Health Assessment for Nursing Practice 6th
Edition Wilson Test Bank
1). Nursing process
Ans: 1. Assessment
2. Diagnosis
3. Planning & Outcome Identification
4. Implementation
5. Evaluation
2). Components of health assessment
Ans: 1. Health History
2. Physical Examination
3). Health history
Ans: Subjective Data
- Symptoms
- Primary source of data: client
- Secondary source of data: others (family, etc.)
4). Physical examination
Ans: Objective data
- Signs
- Measurements, vital signs, observations, labs, odors
- Palpation, auscultation, percussion, inspection
5). Documentation
Ans: - Complete, accurate, descriptive
- Legal permanent record
- Make sure to include client's statements in quotation marks
6). Types of health assessment
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, Ans: - Comprehensive
- Problem based or focused
- Episodic
- Shift assessment
- Screening assessment
7). Comprehensive assessment
Ans: - Detailed exam
- Usually done at onset of admission or if first appointment in a long time
- H&P
8). Problem-based or focused assessment
Ans: - Limited to specific problem/complaint
- Usually done at clinic or urgent care
9). Shift assessment
Ans: - Done by nurse at change of shift
10). Episodic assessment
Ans: - Follow-up to previous visit
11). Screening assessment
Ans: - Focused on disease prevention
- Also done prior to admission to school program or sport
- Health fair
12). Core examination skills- skin
Ans: - Inspect skin
- Inspect for skin lesions and wounds
13). Core examination skills- head, eyes, ears, nose, throat
Ans: - Inspect face
- Inspect oral cavity
- Assess hearing (based on conversation)
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, - Inspect external eyes
- Inspect pupils and response to light and accommodation
- Assess visual acuity
14). Core examination skills- chest and lungs
Ans: - Inspect chest
- Evaluate breathing effort
- Auscultate lung sounds
- Palpate thoracic expansion
15). Core examination skills- cardiovascular
Ans: - Auscultate heart sounds and apical pulse
- Auscultate carotid artery
- Palpate the distal pulse
- Palpate and inspect the nails for capillary refill
- Inspect and palpate extremities for edema
- Palpate extremities for temperature
- Inspect extremities for skin color and hair growth
16). Core examination skills- musculoskeletal
Ans: - Inspect upper and lower extremities for size and symmetry
- Palpate extremities for tenderness
- Observe range of motion
- Assess muscle strength
- Inspect spine
- Assess gait
17). Core examination skills- abdomen
Ans: - Inspect abdomen
- Auscultate bowel sounds, aortic vascular sounds
- Palpate abdomen lightly (generalized tenderness and distention)
18). Core examination skills- neurologic
Ans: - Assess mental status and LOC
- Evaluate speech
- Assess Glasgow coma scale
- Assess sensation to extremities
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Edition Wilson Test Bank
1). Nursing process
Ans: 1. Assessment
2. Diagnosis
3. Planning & Outcome Identification
4. Implementation
5. Evaluation
2). Components of health assessment
Ans: 1. Health History
2. Physical Examination
3). Health history
Ans: Subjective Data
- Symptoms
- Primary source of data: client
- Secondary source of data: others (family, etc.)
4). Physical examination
Ans: Objective data
- Signs
- Measurements, vital signs, observations, labs, odors
- Palpation, auscultation, percussion, inspection
5). Documentation
Ans: - Complete, accurate, descriptive
- Legal permanent record
- Make sure to include client's statements in quotation marks
6). Types of health assessment
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, Ans: - Comprehensive
- Problem based or focused
- Episodic
- Shift assessment
- Screening assessment
7). Comprehensive assessment
Ans: - Detailed exam
- Usually done at onset of admission or if first appointment in a long time
- H&P
8). Problem-based or focused assessment
Ans: - Limited to specific problem/complaint
- Usually done at clinic or urgent care
9). Shift assessment
Ans: - Done by nurse at change of shift
10). Episodic assessment
Ans: - Follow-up to previous visit
11). Screening assessment
Ans: - Focused on disease prevention
- Also done prior to admission to school program or sport
- Health fair
12). Core examination skills- skin
Ans: - Inspect skin
- Inspect for skin lesions and wounds
13). Core examination skills- head, eyes, ears, nose, throat
Ans: - Inspect face
- Inspect oral cavity
- Assess hearing (based on conversation)
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, - Inspect external eyes
- Inspect pupils and response to light and accommodation
- Assess visual acuity
14). Core examination skills- chest and lungs
Ans: - Inspect chest
- Evaluate breathing effort
- Auscultate lung sounds
- Palpate thoracic expansion
15). Core examination skills- cardiovascular
Ans: - Auscultate heart sounds and apical pulse
- Auscultate carotid artery
- Palpate the distal pulse
- Palpate and inspect the nails for capillary refill
- Inspect and palpate extremities for edema
- Palpate extremities for temperature
- Inspect extremities for skin color and hair growth
16). Core examination skills- musculoskeletal
Ans: - Inspect upper and lower extremities for size and symmetry
- Palpate extremities for tenderness
- Observe range of motion
- Assess muscle strength
- Inspect spine
- Assess gait
17). Core examination skills- abdomen
Ans: - Inspect abdomen
- Auscultate bowel sounds, aortic vascular sounds
- Palpate abdomen lightly (generalized tenderness and distention)
18). Core examination skills- neurologic
Ans: - Assess mental status and LOC
- Evaluate speech
- Assess Glasgow coma scale
- Assess sensation to extremities
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