HEALTH ASSESSMENT EXAM
QUESTION AND ANSWERS
*Clarification* - ANSWER-*Clarification.* Use this when the person's word choice is
ambiguous or confusing (e.g., "Tell me what you mean by 'tired blood.' "). Clarification
also is used to summarize the person's words, simplify the words to make them clearer,
and then ask if you are on the right track. You are asking for agreement, and the person
can then confirm or deny your understanding.
*Communication* - ANSWER-*Communication* carries you and the patient through the
interview. Communication is the *exchange of information* so that each person clearly
understands the other.
*complete health history data category 1.* - ANSWER-*complete health history data
category 1.* First, collect *biographic data*, such as the patient's name, address, and
date of birth as well as language and communication needs.
*complete health history data category 2.* - ANSWER-*complete health history data
category 2.* Second, note the *source of the history*, which is usually the patient, but
may be someone else, such as a relative or interpreter.
*complete health history data category 3.* - ANSWER-*complete health history data
category 3.* Third, obtain the *reason for seeking care*, formerly known as the chief
complaint. In the patient's own words, briefly describe the reason for the visit.
*complete health history data category 4.* - ANSWER-*complete health history data
category 4.* Fourth, record the *present health or history of present illness*. For a well
person, briefly note the general state of health. For a sick person, chronologically record
the reason for seeking care. When a patient reports a symptom, perform a *symptom
analysis*. If you find it helpful, use the mnemonic PQRSTU to do this.
*complete health history data category 5.* - ANSWER-*complete health history data
category 5.* Fifth, investigate *past health events*, such as illnesses, injuries,
hospitalizations, and allergies as well as current medications.
*complete health history data category 6.* - ANSWER-*complete health history data
category 6.* Sixth, gather a *family history* to help detect health risks for the patient. To
aid in this process, draw a pedigree or genogram.
*complete health history data category 7.* - ANSWER-*complete health history data
category 7.* Seventh, perform a *review of systems* to evaluate the past and present
health of each body system, double-check for significant data, and assess health
promotion practices. For each body system, assess for symptoms and health-promoting
behaviors.
,*complete health history data category 8.* - ANSWER-*complete health history data
category 8.* Finally, perform a *functional assessment*, including activities of daily
living, such as bathing dressing, toileting, eating, walking, housekeeping, shopping,
cooking, and other factors.
*Confrontation* - ANSWER-*Confrontation.* These responses now include your own
thoughts and feelings. Use this only when merited by the situation. If you use it too
often, you take over at the patient's expense. In the case of confrontation, you have
observed a certain action, feeling, or statement and you now focus the person's
attention on it. You give your honest feedback about what you see or feel.
*Critical thinking* - ANSWER-*Critical thinking* is the multidimensional thinking process
needed for sound diagnostic reasoning and clinical judgment. Seventeen critical
thinking skills have been identified, including *setting priorities.*
*Cultural care* - ANSWER-*Cultural care* is professional health care that is culturally
sensitive, appropriate, and competent. To develop cultural care, you must have
knowledge of *your personal heritage* and the *heritage of the nursing profession, the
health care system, and the patient.*
*Cultural conflicts* - ANSWER-*Cultural conflicts* between nurses and patients from
diverse backgrounds are related to *different time and relationship perceptions*. For
example, in some cultures, the past may influence health practices. When making
decisions about health, patients may rely on relationships with others, and their
behavior may depend on the opinion of others.
*Culture* has which four characteristics? - ANSWER-*Culture* has the following four
characteristics:
(1) it is *learned* from birth through language acquisition and socialization.
(2) it is *shared* by all members of the same cultural group.
(3) it is *adapted* to specific conditions related to environmental and technical factors.
(4) it is *dynamic* and ever changing.
*Diagnostic reasoning* - ANSWER-*Diagnostic reasoning* is the process of analyzing
health data and drawing conclusions to identify diagnoses.
