Barriers to communication—the ten traps of interviewing- providing false assurance or
reassurance, giving unwanted advice, using authority, using avoidance language, engaging in
distancing, using professional jargon, using leading or biased questions, talking too much,
interrupting, using why questions
o Blaming, patronizing, false reassurance, failure to listen, changing the subject or topic
Tips for assessing children under age 5:
What occurs in each step of the nursing process:
o Assessment
o Diagnosis
o Outcome identification
o Planning
o Implementation
o Evaluation
Open ended questions: ask for a narrative response use in following situations: to begin
interview, introduce new section of interview, whenever the patient introduces a new topic
Closed ended questions: ask for apecific information, use in following situations: after opening
narrative questions, when you need specific facts about past health problems, to move interview
along. These are yes and no questions
Subjective Data vs objective data:
Signs vs symptoms: symptoms are subjective sensation person feels from disorder, what a
person says is reason for seeking care is recorded and enclosed in quotation marks to indicate
persons exact words. Signs are objective abnormally that can be detected on physical
examination or in lab reports
Assessing pulses—is it weak or full, rate and rhythm, force, elasticity, regular, irregular
o light pressure, don’t assess pulses on neck at same time
Terms for respiratory patterns—normal is relaxed, regular, automatic, and silent, orthopenic-
shortness of breath when laying down, eupneic- normal good breathing, tachypnea- fast
breathing, bradypneic- slow breathing, positional is just allowing for the best chest expansion
What is included in the family health history--
Why would you want to ask the clients name and DOB?—helps assess mental status
Types of nutritional eating disorders:
o Anorexia nervosa
o bullemia
Components of health history vs health assessment--
What are normal lung sounds and where are they found
What are adventitious lung sounds and where are they found—
o Crackles (rales)- are most commonly heard in dependent lobes: right and left lung bases,
random sudden reinflation of groups of alveoli, fine, short, interrupted crackling sounds
heard during inspiration, expiration, or both; vary in pitch, high or low, may or may not
change with coughing sound like crushing cellophane
o Rhonci- primarily heard over trachea and bronchi, if loud enough can be heard over
most lung fields, fluid or mucus in larger airway causing turbulence; low pitched,
continuous sounds heard more during expiration may be cleared by coughing sounds like
blowing air through milk with a straw
This study source was downloaded by 100000844460766 from CourseHero.com on 03-30-2022 07:56:47 GMT -05:00
https://www.coursehero.com/file/34513545/Health-assessment-final-study-guidedocx/
, o Wheeze- can be heard through all lung fields, severely narrowed bronchus; are high
pitched, musical sounds heard during inspiration or expiration, do not clear with
coughing
o Pleural friction rub- is heard best over anterior lateral lung field, if client is sitting
upright, inflamed pleura, parietal pleura rubbing against visceral pleura; grating quality
heard best during inspiration, does not clear with coughing
What are risk factors for breast cancer: gender, age, genetics, family history, weight, race
What are identifying factors for malignant melanoma: asymmetry, border irregularity, color,
diameter ¼ inch or 6mm
Coordinating function of cranial nerves 3, 4, 6- makes eyes do tricks, oculomoter, trochlear,
abducens
PERRLA—pupils equal, round, reactive to light and accomodate
Tests to evaluate cerebellar function- Romberg test reflex: a procedure used to evaluate
cerebellar function and balance in which the person is asked to stand quietly, with eyes closed,
feet together, and hands at side, and to maintain equilibrium while responding to directions.
o hand coordination: ask them with eyes closed to raise arms fully extended in front of
them; should be able to hold them at equal height in front of them, abnormal would be
unleveled hand positions
o movement coordination: with eyes still closed and their arms fully extended in front of
them ask the patients to make a fist, now ask them to stick out the pinky in both hands,
then ask the patient to try to place the tip of their left pinky on the tip of the nose, ask
them to do it again with their right pinky, should be able to do this without difficulty,
abnormal would be shaky hands, inaccuracy, choppy movements
o movement coordination 2: have them open eyes, stick out your index finger in front of
them at about arms length, now have them stick out their index finger on each of their
hands ask them to touch the tip of their finger to the tip of the nose and then from nose
to your outstretched finger, repeat with both hands; abnormal would be shaky or
inaccuracy
o alternating movement: with the patients eyes open have them extend their arms fully in
front of them, ask them to wave both their hands (wave good bye), then ask them to do
the same but have them pull their hands inwards so that their hands are next to their
chest and their elbows are behind their back , abnormal would be one hand slower than
the other and the inability to coordinate
Spinal curvatures
o Lordosis- big dip in on lower back
o Kyphosis- hump in top of back
o Scoliosis- curved like an S
BP cuff sizing and placement—the cuff has to be the right size, if it is too big the reading will be
low, if it is too small the reading will be high. Should be on the arm and the arm should be at
heart level
IADL ( and what is included):
o Personal hygiene (bathing, grooming, oral, nail and hair care), continence management,
dressing, feeding, ambulating
This study source was downloaded by 100000844460766 from CourseHero.com on 03-30-2022 07:56:47 GMT -05:00
