview

A comprehensive record of the client’s past and current health. • This is gathered during the initial assessment interview.

Health history

Purpose

Interviewing

Focuses of Interview

Establishing rapport and trusting relationship • Client’s response to the health concern as a whole person

Health history

Purpose

Interviewing

Focuses of Interview

What are the abbre of TP SA DL. This is important during interview

Technology, preparation, seating arrangement, duration, language

Time, place, seating arrangement, distance, language

Time, preparation, seating arrangement, date, life

Time, preparation, seating arrangement, duration, language

Arab (Interview distance)

8-12 inches (1 ft)

18 inches (1'6 ft)

24 inches (2ft)

36 inches (3ft)

Britain (Interview distance)

8-12 inches (1 ft)

18 inches (1'6 ft)

24 inches (2ft)

36 inches (3ft)

US (Interview distance)

8-12 inches (1 ft)

18 inches (1'6 ft)

24 inches (2ft)

36 inches (3ft)

Japan (Interview distance)

8-12 inches (1 ft)

18 inches (1'6 ft)

24 inches (2ft)

36 inches (3ft)

the 3 phases of interview EXCEPT

Introductory

Working

Summary and closing

Interviewing

It can be dull, achy, sharp, burning. ® It can be constant, intermittent, mild, moderate, severe

Acute pain

Chronic pain

Cancer pain

Lasts only through the expected recovery period o Does not last longer than six months

Acute pain

Chronic pain

Cancer pain

Ongoing pain and last longer than 6 months

Acute pain

Chronic pain

Cancer pain

A systematic way of collecting objective data from a client using the four examination techniques.

Physical assessment

Mental Assessment

Holistic Assessment

Physiological Assessment

Seated position, back unsupported and legs hanging freely

Standing / Erect

Sitting

Dorsal Recumbent

Sim’s

Assessment of posture, gait & balance

Standing / Erect

Sitting

Dorsal Recumbent

Sim’s

The client is lying on the side with the body turned at 45 degrees. The lower leg is extended, with the upper leg flexed at the hip and knee to a 45 to 90 degree angle.

Standing / Erect

Sitting

Dorsal Recumbent

Sim’s

Back lying position with knees flexed and hips externally rotated; small pillow under the head; soles of the feet on the surface

Standing / Erect

Sitting

Dorsal Recumbent

Sim’s

The client is lying on the abdomen with head turned to the side.

Prone

Lithotomy

Knee-chest

The client is lying on the back with the hips and knees flexed at right angles and feet in stirrups.

Prone

Lithotomy

Knee-chest

Assessment of rectal area (for a brief period only)

Prone

Lithotomy

Knee-chest

Observing the patient holistically

Inspection

Palpation

Percussion

Auscultation

Assessing the physical status of the body of client using the sense of touch

Inspection

Palpation

Percussion

Auscultation

Striking of the body surface with short, sharp strokes. To detect the presence of air or fluid in a body space

Inspection

Palpation

Percussion

Auscultation

Use the diaphragm to pick up high-pitched sounds, such as first (S1) and second (S2) heart sounds.

Inspection

Palpation

Percussion

Auscultation

Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, superficial organs, and masses. Depress the skin (1cm) with your finger pads, using the lightest touch possible.

Light palpation

Deep palpation

Bimanual deep palpitation

Moderate Palpation

Used to assess most of the other structures of the body. Depress the skin surface 1 to 2 cm with your dominant hand, and use a circular motion

Light palpation

Deep palpation

Bimanual deep palpitation

Moderate Palpation

This allows you to feel very deep organs or structures that are covered by thick muscle. This technique provides extra support and pressure and allows the nurse to palpate at a deeper level from 2 to 4cm

Light palpation

Deep palpation

Bimanual deep palpitation

Moderate Palpation

Use two hands, placing one on each side of the body part (e.g., uterus, breasts, spleen) being palpated. Use one hand to apply pressure and the other hand to feel the structure.

Light palpation

Deep palpation

Bimanual deep palpitation

Moderate Palpation

Is used to detect tenderness over organs, by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface

DIRECT PERCUSSION

BLUNT PERCUSSION

INDIRECT PERCUSSION

Is the technique of tapping the body with the fingertips of the dominant hand. -is the direct tapping of a body part with one or two fingertips to elicit possible tenderness

DIRECT PERCUSSION

BLUNT PERCUSSION

INDIRECT PERCUSSION

Two hands are used and the plexor strikes the finger of the examiner’s other hand which is in contact with the body surface being percussed

DIRECT PERCUSSION

BLUNT PERCUSSION

INDIRECT PERCUSSION

Is an abnormally loud, low tone of longer duration than resonance. (it is heard when air is trapped in the lungs

TYMPANY

RESONANCE

HYPERRESONANCE

DULLNESS

FLATNESS

Is a high-pitched tone, very soft and very short duration. (It occurs over solid tissue such as muscle or bone)

TYMPANY

RESONANCE

HYPERRESONANCE

DULLNESS

FLATNESS

- is a high-pitched tone that is soft and of short duration (Usually heard over solid body organs such as the liver or stool-filled colon)

TYMPANY

RESONANCE

HYPERRESONANCE

DULLNESS

FLATNESS

S a loud, low-pitched, hollow tone of long duration. (Normal finding over the lungs

TYMPANY

RESONANCE

HYPERRESONANCE

DULLNESS

FLATNESS

Is a loud, high-pitched, drumlike tone of medium duration characteristic of an organ that is filled with air. (Stomach, over air-filled intestines)

TYMPANY

RESONANCE

HYPERRESONANCE

DULLNESS

FLATNESS

Subjective or objective data that can be directly observed by the nurse; that is, what the client says or what the nurse can see, hear, feel, smell, or measure.

Cues

Inferences

The nurse’s interpretation or conclusions made

Cues

Inferences

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