Health Assessment Final Review,
With Complete Verified Solution
Pain is what form of data?
Subjective data
What are some common forms of objective data?
Vital signs, measurements (essentially anything that the YOU measure as the nurse).
What form of data is this:
A 6in knife was lodged into the patient's abdomen.
Objective because it is a measurable assessment.
What are some common vital signs?
Blood Pressure
Respiration
Heart Rate
Oxygen Saturation
The emergency waiting room is full of people with various complaints. Which
would you choose first and why?
Patient with shortness of breath
Patient with chest pain
Patient with leg pain
Patient with shortness of breath must come first. When in doubt:
Airway, Breathing, Circulation
Brushing your teeth, showering, and driving are all examples of
__________________________.
Activities of daily living
An elderly patient states that they have had mobility issues and imply that they
still drive. What is the major assessment that needs to be performed?
ADL assessment for driving; ask the patient if they can drive or need assistance in
driving
The initial inspection, Observing posture, hygiene, facial expression, assess
breathing, behaviors, body language, and any other observable elements are part
of what assessment partition? (Appearance/Body Structure & Mobility/ Behavior)
The General Survey!
What is an overall review or first impression a nurse has of a person's well being?
The General Survey
A patient states that they have allergies. What should you ask about their
allergies?
What is their allergy to and what is the reaction?
A patient states that she "feel like she is drowning" when she lays down. An x-ray
reveals that there is fluid in her lungs. Her heart is also not pumping effectively.
What is this condition?
,Pulmonary edema due to left-sided Congestive Heart Failure.
What type of patient would you take a rectal temperature from?
Alert or Comatose?
Comatose
The nail bed of a patient is not brittle, no ridges are present and the nail is
smooth, and the angle from nail-to-cuticle is 160 degrees. Is this normal or
abnormal?
Normal
What does a macular look like?
What does a papule look like?
What is a macule?
A macule is a change in the color of the skin. It is flat, if you were to close your eyes and
run your fingers over the surface of a purely macular lesion, you could not detect it. A
macule greater than 1 cm. may be referred to as a patch.
What is a papule?
A papule is a solid raised lesion that has distinct borders and is less than 1 cm in
diameter. Papules may have a variety of shapes in profile (domed, flat-topped,
umbilicated) and may be associated with secondary features such as crusts or scales.
What is a pustule?
Pustules are circumscribed elevated lesions that contain pus. They are most commonly
infected (as in folliculitis) but may be sterile (as in pustular psoriasis)
What are the two cranial nerves that are tested when a patient says "aahhh"...?
Cranial Nerve 9 (Glossopharyngeal): Posterior 1/3 Tongue/Swallowing/Uvula
Cranial Nerve 12 (Hypoglossal): Motor movement to the tongue
Inversion of the foot
Big toe up
Eversion of the foot
Big toe down
Baseball Pitcher's arm movement when pitching
360 Rotation; Circumduction
How would you differentiate chest pain as a respiratory problem or cardiac
problem?
EKG, XRAY, and Diagnostic Testing
A patient states that they have chest pain. What questions must be asked if this
symptom occurs? (4)
Is it radiating?
When did it start?
Was it a sudden onset?
Does it hurt when you take a deep breath or is it constant?
What is the difference between venous insufficiency and arterial insufficiency?
Venous is warm and the pain gets worse as the day goes on and is often associated
with brawny edema.
Arterial is cold and gets worse while ambulating and is often associated with cyanosis.
,Arterial Insufficiency
-Cool
-Cyanosis
-Undefined Borders
-Dry bed in ulcers (decreased blood flow)
-Gets worse with walking
Venous Insufficiency
-Warm skin
-Undefined borders
-Oozing
-Pain gets worse as the day goes on
-Brawny edema (dark pigment and non-pitting)
What is a positive Murphy's sign and what does it identify?
Pain upon and palpation -during inspiration- below the costal margin of the right mid-
claviclar line.
It identifies inflammation in the gallbladder
A patient states that they have an extremely dry mouth all the time. What kind of
medication can cause this dryness?
GI Medications
A patient has tenderness in their costal-vertebral angle (CVA). What does this
indicate?
Kidney swelling and inflammation
How can you differentiate between an upper GI bleed and a lower GI bleed?
Upper: Dark bloody excretion
Lower: Light bloody excretion
Upper GI bleeds will cause feces to have what color ?
DARK
Lower GI bleeds will cause feces to have what color ?
LIGHT
What are the symptoms of lactose intolerance?
