NU136
NU 136 EXAM 2 - Health Assessment, Respiratory, Wounds,
Immobility, Urinary & Bowel (Complete & Includes 100+
NCLEX Style Questions and Answers 2026)
initial assessment
gathering of baseline data, done at admission in all care settings
includes:
-patient history
-demographic data
-health history
-psychosocial data
purpose of patient assessment (5)
- Check health status and body function
- Identify or confirm problems
- Monitor response to treatment
- Decide if more testing is needed
- Help create an accurate, individualized care plan
assessment
a continuous process of determining a patient's condition and progress
psychosocial assessment
A comprehensive document which looks at the client as a whole person (not as a set of
symptoms) and holistically combines the spiritual, emotional, physical, mental,
behavioral, and social dimensions.
psychosocial and cultural assessment includes
daily life, emotions, responsibilities, family stress, cultural assessment, values, etc
assumptions
Use respectful, open ended questions and avoid __________
prioritization
When identifying patient needs, follow ABCs and Maslow’s hierarchy: airway,
breathing, circulation, then safety, etc.
NU136
,NU136
JP drains must remain _________ to provide continuous suction.
compressed
Maslow's Hierarchy of Needs
Use ________ ________ _____ _________ to prioritize nursing care. Start with life-
threatening needs first.
Holistic Approach
Looks at the whole person, not just physical symptoms. Includes: Physical health,
emotional state, cultural values and beliefs, social and family support, spiritual needs,
builds trust and supports individualized care, helps identify underlying issues affecting
health
Always assess these 4 things:
- observe their general appearance and behavior
- ask questions to gather information and symptoms
- measure vital signs and body functions
- signs of sexual/physical/emotional abuse/neglect
Before performing a physical assessment, what data can be gathered?
General data such as patient charts, PMH, medications, test results.
Drape
A covering to provide privacy, give modesty and warmth to a patient when an
assessment is being performed.
Head to toe assessment
Ensures nothing is missed—often preferred in general assessments and by new
clinicians
Body systems approach
This method is efficient for focused assessments
Inspection/Observation
Use your eyes to assess skin, body shape, movements, and behavior
pyuria
presence of purulence (pus) in the urine
Palpation
NU136
,NU136
Use your hands to feel for temperature, swelling, skin turgor, pain, texture, or
abnormal masses. When palpating watch for signs of pain.
Light palpation
- uses the pads of the fingers
- presses 1-2cm deep
deep palpation
- done using one or both hands
- 4-5cm deep
percussion
Tap to assess size, location, or density of organs (chest and abdomen). Doing this on
the chest can help loosen secretions.
percussion
Normal lung tissue produces resonance on ________
auscultation
Use a stethoscope to listen to lungs, heart, bowel sounds, and blood pressure
olfaction
Detect odors that may indicate infection, disease, or poor hygiene (smell)
focused assessment
a detailed exam of a specific problem or system.
performed when:
- new complaints/symptoms
- change in condition
- follow up appointment
subjective data
patient provided information
objective data
information about the patient that was acquired by the nurse
Glasgow Coma Scale (GSC)
Used to assess levels of consciousness (LOC)
NU136
, NU136
Glasgow Coma Scale evaluates which 3 responses?
1. Eye opening
2. Motor response
3. Verbal response
15
A score of __ on the Glasgow Coma Scale is a fully alert patient.
7
A score of __ or lower on the Glasgow Coma Scale indicates a coma and is a medical
emergency.
Symmetry
Always be sure to assess for ______, meaning the left and right sides of the body are
mirror images of each other along the sagittal plane, particularly in their external
appearance and structure.