*Each person responds differently* to the same stimuli, regardless of the primary culture
and value system. You should *guard against stereotyping* individuals. You should also
understand *culture-bound syndromes,* which may have no equivalent from a
biomedical perspective. - ANSWER-...
*Ethnicity* - ANSWER-*Ethnicity* pertains to membership in a social *group that claims
to possess a common* geographic origin, migratory status, religion, race, language,
,shared values, traditions or symbols, and food preferences. One's cultural background
is a fundamental component of one's ethnic background.
*Explanation* - ANSWER-*Explanation.* With these statements, you inform the person.
You share factual and objective information. This may be for orientation to the agency
setting: "Your dinner comes at 5:30 PM." Or, it may be to explain cause: "The reason
you cannot eat or drink before your blood test is that the food will change the test
results."
*Facilitation* - ANSWER-*Facilitation* These responses encourage the patient to say
more, to continue with the story ("mm-hmm, go on, continue, uh-huh"). Also called
general leads, these responses show the person you are interested and will listen
further. Simply maintaining eye contact, shifting forward in your seat with increased
attention, nodding "Yes," or using your hand to gesture, "Yes, go on, I'm with you,"
encourage the person to continue talking.
*First-level priority problems* - ANSWER-*First-level priority problems* are emergent,
life-threatening, and immediate, such as establishing an airway or supporting breathing.
*Internal factors* - ANSWER-*Internal factors* are what *you* bring to the interview.
*Interpretation* - ANSWER-*Interpretation.* This statement is not based on direct
observation as with confrontation, but it is based on your inference or conclusion. It links
events, makes associations, or implies cause: "It seems that every time you feel the
stomach pain, you have had some kind of stress in your life." Interpretation also
ascribes feelings and helps the person understand his or her own feelings in relation to
the verbal message.
*Nonverbal communications convey messages* from the sender to the receiver. Work
to develop the ability to read patients' nonverbal behaviors and to monitor your own
nonverbal communication. - ANSWER-...
A nursing diagnosis is best described as:
A) a determination of the etiology of disease.
B) a pattern of coping.
C) an individual's perception of health.
D) a concise statement of actual or potential health concerns or level of wellness. -
ANSWER-A nursing diagnosis is best described as:
A) a determination of the etiology of disease.
Feedback: INCORRECT
Medical diagnoses determine the etiology (or cause) of disease.
B) a pattern of coping.
Feedback: INCORRECT
Coping patterns would include methods to relieve stress.
, C) an individual's perception of health.
Feedback: INCORRECT
Health perception is how the person describes and defines personal health.
*D) a concise statement of actual or potential health concerns or level of wellness.*
*Feedback: CORRECT*
Nursing diagnoses are clinical judgments about a person's response to an actual or
potential health state.
A patient admitted to the hospital with asthma has the following problems identified
based on an admission health history and physical assessment. Which problem is a
first-level priority?
A) Ineffective self-health management
B) Risk for infection
C) Impaired gas exchange
D) Readiness for enhanced spiritual well-being - ANSWER-A patient admitted to the
hospital with asthma has the following problems identified based on an admission
health history and physical assessment. Which problem is a first-level priority?
A) Ineffective self-health management
Feedback: INCORRECT
Third-level priority problems are those that are import to the patient's health but can be
addressed after more urgent health problems are addressed. Ineffective self-health
management is an example of a third-level priority.
B) Risk for infection
Feedback: INCORRECT
Second-level priority problems are those that are next in urgency; those requiring
prompt intervention to forestall further deterioration. Risk for infection is an example of a
second-level priority.
*C) Impaired gas exchange*
*Feedback: CORRECT*
First-level priority problems are those that are emergent, life threatening, and
immediate. Impaired gas exchange is an emergent and immediate problem.
D) Readiness for enhanced spiritual well-being
Feedback: INCORRECT
Third-level priority problems are those that are import to the patient's health but can be
addressed after more urgent health problems are addressed. Wellness diagnoses are
third-level priority problems.