•Bloating.
•Pain or cramps.
•Gurgling or rumbling sounds in your belly.
•Gas.
• Loose stools or diarrhea.
•Throwing up.
Why must patients drink more water as they age?
Their skin integrity decrease and they are more likely to dehydrate through their skin
than at younger ages
How long must you listen to the bowl if there is no sound present?
5 minutes
A patient states that they have pain in the lower right quadrant of their abdomen.
How would you palpate it?
, Begin palpation away from the pain and then work your way towards the pain. Palpate
the painful side LAST not FIRST.
What is the proper assessment technique for the abdomen?
Inspect, Auscultate, Percuss, Palpate
What is the normal assessment technique for other areas of the body other than
the abdomen?
Inspection, Percussion, Palpation, Auscultation
What is another name for the Blumberg test? How do you preform the Blumberg
test and what is a positive Blumberg sign?
Name: Rebound test
How: Push hand/fingers slowly and deeply to the site away from the pain (left side) and
press. Quickly raise the hand. This will cause the structures to shift and cause rebound
pain near the appendix if there is appendicitis.
Positive Sign: Pain in the lower right quadrant `
What percussion sound should be prominent for the abdomen? Why?
Tympany; The air in the abdomen rises when the patient is supine
What is an expected percussion sound above the liver, a distended bladder,
adipose tissue, fluid, or masses?
Dullness
How long do babies usually have a distended abdomen?
The first 2 years of age
What is the term used for a distended abdomen?
Protuberant Abdomen
What is the term for a concaved abdomen?
Scaphoid Abdomen
Where is the liver located?
Upper Right Quadrant
When is the only time you should be able to percuss the liver or the spleen?
When they are enlarged
What does hepatomegaly refer to?
Enlargement of the liver
What does the term cardiomegaly refer to?
Enlargement of the heart
RUQ organs
Liver and Gall Bladder
LUQ organs
Stomach, Spleen, Pancreas
RLQ organs
Appendix; part of bladder
LLQ organs
Sigmoid Colon; part of bladder
A patient presents with GI issues associated with obstruction. What would be
your recommendation for this patient?
Increase fiber, drink water, light exercise, and take Metamucil (psyllium Metamucil)
An older male client says that he has trouble/pain while urinating. What should he
be screened for?
With Complete Verified Solution
Pain is what form of data?
Subjective data
What are some common forms of objective data?
Vital signs, measurements (essentially anything that the YOU measure as the nurse).
What form of data is this:
A 6in knife was lodged into the patient's abdomen.
Objective because it is a measurable assessment.
What are some common vital signs?
Blood Pressure
Respiration
Heart Rate
Oxygen Saturation
The emergency waiting room is full of people with various complaints. Which
would you choose first and why?
Patient with shortness of breath
Patient with chest pain
Patient with leg pain
Patient with shortness of breath must come first. When in doubt:
Airway, Breathing, Circulation
Brushing your teeth, showering, and driving are all examples of
__________________________.
Activities of daily living
An elderly patient states that they have had mobility issues and imply that they
still drive. What is the major assessment that needs to be performed?
ADL assessment for driving; ask the patient if they can drive or need assistance in
driving
The initial inspection, Observing posture, hygiene, facial expression, assess
breathing, behaviors, body language, and any other observable elements are part
of what assessment partition? (Appearance/Body Structure & Mobility/ Behavior)
The General Survey!
What is an overall review or first impression a nurse has of a person's well being?
The General Survey
A patient states that they have allergies. What should you ask about their
allergies?
What is their allergy to and what is the reaction?
A patient states that she "feel like she is drowning" when she lays down. An x-ray
reveals that there is fluid in her lungs. Her heart is also not pumping effectively.
What is this condition?
,Pulmonary edema due to left-sided Congestive Heart Failure.
What type of patient would you take a rectal temperature from?
Alert or Comatose?
Comatose
The nail bed of a patient is not brittle, no ridges are present and the nail is
smooth, and the angle from nail-to-cuticle is 160 degrees. Is this normal or
abnormal?
Normal
What does a macular look like?
What does a papule look like?
What is a macule?
A macule is a change in the color of the skin. It is flat, if you were to close your eyes and
run your fingers over the surface of a purely macular lesion, you could not detect it. A
macule greater than 1 cm. may be referred to as a patch.
What is a papule?
A papule is a solid raised lesion that has distinct borders and is less than 1 cm in
diameter. Papules may have a variety of shapes in profile (domed, flat-topped,
umbilicated) and may be associated with secondary features such as crusts or scales.