A patient's mental status includes
level of consciousness (awake, alert, oriented), logical thinking
When assessing the hair, observe
- scalp, hair, eyebrows, and eyelashes
- color, texture, and distribution
- debris, blood, trauma, nits, scales
When assessing the scalp, observe
- inspect the surface
- should be smooth, intact, no lesions
- palpate the skull for unusual contour
When assessing the neck, observe
- swelling, lumps, stiffness, pain
- trachea should be midline
A wound that contains slough or eschar is ____________ to stage.
impossible
When assessing the face, observe
NU136
NU 136 EXAM 2 - Health Assessment, Respiratory, Wounds,
Immobility, Urinary & Bowel (Complete & Includes 100+
NCLEX Style Questions and Answers 2026)
initial assessment
gathering of baseline data, done at admission in all care settings
includes:
-patient history
-demographic data
-health history
-psychosocial data
purpose of patient assessment (5)
- Check health status and body function
- Identify or confirm problems
- Monitor response to treatment
- Decide if more testing is needed
- Help create an accurate, individualized care plan
assessment
a continuous process of determining a patient's condition and progress
psychosocial assessment
A comprehensive document which looks at the client as a whole person (not as a set of
symptoms) and holistically combines the spiritual, emotional, physical, mental,
behavioral, and social dimensions.
psychosocial and cultural assessment includes
daily life, emotions, responsibilities, family stress, cultural assessment, values, etc
assumptions
Use respectful, open ended questions and avoid __________
prioritization
When identifying patient needs, follow ABCs and Maslow’s hierarchy: airway,
breathing, circulation, then safety, etc.
NU136
,NU136
JP drains must remain _________ to provide continuous suction.
compressed
Maslow's Hierarchy of Needs
Use ________ ________ _____ _________ to prioritize nursing care. Start with life-
threatening needs first.
Holistic Approach
Looks at the whole person, not just physical symptoms. Includes: Physical health,
emotional state, cultural values and beliefs, social and family support, spiritual needs,
builds trust and supports individualized care, helps identify underlying issues affecting
health
Always assess these 4 things:
- observe their general appearance and behavior
- ask questions to gather information and symptoms
- measure vital signs and body functions
- signs of sexual/physical/emotional abuse/neglect
Before performing a physical assessment, what data can be gathered?
General data such as patient charts, PMH, medications, test results.
Drape
A covering to provide privacy, give modesty and warmth to a patient when an
assessment is being performed.
Head to toe assessment
Ensures nothing is missed—often preferred in general assessments and by new
clinicians
Body systems approach
This method is efficient for focused assessments
Inspection/Observation
Use your eyes to assess skin, body shape, movements, and behavior
pyuria
presence of purulence (pus) in the urine
Palpation
NU136
,NU136
Use your hands to feel for temperature, swelling, skin turgor, pain, texture, or
abnormal masses. When palpating watch for signs of pain.
Light palpation
- uses the pads of the fingers
- presses 1-2cm deep
deep palpation
- done using one or both hands
- 4-5cm deep
percussion
Tap to assess size, location, or density of organs (chest and abdomen). Doing this on
the chest can help loosen secretions.
percussion
Normal lung tissue produces resonance on ________
auscultation
Use a stethoscope to listen to lungs, heart, bowel sounds, and blood pressure
olfaction
Detect odors that may indicate infection, disease, or poor hygiene (smell)
focused assessment
a detailed exam of a specific problem or system.
performed when:
- new complaints/symptoms
- change in condition
- follow up appointment
subjective data
patient provided information
objective data
information about the patient that was acquired by the nurse
Glasgow Coma Scale (GSC)
Used to assess levels of consciousness (LOC)
NU136
, NU136
Glasgow Coma Scale evaluates which 3 responses?
1. Eye opening
2. Motor response
3. Verbal response
15
A score of __ on the Glasgow Coma Scale is a fully alert patient.
7
A score of __ or lower on the Glasgow Coma Scale indicates a coma and is a medical
emergency.
Symmetry
Always be sure to assess for ______, meaning the left and right sides of the body are
mirror images of each other along the sagittal plane, particularly in their external
appearance and structure.
A patient's mental status includes
level of consciousness (awake, alert, oriented), logical thinking
When assessing the hair, observe
- scalp, hair, eyebrows, and eyelashes
- color, texture, and distribution
- debris, blood, trauma, nits, scales
When assessing the scalp, observe
- inspect the surface
- should be smooth, intact, no lesions
- palpate the skull for unusual contour
When assessing the neck, observe
- swelling, lumps, stiffness, pain
- trachea should be midline
A wound that contains slough or eschar is ____________ to stage.
impossible
When assessing the face, observe
NU136
