NUR2092 Health Assessment Final Exam Study Guide
• Assessment – Point of Entry In an Going Process (Chapter 1)
• Subjective Data: Information that a patient says about self.
• Objective data: What the health professional observes by inspecting, percussing, palpating and
auscultating during physical examination.
• (You need to know the definition of both to answer test questions)
• Nursing process (Chapter 1)
o Assessment: collection of data about person’s health state.
▪ Collect Data: Review of the clinical record, health history, physical examination, functional
assessment, risk assessment, review of literature
▪ Use evidence-based assessment techniques
▪ Document relevant data.
Comprehensive assessment: is usually the initial assessment it very thorough and includes detailed
health history and physical examination and examine the client's overall health status.
Focused assessment: is problem oriented and may be the initial assessment or an ongoing assessment.
Problem focus assessment collects data about a problem that has already been identified. This type of
assessment has a narrower scope and a shorter time frame than the initial assessment. In focus
assessments, nurse determine whether the problems still exist and whether the status of the problem has
changed (i.e. improved, worsened, or resolved). This assessment also includes the appraisal of any new,
overlooked or misdiagnosed problems. In intensive care units, may perform focus assessment every few
minutes.
o Diagnosis:
▪ Compare clinical findings with normal and abnormal and developmental needs
▪ Interpret data:
✓ Identify clusters of clues
✓ Make hypothesis
✓ Test hypothesis
✓ Derive diagnosis
▪ Validate Diagnosis
▪ Document Diagnosis
o Outcome Identification:
▪ Identify expected outcomes
▪ Individualize to the person
▪ Culturally appropriate
▪ Realistic and measurable
▪ Include a timeline
▪ Ensure outcomes have the SMART components
SMART: Specific, measurable, attainable, Relevant, Time-bound
o Planning:
▪ Establish Priorities
▪ Develop outcomes
▪ Set timelines for outcomes
▪ Identify interventions
▪ Integrate evidence-based trends and research
▪ Document Plan of Care
o Implementation:
▪ Implement in a safe and timely manner
▪ Use evidence-based interventions
▪ Collaborate with colleagues
▪ Use community resources
▪ Coordinate care delivery
▪ Provide health teaching and health promotion
▪ Document implementation and any modification
,o Evaluation
▪ Progress toward outcomes
▪ Conduct systematic, ongoing, criterion-based evaluation
▪ Include patient and significant others
▪ Use ongoing assessment to revise diagnoses, outcomes, plan
▪ Disseminate results to patient and family
▪ If outcome reached, does something else need to be done or does client no longer have this
diagnosis
▪ If failure, identify reasons for not achieving expected outcomes
▪ Take corrective action to modify plan of care
▪ Document
(You need to know the process to answer test questions)
a. Review (Fig.1-2) Critical Thinking and the Diagnostic Process
• Chapter 2
a. Know the difference between the (Biomedical, Naturalistic, Magicoreligious)
▪ Biomedical or Scientific: Assumes all events in life have a cause and effect, that the human
body functions more or less mechanically, that all life can be reduced or divided into smaller
, parts.
❖ Germ Theory: microorganisms such as bacteria and viruses cause specific disease conditions.
Most educational programs embrace this.
▪ Naturalistic or Holistic: believe that human life is only one aspect of nature. Believe that the
forces of nature must be kept in natural balance or harmony.
▪ Magicoreligious: basic premise that the world is an arena in which supernatural forces
dominate. The fate of the world and those in it depends on the action of supernatural forces for
good or evil. (Voodoo, Faith Healings..)
• Techniques of Communication (Chapter 3)
Closed ended vs open ended and when to use them:
• Closed ended questions: Do you have pain?
a. For specific information
b. 1-2-word answers, yes/no
c. Limits rapport, Elicits cold facts, neutral interaction
• Open ended questions: Tell me about; How are you doing today? What brings you to the
hospital?
a. Narrative answers
b. Feelings, opinions
c. Develops rapport
• 1 question at a time; appropriate language
• Review Chapter 3 Examiner’s Verbal Responses (Table 3-3)
Facilitation – “mm-hmm”, “uh-huh”, “Go on”
Silence – gives time to think
Reflection – “It’s hard to get up in the morning.” “You have difficulty getting the day started.”
Empathy – “I can’t do anything for myself anymore.” “It must be difficult not being independent, losing
control.”
Clarification –“So you have difficulty when lying down if you have to lie flat and you need several pillows
to breath comfortably. Correct?”
Response when you express your own thoughts & feelings
Confrontation – “Before you said you don’t smoke but now you mentioned smoking with your friends.”
Interpretation – “I always take this blanket with me.” “So the blanket must be very important to you.”
Explanation – “You can not eat for 12 hours prior to your surgery to decrease the risk of aspiration.”
Summary – Condenses the facts discussed, allows client to make corrections as needed
• Health History of the Adult (Chapter 4)
a. Present Health or History of Present Illness – PQRSTU:
• P = Provocative or Palliative
• • What makes the symptom(s) better or worse?
• Q = Quality
• • Describe the symptom(s).
• R = Region or Radiation
• • Where in the body does the symptom occur? Is there radiation or extension of the
• symptom(s) to another area of the body?
• S = Severity
• • On a scale of 1-10, (10 being the worst) how bad is the symptom(s)? Another visual scale
• may be appropriate for patients that are unable to identify with this scale.
• T = Timing
• • Does it occur in association with something else (i.e. eating, exertion, movement)?