*Cultural conflicts* - ANSWER-*Cultural conflicts* between nurses and patients from
diverse backgrounds are related to *different time and relationship perceptions*. For
QUESTION AND ANSWERS
*Clarification* - ANSWER-*Clarification.* Use this when the person's word choice is
ambiguous or confusing (e.g., "Tell me what you mean by 'tired blood.' "). Clarification
also is used to summarize the person's words, simplify the words to make them clearer,
and then ask if you are on the right track. You are asking for agreement, and the person
can then confirm or deny your understanding.
*Communication* - ANSWER-*Communication* carries you and the patient through the
interview. Communication is the *exchange of information* so that each person clearly
understands the other.
*complete health history data category 1.* - ANSWER-*complete health history data
category 1.* First, collect *biographic data*, such as the patient's name, address, and
date of birth as well as language and communication needs.
*complete health history data category 2.* - ANSWER-*complete health history data
category 2.* Second, note the *source of the history*, which is usually the patient, but
may be someone else, such as a relative or interpreter.
*complete health history data category 3.* - ANSWER-*complete health history data
category 3.* Third, obtain the *reason for seeking care*, formerly known as the chief
complaint. In the patient's own words, briefly describe the reason for the visit.
*complete health history data category 4.* - ANSWER-*complete health history data
category 4.* Fourth, record the *present health or history of present illness*. For a well
person, briefly note the general state of health. For a sick person, chronologically record
the reason for seeking care. When a patient reports a symptom, perform a *symptom
analysis*. If you find it helpful, use the mnemonic PQRSTU to do this.
*complete health history data category 5.* - ANSWER-*complete health history data
category 5.* Fifth, investigate *past health events*, such as illnesses, injuries,
hospitalizations, and allergies as well as current medications.
*complete health history data category 6.* - ANSWER-*complete health history data
category 6.* Sixth, gather a *family history* to help detect health risks for the patient. To
aid in this process, draw a pedigree or genogram.
*complete health history data category 7.* - ANSWER-*complete health history data
category 7.* Seventh, perform a *review of systems* to evaluate the past and present
health of each body system, double-check for significant data, and assess health
promotion practices. For each body system, assess for symptoms and health-promoting
behaviors.
,*complete health history data category 8.* - ANSWER-*complete health history data
category 8.* Finally, perform a *functional assessment*, including activities of daily
living, such as bathing dressing, toileting, eating, walking, housekeeping, shopping,
cooking, and other factors.
*Confrontation* - ANSWER-*Confrontation.* These responses now include your own
thoughts and feelings. Use this only when merited by the situation. If you use it too
often, you take over at the patient's expense. In the case of confrontation, you have
observed a certain action, feeling, or statement and you now focus the person's
attention on it. You give your honest feedback about what you see or feel.
*Critical thinking* - ANSWER-*Critical thinking* is the multidimensional thinking process
needed for sound diagnostic reasoning and clinical judgment. Seventeen critical
thinking skills have been identified, including *setting priorities.*
*Cultural care* - ANSWER-*Cultural care* is professional health care that is culturally
sensitive, appropriate, and competent. To develop cultural care, you must have
knowledge of *your personal heritage* and the *heritage of the nursing profession, the
health care system, and the patient.*
*Cultural conflicts* - ANSWER-*Cultural conflicts* between nurses and patients from
diverse backgrounds are related to *different time and relationship perceptions*. For
example, in some cultures, the past may influence health practices. When making
decisions about health, patients may rely on relationships with others, and their
behavior may depend on the opinion of others.
*Culture* has which four characteristics? - ANSWER-*Culture* has the following four
characteristics:
(1) it is *learned* from birth through language acquisition and socialization.
(2) it is *shared* by all members of the same cultural group.
(3) it is *adapted* to specific conditions related to environmental and technical factors.
(4) it is *dynamic* and ever changing.
*Diagnostic reasoning* - ANSWER-*Diagnostic reasoning* is the process of analyzing
health data and drawing conclusions to identify diagnoses.
*Each person responds differently* to the same stimuli, regardless of the primary culture
and value system. You should *guard against stereotyping* individuals. You should also
understand *culture-bound syndromes,* which may have no equivalent from a
biomedical perspective. - ANSWER-...
