EXAM 1 NURS 3325 QUESTIONS WITH
CORRECT ANSWERS
Components of health assessment - CORRECT ANSWERV-Health History (subjective data)
Physical Examination (objective data)
Documentation of Data (complete, concise, factual)
Why we Learn about health assessments - CORRECT ANSWERV-
Systematic way of collecting and analyzing
Used to start patient plan of care
First step in the health assessment
The types of health assessments depends on - CORRECT ANSWERV-Context of Care
Patient Need
Nurse Expertise
Type of health assessments - CORRECT ANSWER -Comprehensive Assessment
Focused Assessment
Follow-up Assessment
Shift Assessment
Screening Assessment
Clinical reasoning and judgment - CORRECT ANSWER -Collect, organize, analyze, and
interpret data
Create plan of care using clinical judgment
CLINICAL JUDGMENT - CORRECT ANSWER -
"interpretation or conclusion about a patient's needs, concerns, or health programs and/or the decision t
o take action (or not), use or modify standard approaches, or improvise new ones as deemed by the pat
ient response."
health promotion - CORRECT ANSWERV-increase well-being and actualize human health potential
primary health promotion - CORRECT ANSWER -
prevent disease development through healthy lifestyle choices
secondary health promotion - CORRECT ANSWERV-
screening efforts to promote early detection of disease
tertiary health promotion - CORRECT ANSWER -minimizing disability from acute or chronic disease
health protection - CORRECT ANSWER -
actively avoid illness, early detection, maintain function with illness
Healthy people 2030 - CORRECT ANSWERV-
goal of reducing most significant preventable health threats and reducing preventable health threats
Skin assessment- when documenting a skin assessment, the nurse should: - CORRECT ANSWER -
Use standardized terminology to report findings
, • Use standardized terminology to record findings
• Perform assessment when risk factors identified
• Allow information from the history to help direct the assessment
• Document both normal and abnormal skin strategies from the assessment
OLD CARTS - CORRECT ANSWER -
Onset, Location, Duration, Characteristics, Aggravating Factors, Related Symptoms, Treatment, and Se
verity
• Example:
• When did the rash start (onset)
• What makes the rash worse (aggravating factors)
• What do you do to make the rash better (treatment)
• Describe the sensation from the burn, does it burn or itch (related symptoms)
• Describe what the rash looked like initially (duration/characteristics)
stage 1 pressure injury - CORRECT ANSWER -intact skin, non-
blanchable redness over coccyx, tender, warm
stage 2 pressure injury - CORRECT ANSWER -
partial thickness loss of dermis, pink wound bed, no slough or bruising
stage 3 pressure injury - CORRECT ANSWER -
full thickness skin loss, subcutaneous fat visible, no visible bone
stage 4 pressure injury - CORRECT ANSWER -
full thickness tissue loss, tendon exposed, tunneling, slough present
Nail Assessment - CORRECT ANSWERV-
Nail surface should be smooth and flat in the center and slightly curved downward at the edges. The s
kin adjacent to the nail should be intact, the same color as adjacent skin and without edema. The expec
ted angle of the nail base is 160 degrees. The nail should have uniform thickness and the base should f
eel firm and adhere to the nail bed.
jaundice - CORRECT ANSWERV-which is a yellowish-green color in light and dark skinned patients
Jaundice can best be assessed in - CORRECT ANSWER -Sclera of the eye
Palms of the hands
Soles of the feet
The appearance of the normal tympanic membrane is - CORRECT ANSWERV-
Translucent and pearly gray
tympanic membrane - CORRECT ANSWER -
Redness of the tympanic membrane may indicate infection
A brown sticky discharge is cerumen which is a normal finding, but may cause the tympanic membran
e to be obscured
Pink may indicate possible otitis externa or impending infection
CORRECT ANSWERS
Components of health assessment - CORRECT ANSWERV-Health History (subjective data)
Physical Examination (objective data)
Documentation of Data (complete, concise, factual)
Why we Learn about health assessments - CORRECT ANSWERV-
Systematic way of collecting and analyzing
Used to start patient plan of care
First step in the health assessment
The types of health assessments depends on - CORRECT ANSWERV-Context of Care
Patient Need
Nurse Expertise
Type of health assessments - CORRECT ANSWER -Comprehensive Assessment
Focused Assessment
Follow-up Assessment
Shift Assessment
Screening Assessment
Clinical reasoning and judgment - CORRECT ANSWER -Collect, organize, analyze, and
interpret data
Create plan of care using clinical judgment
CLINICAL JUDGMENT - CORRECT ANSWER -
"interpretation or conclusion about a patient's needs, concerns, or health programs and/or the decision t
o take action (or not), use or modify standard approaches, or improvise new ones as deemed by the pat
ient response."
health promotion - CORRECT ANSWERV-increase well-being and actualize human health potential
primary health promotion - CORRECT ANSWER -
prevent disease development through healthy lifestyle choices
secondary health promotion - CORRECT ANSWERV-
screening efforts to promote early detection of disease
tertiary health promotion - CORRECT ANSWER -minimizing disability from acute or chronic disease
health protection - CORRECT ANSWER -
actively avoid illness, early detection, maintain function with illness
Healthy people 2030 - CORRECT ANSWERV-
goal of reducing most significant preventable health threats and reducing preventable health threats
Skin assessment- when documenting a skin assessment, the nurse should: - CORRECT ANSWER -
Use standardized terminology to report findings
, • Use standardized terminology to record findings
• Perform assessment when risk factors identified
• Allow information from the history to help direct the assessment
• Document both normal and abnormal skin strategies from the assessment
OLD CARTS - CORRECT ANSWER -
Onset, Location, Duration, Characteristics, Aggravating Factors, Related Symptoms, Treatment, and Se
verity
• Example:
• When did the rash start (onset)
• What makes the rash worse (aggravating factors)
• What do you do to make the rash better (treatment)
• Describe the sensation from the burn, does it burn or itch (related symptoms)
• Describe what the rash looked like initially (duration/characteristics)
stage 1 pressure injury - CORRECT ANSWER -intact skin, non-
blanchable redness over coccyx, tender, warm
stage 2 pressure injury - CORRECT ANSWER -
partial thickness loss of dermis, pink wound bed, no slough or bruising
stage 3 pressure injury - CORRECT ANSWER -
full thickness skin loss, subcutaneous fat visible, no visible bone
stage 4 pressure injury - CORRECT ANSWER -
full thickness tissue loss, tendon exposed, tunneling, slough present
Nail Assessment - CORRECT ANSWERV-
Nail surface should be smooth and flat in the center and slightly curved downward at the edges. The s
kin adjacent to the nail should be intact, the same color as adjacent skin and without edema. The expec
ted angle of the nail base is 160 degrees. The nail should have uniform thickness and the base should f
eel firm and adhere to the nail bed.
jaundice - CORRECT ANSWERV-which is a yellowish-green color in light and dark skinned patients
Jaundice can best be assessed in - CORRECT ANSWER -Sclera of the eye
Palms of the hands
Soles of the feet
The appearance of the normal tympanic membrane is - CORRECT ANSWERV-
Translucent and pearly gray
tympanic membrane - CORRECT ANSWER -
Redness of the tympanic membrane may indicate infection
A brown sticky discharge is cerumen which is a normal finding, but may cause the tympanic membran
e to be obscured
Pink may indicate possible otitis externa or impending infection
