assessment Ques ons and answers Updated Rated A+
2025/2026 NEW!!
Subjec ve data - Ans Said by the client (S)
Obejec ve data - Ans Observed by the nurse (O)
Assessment Techniques is as follows - Ans Inspect-Palpa on-Percussion-Ausculta on
Order of Abdomen Assessment - Ans Inspect-Ausculta on-Percuss-Palapate
Inspec on - Ans *always first*
1. Take me to observe with eyes ear nose
2.Use good ligh ng
3.Look at color shape symmetry posi on
4.Observe for odors from skin breath wound
5. Develop and use nursing ins ncts
6.Inspec on is done alone and in combina on with other assessment techniuqes
Back of hand - Ans To assess skin temperature use
Deep Palpa on - Ans 5-8cm or (2-3") deep is considered
Light Paplpa on - Ans 1cm deep is considered
,Percussion - Ans sounds produced by striking body surface
sounds are dull resonant flat tympanic
ac on is performed in the wrist
Auscula on - Ans listening to sounds produced by the body
Bell - Ans picks up low pitched sounds such as heart murmurs
General Survey - Ans is an overall review or first impression a nurse has of person's well being.
Appearance - Ans appears to be reported age
sexual development appropriate
alert and oriented
facial features symmetric
no signs of acute distress
Body Structure/mobilty - Ans 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
Behavior - Ans maintains eye contact with appropriate expressions
comfortable and coopera ve
, speech clear
clothing is correct for climate
looks cleat and fit
appears clean and well groomed
Comprehensive history - Ans 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 pa ent regardless of se<ng and by a RN
Family Health Hx - Ans Are completed across three genera ons looking specifically for pa@erns
in gene c issues that nega vely impact quality of life
Health Hx - Ans gives a picture of pa ent's current health and documenta on must be
completed for each visit and or assessment
How to measure height less than 2 years of age - Ans 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 sta onary
headboard and a sliding ver cal 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 un l 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 se<ngs 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 p 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 plo@ed on the birth to
36 months growth chart. When a standing height is obtained for a two year old, plot the finding