*Ethnicity* - ANSWER-*Ethnicity* pertains to membership in a social *group that claims
to possess a common* geographic origin, migratory status, religion, race, language,
,shared values, traditions or symbols, and food preferences. One's cultural background
is a fundamental component of one's ethnic background.
*Explanation* - ANSWER-*Explanation.* With these statements, you inform the person.
You share factual and objective information. This may be for orientation to the agency
setting: "Your dinner comes at 5:30 PM." Or, it may be to explain cause: "The reason
you cannot eat or drink before your blood test is that the food will change the test
results."
*Facilitation* - ANSWER-*Facilitation* These responses encourage the patient to say
more, to continue with the story ("mm-hmm, go on, continue, uh-huh"). Also called
general leads, these responses show the person you are interested and will listen
further. Simply maintaining eye contact, shifting forward in your seat with increased
attention, nodding "Yes," or using your hand to gesture, "Yes, go on, I'm with you,"
encourage the person to continue talking.
*First-level priority problems* - ANSWER-*First-level priority problems* are emergent,
life-threatening, and immediate, such as establishing an airway or supporting breathing.
*Internal factors* - ANSWER-*Internal factors* are what *you* bring to the interview.
*Interpretation* - ANSWER-*Interpretation.* This statement is not based on direct
observation as with confrontation, but it is based on your inference or conclusion. It links
events, makes associations, or implies cause: "It seems that every time you feel the
stomach pain, you have had some kind of stress in your life." Interpretation also
ascribes feelings and helps the person understand his or her own feelings in relation to
the verbal message.
*Nonverbal communications convey messages* from the sender to the receiver. Work
to develop the ability to read patients' nonverbal behaviors and to monitor your own
nonverbal communication. - ANSWER-...
A nursing diagnosis is best described as:
A) a determination of the etiology of disease.
B) a pattern of coping.
C) an individual's perception of health.
D) a concise statement of actual or potential health concerns or level of wellness. -
ANSWER-A nursing diagnosis is best described as:
A) a determination of the etiology of disease.
Feedback: INCORRECT
Medical diagnoses determine the etiology (or cause) of disease.
B) a pattern of coping.
Feedback: INCORRECT
Coping patterns would include methods to relieve stress.
, C) an individual's perception of health.
Feedback: INCORRECT
Health perception is how the person describes and defines personal health.
*D) a concise statement of actual or potential health concerns or level of wellness.*
*Feedback: CORRECT*
Nursing diagnoses are clinical judgments about a person's response to an actual or
potential health state.
A patient admitted to the hospital with asthma has the following problems identified
based on an admission health history and physical assessment. Which problem is a
first-level priority?
A) Ineffective self-health management
B) Risk for infection
C) Impaired gas exchange
D) Readiness for enhanced spiritual well-being - ANSWER-A patient admitted to the
hospital with asthma has the following problems identified based on an admission
health history and physical assessment. Which problem is a first-level priority?
A) Ineffective self-health management
Feedback: INCORRECT
Third-level priority problems are those that are import to the patient's health but can be
addressed after more urgent health problems are addressed. Ineffective self-health
management is an example of a third-level priority.
B) Risk for infection
Feedback: INCORRECT
Second-level priority problems are those that are next in urgency; those requiring
prompt intervention to forestall further deterioration. Risk for infection is an example of a
second-level priority.
*C) Impaired gas exchange*
*Feedback: CORRECT*
First-level priority problems are those that are emergent, life threatening, and
immediate. Impaired gas exchange is an emergent and immediate problem.
D) Readiness for enhanced spiritual well-being
Feedback: INCORRECT
Third-level priority problems are those that are import to the patient's health but can be
addressed after more urgent health problems are addressed. Wellness diagnoses are
third-level priority problems.
*Cultural conflicts* - ANSWER-*Cultural conflicts* between nurses and patients from
diverse backgrounds are related to *different time and relationship perceptions*. For
