NSG2317 Midterm – Health Assessment Nursing Exam Review Questions
the patient trajectory - ANS ✔✔describes the dynamic (changing) course of health and illness
What is the nursing process? - ANS ✔✔ADPIE:
Assessment
Diagnosis
Planning
Intervention/Implementation
Evaluation
communicating assessment findings - ANS ✔✔SBAR and SOAP
SBAR - ANS ✔✔Situation
Background
Assessment
Recommendation
SOAP - ANS ✔✔subjective, objective, assessment, plan
history of present illness - ANS ✔✔PQRSTU
provocation/palliative
quality/quantity
region/radiation
severity
timing
,understanding
Review of Systems (ROS) - ANS ✔✔physical examination of all body systems in a systematic
manner as part of the nursing assessment (head to toe assessment)
Past Medical History (PMH) - ANS ✔✔information gathered regarding the patient's health
problems in the past and asking questions about allergies, medications, previous/current
illnesses, injuries, surgeries, last examination date, vaccination status, etc.
Family History (FH) - ANS ✔✔Facts about the health of the patient's parents, siblings, and other
blood relatives that might be significant to the patient's condition; looking for risk factor.
- may need to construct a genogram
Social History (SH) - ANS ✔✔information about the patient's tobacco use, alcohol and drug use,
sexual history, relationship status, and other significant social facts that may contribute to the
care of the patient
care continuum - ANS ✔✔skills are useless if patients do not/cannot present for/follow through
with care
General Survey - ANS ✔✔physical appearance, body structure, mobility, behaviour of patient
when they first walk in
Gestalt - ANS ✔✔an organized whole that is perceived as more than the sum of its parts
mental status exam - ANS ✔✔analyzing appearance, behaviour and cognition
Glasgow Coma Scale (GCS) - ANS ✔✔a scale used to assess the consciousness of a patient upon
physical examination, typically in patients with neurological concerns or complaints
,scale is divided into 3 parts:
eye opening
verbal response
motor response
MOCA - ANS ✔✔Montreal Cognitive Assessment
used for stoke and cardiac arrest patients to determine appropriate type of rehab
- patient is asked to draw a clock that has to have a certain number of requirements
BMI formula - ANS ✔✔weight (kg) / height (m^2)
What BMI is considered overweight? - ANS ✔✔25-29.9
What BMI is considered obese? - ANS ✔✔over 30
temperature normal range and critical value - ANS ✔✔37.2 (internal setpoint)
greater than 38 or less than 36
Hypothermia - ANS ✔✔abnormally low body temperature (less than 36)
Pyrexia (fever) high and low grade - ANS ✔✔low grade: 37.5-38.2
high grade: greater than 38
Hyperthermia - ANS ✔✔Abnormally high body temperature (greater than 40)
Heart Rate normal range and critical findings - ANS ✔✔60-100bpm
, anything less than 60 or greater than 100
Bradycardia - ANS ✔✔slow heart rate (less than 60 bpm)
Tachycardia - ANS ✔✔Fast heart rate (HR greater than 100bpm)
respirations normal and critical range - ANS ✔✔10 -20 in adult (increased in older adults)
anything less than 10 or greater than 24
- Respiratory rates decrease with age, neonates and children have higher breathing rates
(neonates 30-40 breaths per min is average)
bradypnea - ANS ✔✔an abnormally slow rate of respiration usually of less than 10 breaths per
minute
Tachypnea - ANS ✔✔Increased breathing rate (greater than 24 breaths per minute)
blood pressure normal and critical ranges - ANS ✔✔120/80
systolic pressure less than 90mmHG or greater than 160mmHG
hypotension - ANS ✔✔abnormally low blood pressure 90/60; 90 is a concern because you are
not really profusing body
Hypertension - ANS ✔✔high blood pressure 140/90 or higher
oxygen saturation normal and critical ranges - ANS ✔✔97-98%
anything less than 92%
the patient trajectory - ANS ✔✔describes the dynamic (changing) course of health and illness
What is the nursing process? - ANS ✔✔ADPIE:
Assessment
Diagnosis
Planning
Intervention/Implementation
Evaluation
communicating assessment findings - ANS ✔✔SBAR and SOAP
SBAR - ANS ✔✔Situation
Background
Assessment
Recommendation
SOAP - ANS ✔✔subjective, objective, assessment, plan
history of present illness - ANS ✔✔PQRSTU
provocation/palliative
quality/quantity
region/radiation
severity
timing
,understanding
Review of Systems (ROS) - ANS ✔✔physical examination of all body systems in a systematic
manner as part of the nursing assessment (head to toe assessment)
Past Medical History (PMH) - ANS ✔✔information gathered regarding the patient's health
problems in the past and asking questions about allergies, medications, previous/current
illnesses, injuries, surgeries, last examination date, vaccination status, etc.
Family History (FH) - ANS ✔✔Facts about the health of the patient's parents, siblings, and other
blood relatives that might be significant to the patient's condition; looking for risk factor.
- may need to construct a genogram
Social History (SH) - ANS ✔✔information about the patient's tobacco use, alcohol and drug use,
sexual history, relationship status, and other significant social facts that may contribute to the
care of the patient
care continuum - ANS ✔✔skills are useless if patients do not/cannot present for/follow through
with care
General Survey - ANS ✔✔physical appearance, body structure, mobility, behaviour of patient
when they first walk in
Gestalt - ANS ✔✔an organized whole that is perceived as more than the sum of its parts
mental status exam - ANS ✔✔analyzing appearance, behaviour and cognition
Glasgow Coma Scale (GCS) - ANS ✔✔a scale used to assess the consciousness of a patient upon
physical examination, typically in patients with neurological concerns or complaints
,scale is divided into 3 parts:
eye opening
verbal response
motor response
MOCA - ANS ✔✔Montreal Cognitive Assessment
used for stoke and cardiac arrest patients to determine appropriate type of rehab
- patient is asked to draw a clock that has to have a certain number of requirements
BMI formula - ANS ✔✔weight (kg) / height (m^2)
What BMI is considered overweight? - ANS ✔✔25-29.9
What BMI is considered obese? - ANS ✔✔over 30
temperature normal range and critical value - ANS ✔✔37.2 (internal setpoint)
greater than 38 or less than 36
Hypothermia - ANS ✔✔abnormally low body temperature (less than 36)
Pyrexia (fever) high and low grade - ANS ✔✔low grade: 37.5-38.2
high grade: greater than 38
Hyperthermia - ANS ✔✔Abnormally high body temperature (greater than 40)
Heart Rate normal range and critical findings - ANS ✔✔60-100bpm
, anything less than 60 or greater than 100
Bradycardia - ANS ✔✔slow heart rate (less than 60 bpm)
Tachycardia - ANS ✔✔Fast heart rate (HR greater than 100bpm)
respirations normal and critical range - ANS ✔✔10 -20 in adult (increased in older adults)
anything less than 10 or greater than 24
- Respiratory rates decrease with age, neonates and children have higher breathing rates
(neonates 30-40 breaths per min is average)
bradypnea - ANS ✔✔an abnormally slow rate of respiration usually of less than 10 breaths per
minute
Tachypnea - ANS ✔✔Increased breathing rate (greater than 24 breaths per minute)
blood pressure normal and critical ranges - ANS ✔✔120/80
systolic pressure less than 90mmHG or greater than 160mmHG
hypotension - ANS ✔✔abnormally low blood pressure 90/60; 90 is a concern because you are
not really profusing body
Hypertension - ANS ✔✔high blood pressure 140/90 or higher
oxygen saturation normal and critical ranges - ANS ✔✔97-98%
anything less than 92%