What is a pustule?
Pustules are circumscribed elevated lesions that contain pus. They are most commonly
infected (as in folliculitis) but may be sterile (as in pustular psoriasis)
What are the two cranial nerves that are tested when a patient says "aahhh"...?
Cranial Nerve 9 (Glossopharyngeal): Posterior 1/3 Tongue/Swallowing/Uvula
Cranial Nerve 12 (Hypoglossal): Motor movement to the tongue
Inversion of the foot
Big toe up
Eversion of the foot
Big toe down
Baseball Pitcher's arm movement when pitching
360 Rotation; Circumduction
How would you differentiate chest pain as a respiratory problem or cardiac
problem?
EKG, XRAY, and Diagnostic Testing
A patient states that they have chest pain. What questions must be asked if this
symptom occurs? (4)
Is it radiating?
When did it start?
Was it a sudden onset?
Does it hurt when you take a deep breath or is it constant?
What is the difference between venous insufficiency and arterial insufficiency?
Venous is warm and the pain gets worse as the day goes on and is often associated
with brawny edema.
Arterial is cold and gets worse while ambulating and is often associated with cyanosis.
,Arterial Insufficiency
-Cool
-Cyanosis
-Undefined Borders
-Dry bed in ulcers (decreased blood flow)
-Gets worse with walking
Venous Insufficiency
-Warm skin
-Undefined borders
-Oozing
-Pain gets worse as the day goes on
-Brawny edema (dark pigment and non-pitting)
What is a positive Murphy's sign and what does it identify?
Pain upon and palpation -during inspiration- below the costal margin of the right mid-
claviclar line.
It identifies inflammation in the gallbladder
A patient states that they have an extremely dry mouth all the time. What kind of
medication can cause this dryness?
GI Medications
A patient has tenderness in their costal-vertebral angle (CVA). What does this
indicate?
Kidney swelling and inflammation
How can you differentiate between an upper GI bleed and a lower GI bleed?
Upper: Dark bloody excretion
Lower: Light bloody excretion
Upper GI bleeds will cause feces to have what color ?
DARK
Lower GI bleeds will cause feces to have what color ?
LIGHT
What are the symptoms of lactose intolerance?
•Bloating.
•Pain or cramps.
•Gurgling or rumbling sounds in your belly.
•Gas.
• Loose stools or diarrhea.
•Throwing up.
Why must patients drink more water as they age?
Their skin integrity decrease and they are more likely to dehydrate through their skin
than at younger ages
How long must you listen to the bowl if there is no sound present?
5 minutes
A patient states that they have pain in the lower right quadrant of their abdomen.
How would you palpate it?
, Begin palpation away from the pain and then work your way towards the pain. Palpate
the painful side LAST not FIRST.
What is the proper assessment technique for the abdomen?
Inspect, Auscultate, Percuss, Palpate
What is the normal assessment technique for other areas of the body other than
the abdomen?
Inspection, Percussion, Palpation, Auscultation
What is another name for the Blumberg test? How do you preform the Blumberg
test and what is a positive Blumberg sign?
Name: Rebound test
How: Push hand/fingers slowly and deeply to the site away from the pain (left side) and
press. Quickly raise the hand. This will cause the structures to shift and cause rebound
pain near the appendix if there is appendicitis.
Positive Sign: Pain in the lower right quadrant `
What percussion sound should be prominent for the abdomen? Why?
Tympany; The air in the abdomen rises when the patient is supine
What is an expected percussion sound above the liver, a distended bladder,
adipose tissue, fluid, or masses?
Dullness
How long do babies usually have a distended abdomen?
The first 2 years of age
What is the term used for a distended abdomen?
Protuberant Abdomen
What is the term for a concaved abdomen?
Scaphoid Abdomen
Where is the liver located?
Upper Right Quadrant
When is the only time you should be able to percuss the liver or the spleen?
When they are enlarged
What does hepatomegaly refer to?
Enlargement of the liver
What does the term cardiomegaly refer to?
Enlargement of the heart
RUQ organs
Liver and Gall Bladder
LUQ organs
Stomach, Spleen, Pancreas
RLQ organs
Appendix; part of bladder
LLQ organs
Sigmoid Colon; part of bladder
A patient presents with GI issues associated with obstruction. What would be
your recommendation for this patient?
Increase fiber, drink water, light exercise, and take Metamucil (psyllium Metamucil)
An older male client says that he has trouble/pain while urinating. What should he
be screened for?
