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NURS 301 Health Assessment Exam 1 Focused Review

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NURS 301 Health Assessment Exam 1 Focused Review

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NURS 301 Health Assessment Exam 1 Focused Review




NURS 301 Health Assessment Exam
1 Focused Review
Exam 1 will cover Chapters 1 to 5, Chapters 8, 9, 13, 14, 19, 23 Exam
Items: 50 multiple choice, True or False.
Review:
Explain the purpose of a nursing health assessment.
To establish a baseline build a rapport with patients , create a baseline and collect holistic
subjective and objective data to determine a clients overall level of functioning in order to make
a professional clinical judgement.
Compare and contrast medical assessment from nursing health assessment.
Medical assessment – focuses primarily on the clients physiologic status. Example: pain, airway,
vital signs, ECG, labs, medication, discharge education
Nursing health assessment- its sub and objective data collection and is on going and continuous
to get the overall patients physical level of functioning
Describe the phases of the nursing process involved in health assessment by the nurse.
Assessment: collecting objective and subjective data
Diagnosis: analyzing sub and obj to make a professional nursing judgment
Planning: determine outcome criteria and developing a plan
Implementation: carrying out the plan
Evaluation: assessing whether outcome criteria have been met and revision of the plan if needed.
Compare and contrast subjective from objective data Compare and contrast the four basic
types of nursing assessment:
Subjective data is what the patient tells us, things we can’t confirm.
Objective are what we evaluate and see and do. Ex: vital signs, rashes.
(a) initial comprehensive is the full physical assessment usually done the first time the pt is
seen. Full physical health history review of systems and head to toe.
(b) ongoing or partial -after comprehensive is database is established. Ex: pt admitted to hx
required frequent assessments of o2, lungs or abdomen. Etc..
(c)focused/problem oriented Is a brief individualized examination mainly on what the problem
is leading to ex. Appendicitis=abdominal assessment.


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, NURS 301 Health Assessment Exam 1 Focused Review




(d) emergency is a physical examination done when time is a factor treatment must
begin immediately.
Describe the three phases of a client interview process. Give examples on what occurs in
each phase.
Introductory: introduction, explaining the purpose, types of questions that will be asked, assuring
confidentiality, making sure the client is comfortable and privacy. Developing trust and rapport
Working: bio data, reason for seeking care, past health history and family history, review of body
systems. Lifestyle and health practices.
Summary and closing-summarizing information validating problems and goals, identifying and
discussing plans to resolve problems with clients, is there anything else the client needs or any
questions.
Describe effective verbal and nonverbal communication techniques to collect
subjective client data. Identify verbal communication to avoid during a client
interview. Describe ways to adapt the interview for the older client.
Verbal: open-ended questions “how or “what” Ex: how have you been feeling today? Closed
ended questions “when or did” only can answer to that question Ex: when did the nausea start?,
rephrasing, providing information.
Non-verbal- appearance, demeanor, facial expressions, silence, listening, posture and attitude.
Things to AVOID: biased or leading questions, rushing, reading the questions. Too much or too
little eye contact, distraction, or standing.
Describe the purpose of performing genogram.
Helps organize and illustrates the clients family history. It helps us see if there are health
problems that run in the family and those of genetic predisposition.
Summarize the ways that the nurse can prepare the client for a physical examination
Keep room temp comfortable, private area, quiet and adequate lighting, firm examination table
or bed, bedside table/tray to hold equipment
Explain the 4 physical assessment techniques and sequence of physical assessment.
Inspection, Palpation, percussion, Auscultation.
Abdomen is: Inspection, Auscultation, percussion, and palpation
Describe ways to validate data Explain the purposes of documenting assessment data
Ways to validate repeat the assessment, clarify data with the client, verify with another health
care professional, compare obj and subj findings.




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