Holistic Assessment Final Exam
Questions And Answers Rated 100%
Clinical Tip - ANS -Before performing a complete assessment, read your state's Nurse
Practice Act to determine your legal scope of practice (what you can legally assess and
diagnosis)
Patient Consent and Rights - ANS -respect the client's desires and requests related to the
physical examination
- whether or not to have the examination is the client's decision
- some health care providers ask the client to sign a consent form
Assessing Client's Cognitive Abilities - ANS - use the SLUMS examination
OR assess the patient's knowing of:
- orientation to person, time, and place
- concentration, ability to focus and follow direction
- recent memory
- remote memory
- recall of unrelated information in 5, 10, and 30 minute periods
- abstract reasoning
- judgment
- visual perceptual and constructional ability
Saint Louis University Mental Status Exam (SLUMS) - ANS -a score between 27 and 30 for
clients with a high school education and a score of 20-30 for clients without high school
educations are NORMAL-a score of 20-27 for clients with a high school degree and a score of
14-19 for clients without a high school degree indicate MCI (middle cognitive impairment)-a
score of 1-19 for clients with a high school education and a score of 1-14 for clients without a
high school education indicates DEMENTIA
Equipment for general survey - ANS - assessment documentation forms
- scale with height attachment
- flexible tape measures
- skin-fold calipers
- stethoscope and blood pressure cuff
- thermometers
- watch with a second hand
, Equipment for hair, skin, and nails assessment - ANS -gloves
-mirror
-magnifying glass
-penlight
-ruler with centimeter markings
-skin marking pen
Equipment for Head and Neck Assessment - ANS -stethoscope
-small cup of water for client to drink
Equipment for Eye Assessment - ANS -cover card
-newspaper print or Rosenbaum pocket screener
-opthalmoscope
-penlight
-snellen chart
Equipment for Ear Assessment - ANS -otoscope
-tuning fork
-watch with second hand
Equipment for Thorax and Lung Assessment - ANS -client gown and draping sheet
-gloves and mask (for nurse if client is actively coughing)
-metric ruler
-skin marking pen
-stethoscope
Equipment for Mouth, Throat, and Nose Assessment - ANS - 4 x4 inch gauze pad
- penlight
-tongue depressor
Equipment for Breast Assessment - ANS - client gown
- gloves for nurse
- small pillow
- metric ruler
- breast self-examination teaching pamphlet
Equipment for Heart and Neck Vessels Assessment - ANS - client draping sheet
- metric rulers (2)
- penlight
- small pillow
- stethoscope
- watch with second hand
Equipment for Peripheral Vascular Assessment - ANS - client gown
Questions And Answers Rated 100%
Clinical Tip - ANS -Before performing a complete assessment, read your state's Nurse
Practice Act to determine your legal scope of practice (what you can legally assess and
diagnosis)
Patient Consent and Rights - ANS -respect the client's desires and requests related to the
physical examination
- whether or not to have the examination is the client's decision
- some health care providers ask the client to sign a consent form
Assessing Client's Cognitive Abilities - ANS - use the SLUMS examination
OR assess the patient's knowing of:
- orientation to person, time, and place
- concentration, ability to focus and follow direction
- recent memory
- remote memory
- recall of unrelated information in 5, 10, and 30 minute periods
- abstract reasoning
- judgment
- visual perceptual and constructional ability
Saint Louis University Mental Status Exam (SLUMS) - ANS -a score between 27 and 30 for
clients with a high school education and a score of 20-30 for clients without high school
educations are NORMAL-a score of 20-27 for clients with a high school degree and a score of
14-19 for clients without a high school degree indicate MCI (middle cognitive impairment)-a
score of 1-19 for clients with a high school education and a score of 1-14 for clients without a
high school education indicates DEMENTIA
Equipment for general survey - ANS - assessment documentation forms
- scale with height attachment
- flexible tape measures
- skin-fold calipers
- stethoscope and blood pressure cuff
- thermometers
- watch with a second hand
, Equipment for hair, skin, and nails assessment - ANS -gloves
-mirror
-magnifying glass
-penlight
-ruler with centimeter markings
-skin marking pen
Equipment for Head and Neck Assessment - ANS -stethoscope
-small cup of water for client to drink
Equipment for Eye Assessment - ANS -cover card
-newspaper print or Rosenbaum pocket screener
-opthalmoscope
-penlight
-snellen chart
Equipment for Ear Assessment - ANS -otoscope
-tuning fork
-watch with second hand
Equipment for Thorax and Lung Assessment - ANS -client gown and draping sheet
-gloves and mask (for nurse if client is actively coughing)
-metric ruler
-skin marking pen
-stethoscope
Equipment for Mouth, Throat, and Nose Assessment - ANS - 4 x4 inch gauze pad
- penlight
-tongue depressor
Equipment for Breast Assessment - ANS - client gown
- gloves for nurse
- small pillow
- metric ruler
- breast self-examination teaching pamphlet
Equipment for Heart and Neck Vessels Assessment - ANS - client draping sheet
- metric rulers (2)
- penlight
- small pillow
- stethoscope
- watch with second hand
Equipment for Peripheral Vascular Assessment - ANS - client gown