• Assessment – Point of Entry In an Going Process (Chapter 1)
• Subjective Data: Information that a patient says about self.
• Objective data: What the health professional observes by inspecting, percussing, palpating and
auscultating during physical examination.
• (You need to know the definition of both to answer test questions)
• Nursing process (Chapter 1)
o Assessment: collection of data about person’s health state.
▪ Collect Data: Review of the clinical record, health history, physical examination, functional
assessment, risk assessment, review of literature
▪ Use evidence-based assessment techniques
▪ Document relevant data.
Comprehensive assessment: is usually the initial assessment it very thorough and includes detailed
health history and physical examination and examine the client's overall health status.
Focused assessment: is problem oriented and may be the initial assessment or an ongoing assessment.
Problem focus assessment collects data about a problem that has already been identified. This type of
assessment has a narrower scope and a shorter time frame than the initial assessment. In focus
assessments, nurse determine whether the problems still exist and whether the status of the problem has
changed (i.e. improved, worsened, or resolved). This assessment also includes the appraisal of any new,
overlooked or misdiagnosed problems. In intensive care units, may perform focus assessment every few
minutes.
o Diagnosis:
▪ Compare clinical findings with normal and abnormal and developmental needs
▪ Interpret data:
✓ Identify clusters of clues
✓ Make hypothesis
✓ Test hypothesis
✓ Derive diagnosis
▪ Validate Diagnosis
▪ Document Diagnosis
o Outcome Identification:
▪ Identify expected outcomes
▪ Individualize to the person
▪ Culturally appropriate
▪ Realistic and measurable
▪ Include a timeline
▪ Ensure outcomes have the SMART components
SMART: Specific, measurable, attainable, Relevant, Time-bound
o Planning:
▪ Establish Priorities
▪ Develop outcomes
▪ Set timelines for outcomes
▪ Identify interventions
▪ Integrate evidence-based trends and research
▪ Document Plan of Care
o Implementation:
▪ Implement in a safe and timely manner
▪ Use evidence-based interventions
▪ Collaborate with colleagues
▪ Use community resources
▪ Coordinate care delivery
▪ Provide health teaching and health promotion
▪ Document implementation and any modification
,o Evaluation
▪ Progress toward outcomes
▪ Conduct systematic, ongoing, criterion-based evaluation
▪ Include patient and significant others
▪ Use ongoing assessment to revise diagnoses, outcomes, plan
▪ Disseminate results to patient and family
▪ If outcome reached, does something else need to be done or does client no longer have this
diagnosis
▪ If failure, identify reasons for not achieving expected outcomes
▪ Take corrective action to modify plan of care
▪ Document
(You need to know the process to answer test questions)
a. Review (Fig.1-2) Critical Thinking and the Diagnostic Process
• Chapter 2
a. Know the difference between the (Biomedical, Naturalistic, Magicoreligious)
▪ Biomedical or Scientific: Assumes all events in life have a cause and effect, that the human
body functions more or less mechanically, that all life can be reduced or divided into smaller
, parts.
❖ Germ Theory: microorganisms such as bacteria and viruses cause specific disease conditions.
Most educational programs embrace this.
▪ Naturalistic or Holistic: believe that human life is only one aspect of nature. Believe that the
forces of nature must be kept in natural balance or harmony.
▪ Magicoreligious: basic premise that the world is an arena in which supernatural forces
dominate. The fate of the world and those in it depends on the action of supernatural forces for
good or evil. (Voodoo, Faith Healings..)
• Techniques of Communication (Chapter 3)
Closed ended vs open ended and when to use them:
• Closed ended questions: Do you have pain?
a. For specific information
b. 1-2-word answers, yes/no
c. Limits rapport, Elicits cold facts, neutral interaction
• Open ended questions: Tell me about; How are you doing today? What brings you to the
hospital?
a. Narrative answers
b. Feelings, opinions
c. Develops rapport
• 1 question at a time; appropriate language
• Review Chapter 3 Examiner’s Verbal Responses (Table 3-3)
Facilitation – “mm-hmm”, “uh-huh”, “Go on”
Silence – gives time to think
Reflection – “It’s hard to get up in the morning.” “You have difficulty getting the day started.”
Empathy – “I can’t do anything for myself anymore.” “It must be difficult not being independent, losing
control.”
Clarification –“So you have difficulty when lying down if you have to lie flat and you need several pillows
to breath comfortably. Correct?”
Response when you express your own thoughts & feelings
Confrontation – “Before you said you don’t smoke but now you mentioned smoking with your friends.”
Interpretation – “I always take this blanket with me.” “So the blanket must be very important to you.”
Explanation – “You can not eat for 12 hours prior to your surgery to decrease the risk of aspiration.”
Summary – Condenses the facts discussed, allows client to make corrections as needed
• Health History of the Adult (Chapter 4)
a. Present Health or History of Present Illness – PQRSTU:
• P = Provocative or Palliative
• • What makes the symptom(s) better or worse?
• Q = Quality
• • Describe the symptom(s).
• R = Region or Radiation
• • Where in the body does the symptom occur? Is there radiation or extension of the
• symptom(s) to another area of the body?
• S = Severity
• • On a scale of 1-10, (10 being the worst) how bad is the symptom(s)? Another visual scale
• may be appropriate for patients that are unable to identify with this scale.
• T = Timing
• • Does it occur in association with something else (i.e. eating, exertion, movement)?
