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NURS 301 HEALTH ASSESSMENT EXAM 1 FOCUS TOPICS TO REVIEW

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Assessment_Nursing_Care_of_Children 1. A home health nurse is providing teaching about post seizure management to the parents of a school age child who has epilepsy and experiences tonic-clonic seizures.Which of the following instructions should the nurse include in the teaching? (Selectall that apply.) "Hyperextend your child's head for 5 minutes following a seizure." "Immediately following a seizure, give your child 6 ounces of water." "Following a seizure, record the length and characteristics of your child's seizure.""Administer rectal diazepam to your child following a seizure." "Call for emergency medical services if the size of your child's pupils are unequal after aseizure." 2. A nurse in a pediatric clinic is discussing the pathophysiology of Reye syndrome with a newly licensed nurse. Which of the following statements by the newly licensednurse indicate an understanding of the disorder? "Reye syndrome causes fatty changes in the liver." "Reye syndrome leads to venous thrombus formation." "Reye syndrome is associated with misuse of acetaminophen.""Reye syndrome is linked to decreased serum ammonia levels 3. A nurse is teaching the parents of a toddler about strategies to manage tempertantrums. Which of the following instructions should the nurse include in the teaching? "Honor the child's request if she holds her breath.""Establish a structured daily routine for the child." "Place the child in her room alone until the temper tantrum ends.""Comfort the child during the temper tantrum." 4. A nurse is completing an assessment following suctioning of a child who has a tracheostomy. Which of the following findings should the nurse i

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Exam 1 will cover Chapters 1 to 5, 6, 8, 9, 13, 14, 19, 45 Multiple Choice &
23 True/False


NURS 301 HEALTH ASSESSMENT EXAM 1
FOCUS TOPICS TO REVIEW




1

,Exam 1 will cover Chapters 1 to 5, 6, 8, 9, 13, 14, 19, 45 Multiple Choice &
23 True/False

NURS 301 Health Assessment Exam 1 Focus Topics to
Review

1. Explain the purpose of a nursing health assessment. (pg. 4)
(a) Collecting holistic subjective and objective data to determine a client’s
overall level of functioning in order to make a professional clinical
judgement

2. Compare and contrast medical assessment from nursing health assessment. (pg. 4)
(a) A nursing assessment
i. Physiological, psychological, sociocultural, developmental, and
spiritual data about the client.
ii. These are considered to be interdependent factors that affect a
person level of health
(b) A medical assessment focuses on disease and pathology.
i. Focuses primarily on the client’s physiological status


3. Describe the phases of the nursing process involved in health assessment by the
nurse. (pg. 3)
(a) Assessment
i. Collecting subjective and objective data (ex. Nurses assess patients by
looking at medical history/chart, interviewing patients and obtaining
vital signs/physical examination of patients.)
(b) Diagnosis
i. Analyzing subjective and objective data to make a professional nursing
judgement – nursing diagnosis (ex. Nurses complete a diagnosis from
the patient data collected during initial assessment. Impaired skin
integrity related to fecal incontinence.
(c) Planning
i. Determining outcome criteria and developing a plan. (ex. Patient will
remain free from infection throughout hospitalization(goal/outcome)
by replacing patient's dressing with Neosporin ointment to wound and
two dry 4x4 dressings secured with hypoallergenic tape once a shift:
14:00 - 21:00 - 06:00. (nursing intervention)
(d) Implementation
i. Carrying out the plan (ex. Changing a patient's wound dressing once
a shift)
(e) Evaluation
i. Assessing whether outcome criteria have been met and revising the
plan as necessary (ex. Re-assess patient vitals/physical exam, re-
interview patient and discontinue or modify care plan based on goals/
outcomes met)


2

, Exam 1 will cover Chapters 1 to 5, 6, 8, 9, 13, 14, 19, 45 Multiple Choice &
23 True/False

4. Compare and contrast subjective from objective data (pg. 7)
(a) Subjective: what the patient says
i. Sensations or symptoms i.e. pain, hunger, feelings, happiness,
sadness, perceptions, desires, preferences, beliefs, ideas, values, and
person information Objective
ii. Biographical information, history of present health concern,
personal health history, family history, health and lifestyle
(b) Objective
i. Examiner directly observes objective data or something the
observer collect
ii. Physical characteristics (skin color, posture), body functions (heart
rate, respiratory rate), appearance (dress), behavior (mood swings),
measurements (body temp, BP, height, weight), results of laboratory
testing.

5. Compare and contrast the four basic types of nursing assessment: Give examples
of what occurs in each phase. (pg. 5-6)
(a) initial comprehensive : coming into the ER or Doc office
i. involves collection of subjective data about the client's perception of his
or her health of all body parts, past health history, family history,
lifestyle and health practices, and objective data from step-by-step
physical exam
(b) ongoing or partial: being admitted to the hospital
i. consists of data collection that occurs after the comprehensive database
is established (this consists of a mini overview of the client’s body system
and holistic health patterns as a follow up on health status) reassessed to
determine any new changes or problems
ex: lung cancer patient getting frequent assessments
(c) focused/problem-oriented: going to the doctor for a specific reason
i. a problem-oriented assessment does not replace the
comprehensive health assessment
ii. when a comprehensive database exists for a client who comes to
the health care agency with a specific health concern
iii. going to dermatologist
(d) emergency: ambulance to ER
i. very rapid assessment performed in life-threatening situations
ii. choking, cardiac arrest, drowning, a FAST assessment is needed to
provide prompt treatment. ex: evaluation of client's airway,
breathing, circulation (ABC's) when cardiac arrest is suspected



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