https://www.coursehero.com/file/34513545/Health-assessment-final-study-guidedocx/
reassurance, giving unwanted advice, using authority, using avoidance language, engaging in
distancing, using professional jargon, using leading or biased questions, talking too much,
interrupting, using why questions
o Blaming, patronizing, false reassurance, failure to listen, changing the subject or topic
Tips for assessing children under age 5:
What occurs in each step of the nursing process:
o Assessment
o Diagnosis
o Outcome identification
o Planning
o Implementation
o Evaluation
Open ended questions: ask for a narrative response use in following situations: to begin
interview, introduce new section of interview, whenever the patient introduces a new topic
Closed ended questions: ask for apecific information, use in following situations: after opening
narrative questions, when you need specific facts about past health problems, to move interview
along. These are yes and no questions
Subjective Data vs objective data:
Signs vs symptoms: symptoms are subjective sensation person feels from disorder, what a
person says is reason for seeking care is recorded and enclosed in quotation marks to indicate
persons exact words. Signs are objective abnormally that can be detected on physical
examination or in lab reports
Assessing pulses—is it weak or full, rate and rhythm, force, elasticity, regular, irregular
o light pressure, don’t assess pulses on neck at same time
Terms for respiratory patterns—normal is relaxed, regular, automatic, and silent, orthopenic-
shortness of breath when laying down, eupneic- normal good breathing, tachypnea- fast
breathing, bradypneic- slow breathing, positional is just allowing for the best chest expansion
What is included in the family health history--
Why would you want to ask the clients name and DOB?—helps assess mental status
Types of nutritional eating disorders:
o Anorexia nervosa
o bullemia
Components of health history vs health assessment--
What are normal lung sounds and where are they found
What are adventitious lung sounds and where are they found—
o Crackles (rales)- are most commonly heard in dependent lobes: right and left lung bases,
random sudden reinflation of groups of alveoli, fine, short, interrupted crackling sounds
heard during inspiration, expiration, or both; vary in pitch, high or low, may or may not
change with coughing sound like crushing cellophane
o Rhonci- primarily heard over trachea and bronchi, if loud enough can be heard over
most lung fields, fluid or mucus in larger airway causing turbulence; low pitched,
continuous sounds heard more during expiration may be cleared by coughing sounds like
blowing air through milk with a straw
This study source was downloaded by 100000844460766 from CourseHero.com on 03-30-2022 07:56:47 GMT -05:00
https://www.coursehero.com/file/34513545/Health-assessment-final-study-guidedocx/
, o Wheeze- can be heard through all lung fields, severely narrowed bronchus; are high
pitched, musical sounds heard during inspiration or expiration, do not clear with
coughing
o Pleural friction rub- is heard best over anterior lateral lung field, if client is sitting
upright, inflamed pleura, parietal pleura rubbing against visceral pleura; grating quality
heard best during inspiration, does not clear with coughing
What are risk factors for breast cancer: gender, age, genetics, family history, weight, race
What are identifying factors for malignant melanoma: asymmetry, border irregularity, color,
diameter ¼ inch or 6mm
Coordinating function of cranial nerves 3, 4, 6- makes eyes do tricks, oculomoter, trochlear,
abducens
PERRLA—pupils equal, round, reactive to light and accomodate
Tests to evaluate cerebellar function- Romberg test reflex: a procedure used to evaluate
cerebellar function and balance in which the person is asked to stand quietly, with eyes closed,
feet together, and hands at side, and to maintain equilibrium while responding to directions.
o hand coordination: ask them with eyes closed to raise arms fully extended in front of
them; should be able to hold them at equal height in front of them, abnormal would be
unleveled hand positions
o movement coordination: with eyes still closed and their arms fully extended in front of
them ask the patients to make a fist, now ask them to stick out the pinky in both hands,
then ask the patient to try to place the tip of their left pinky on the tip of the nose, ask
them to do it again with their right pinky, should be able to do this without difficulty,
abnormal would be shaky hands, inaccuracy, choppy movements
o movement coordination 2: have them open eyes, stick out your index finger in front of
them at about arms length, now have them stick out their index finger on each of their
hands ask them to touch the tip of their finger to the tip of the nose and then from nose
to your outstretched finger, repeat with both hands; abnormal would be shaky or
inaccuracy
o alternating movement: with the patients eyes open have them extend their arms fully in
front of them, ask them to wave both their hands (wave good bye), then ask them to do
the same but have them pull their hands inwards so that their hands are next to their
chest and their elbows are behind their back , abnormal would be one hand slower than
the other and the inability to coordinate
Spinal curvatures
o Lordosis- big dip in on lower back
o Kyphosis- hump in top of back
o Scoliosis- curved like an S
BP cuff sizing and placement—the cuff has to be the right size, if it is too big the reading will be
low, if it is too small the reading will be high. Should be on the arm and the arm should be at
heart level
IADL ( and what is included):
o Personal hygiene (bathing, grooming, oral, nail and hair care), continence management,
dressing, feeding, ambulating
This study source was downloaded by 100000844460766 from CourseHero.com on 03-30-2022 07:56:47 GMT -05:00
https://www.coursehero.com/file/34513545/Health-assessment-final-study-guidedocx/
