WGU Health Assessment
Questions and Answers | Update | 100% Correct.
1. Subjective data: Said by the client (S)
2. Obejective data: Observed by the nurse (O)
3. Assessment Techniques is as follows: Inspect-Palpation-Percussion-Auscultation
4. Order of Abdomen Assessment: Inspect-Auscultation-Percuss-Palapate
5. Inspection: *always first*
1. Take time to observe with eyes ear nose
2. Use good lighting
3. Look at color shape symmetry position
4. Observe for odors from skin breath wound
5. Develop and use nursing instincts
6. Inspection is done alone and in combination with other assessment techniuqes
6. Back of hand: To assess skin temperature use
7. Deep Palpation: 5-8cm or (2-3") deep is considered
8. Light Paplpation: 1cm deep is considered
9. Percussion: sounds produced by striking body surface
sounds are dull resonant flat tympanic
action is performed in the wrist
10. Ausculation: listening to sounds produced by the body
11. Bell: picks up low pitched sounds such as heart murmurs
12. General Survey: is an overall review or first impression a nurse has of person's well being.
13. Appearance: appears to be reported age
sexual development appropriate
alert and oriented
facial features symmetric
no signs of acute distress
14. Body Structure/mobilty: weight and height WNL BMI guidelines
,body parts equal bilaterally
stands erect
sits comfortably
gait is coordinated
walk is smooth and well balanced
full mobility of joints
, 15. Behavior: maintains eye contact with appropriate expressions
comfortable and cooperative
speech clear
clothing is correct for climate
looks cleat and fit
appears clean and well groomed
16. Comprehensive history: which includes chief complaint or reason for the visit a complete review of
systems and complete past family and social history should be obtained on the first encounter with a patient regardless
of setting and by a RN
17. Family Health Hx: Are completed across three generations looking specifically for patterns in genetic issues
that negatively impact quality of life
18. Health Hx: gives a picture of patient's current health and documentation must be completed for each visit and
or assessment
19. How to measure height less than 2 years of age: Obtain height by measuring the recumbent
length of children less than 2 years of age and
children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary headboard and a sliding
vertical foot piece is ideal, but a tape measure can also be used
a) Lay the child flat against the center of the board. The head should be held against the
headboard by the parent or an assistant and the knees held so that the hips and knees are extended. The foot piece is
moved until it is firmly against the child's heels. Read and record the measurement to the nearest 1/8 inch.
b) A modified technique in home settings is to lay the child flat and straight where the head should be held by the
parent and the knees held so that the hips and knees are extended, mark the flat surface at the top of the head and
tip of the heels. Move child and measure the distance between the marks with a tape measure. Read and record the
measurement to the nearest 1/8 inch
2. When a recumbent length is obtained for a two year old, it should be plotted on the birth to 36 months growth
chart. When a standing height is obtained for a two year old, plot the finding on the 2 year to 18 year chart. After
plotting measurements for children on age and gender specific growth charts, evaluate, educate and refer according
to findings.
20. Height children 2-3 and older: 3. Obtain a standing height on children greater than 2 to 3 years of
age, adolescents, and adults, using a portable stadiometer. The patient is to be wearing only socks or be bare foot.
Have the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees are to be straight
Questions and Answers | Update | 100% Correct.
1. Subjective data: Said by the client (S)
2. Obejective data: Observed by the nurse (O)
3. Assessment Techniques is as follows: Inspect-Palpation-Percussion-Auscultation
4. Order of Abdomen Assessment: Inspect-Auscultation-Percuss-Palapate
5. Inspection: *always first*
1. Take time to observe with eyes ear nose
2. Use good lighting
3. Look at color shape symmetry position
4. Observe for odors from skin breath wound
5. Develop and use nursing instincts
6. Inspection is done alone and in combination with other assessment techniuqes
6. Back of hand: To assess skin temperature use
7. Deep Palpation: 5-8cm or (2-3") deep is considered
8. Light Paplpation: 1cm deep is considered
9. Percussion: sounds produced by striking body surface
sounds are dull resonant flat tympanic
action is performed in the wrist
10. Ausculation: listening to sounds produced by the body
11. Bell: picks up low pitched sounds such as heart murmurs
12. General Survey: is an overall review or first impression a nurse has of person's well being.
13. Appearance: appears to be reported age
sexual development appropriate
alert and oriented
facial features symmetric
no signs of acute distress
14. Body Structure/mobilty: weight and height WNL BMI guidelines
,body parts equal bilaterally
stands erect
sits comfortably
gait is coordinated
walk is smooth and well balanced
full mobility of joints
, 15. Behavior: maintains eye contact with appropriate expressions
comfortable and cooperative
speech clear
clothing is correct for climate
looks cleat and fit
appears clean and well groomed
16. Comprehensive history: which includes chief complaint or reason for the visit a complete review of
systems and complete past family and social history should be obtained on the first encounter with a patient regardless
of setting and by a RN
17. Family Health Hx: Are completed across three generations looking specifically for patterns in genetic issues
that negatively impact quality of life
18. Health Hx: gives a picture of patient's current health and documentation must be completed for each visit and
or assessment
19. How to measure height less than 2 years of age: Obtain height by measuring the recumbent
length of children less than 2 years of age and
children between 2 and 3 who cannot stand unassisted. A measuring board with a stationary headboard and a sliding
vertical foot piece is ideal, but a tape measure can also be used
a) Lay the child flat against the center of the board. The head should be held against the
headboard by the parent or an assistant and the knees held so that the hips and knees are extended. The foot piece is
moved until it is firmly against the child's heels. Read and record the measurement to the nearest 1/8 inch.
b) A modified technique in home settings is to lay the child flat and straight where the head should be held by the
parent and the knees held so that the hips and knees are extended, mark the flat surface at the top of the head and
tip of the heels. Move child and measure the distance between the marks with a tape measure. Read and record the
measurement to the nearest 1/8 inch
2. When a recumbent length is obtained for a two year old, it should be plotted on the birth to 36 months growth
chart. When a standing height is obtained for a two year old, plot the finding on the 2 year to 18 year chart. After
plotting measurements for children on age and gender specific growth charts, evaluate, educate and refer according
to findings.
20. Height children 2-3 and older: 3. Obtain a standing height on children greater than 2 to 3 years of
age, adolescents, and adults, using a portable stadiometer. The patient is to be wearing only socks or be bare foot.
Have the patient stand with head, shoulder blades, buttocks, and heels touching the wall. The knees are to be straight
