BRAINSCAPE1
WGU Health Assessment Exam
with complete solutions latest
version
Subjective data - CORRECT ANSWER-Said by the client (S)
Obejective data - CORRECT ANSWER-Observed by the nurse (O)
Assessment Techniques is as follows - CORRECT ANSWER-Inspect-Palpation-
Percussion-Auscultation
Order of Abdomen Assessment - CORRECT ANSWER-Inspect-Auscultation-Percuss-
Palapate
Inspection - CORRECT ANSWER-*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
Back of hand - CORRECT ANSWER-To assess skin temperature use
Deep Palpation - CORRECT ANSWER-5-8cm or (2-3") deep is considered
Light Paplpation - CORRECT ANSWER-1cm deep is considered
Percussion - CORRECT ANSWER-sounds produced by striking body surface
sounds are dull resonant flat tympanic
action is performed in the wrist
Ausculation - CORRECT ANSWER-listening to sounds produced by the body
BRAINSCAPE1
, BRAINSCAPE1
Bell - CORRECT ANSWER-picks up low pitched sounds such as heart murmurs
General Survey - CORRECT ANSWER-is an overall review or first impression a nurse
has of person's well being.
Appearance - CORRECT ANSWER-appears to be reported age
sexual development appropriate
alert and oriented
facial features symmetric
no signs of acute distress
Body Structure/mobilty - CORRECT ANSWER-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 - CORRECT ANSWER-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
Comprehensive history - CORRECT ANSWER-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
Family Health Hx - CORRECT ANSWER-Are completed across three generations
looking specifically for patterns in genetic issues that negatively impact quality of life
Health Hx - CORRECT ANSWER-gives a picture of patient's current health and
documentation must be completed for each visit and or assessment
How to measure height less than 2 years of age - CORRECT ANSWER-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.
BRAINSCAPE1
, BRAINSCAPE1
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.
Height children 2-3 and older - CORRECT ANSWER-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 and feet flat on the floor, and the patient is asked to look straight ahead.
The flat surface of the stadiometer is lowered until it touches the crown of the head,
compress the hair. A measuring rod attached to a weight scale should not be used.
Measuring weight: - CORRECT ANSWER-1. Balance beam or digital scales should be
used to weigh patients of all ages. Spring type
scales are not acceptable. CDC recommends that all scales should be zero balanced
and calibrated. Scales must be checked for accuracy on an annual basis and calibrated
in accordance with manufacturer's instructions.
2. Prior to obtaining weight measurements, make sure the scale is "zeroed".
Weight infants, children, and teens and adults - CORRECT ANSWER-3. Weigh infants
wearing only a dry diaper or light undergarments. Weigh children after removing
outer clothing and shoes. Weigh adolescents and adults with the patient wearing
minimal
clothing.
4. Place the patient in the middle of the scale. Read the measurement and record
results
immediately. Plot measurements on age and gender specific growth charts and
evaluate
accordingly
Measuring head circumference - CORRECT ANSWER-Obtain measurement on
children from birth to 36 months of age by extending a non stretchable measuring tape
around the broadest part of the child's head For greatest accuracy the tape is placed 3
times with a reading taken at the right side at the left side and at the mid forehead and
the greatest circumference is plotted. The tape should be pulled adequately compress
the hair
Should be measured each visit
Chest circumference - CORRECT ANSWER-This is measured at the nipple line
BRAINSCAPE1
WGU Health Assessment Exam
with complete solutions latest
version
Subjective data - CORRECT ANSWER-Said by the client (S)
Obejective data - CORRECT ANSWER-Observed by the nurse (O)
Assessment Techniques is as follows - CORRECT ANSWER-Inspect-Palpation-
Percussion-Auscultation
Order of Abdomen Assessment - CORRECT ANSWER-Inspect-Auscultation-Percuss-
Palapate
Inspection - CORRECT ANSWER-*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
Back of hand - CORRECT ANSWER-To assess skin temperature use
Deep Palpation - CORRECT ANSWER-5-8cm or (2-3") deep is considered
Light Paplpation - CORRECT ANSWER-1cm deep is considered
Percussion - CORRECT ANSWER-sounds produced by striking body surface
sounds are dull resonant flat tympanic
action is performed in the wrist
Ausculation - CORRECT ANSWER-listening to sounds produced by the body
BRAINSCAPE1
, BRAINSCAPE1
Bell - CORRECT ANSWER-picks up low pitched sounds such as heart murmurs
General Survey - CORRECT ANSWER-is an overall review or first impression a nurse
has of person's well being.
Appearance - CORRECT ANSWER-appears to be reported age
sexual development appropriate
alert and oriented
facial features symmetric
no signs of acute distress
Body Structure/mobilty - CORRECT ANSWER-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 - CORRECT ANSWER-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
Comprehensive history - CORRECT ANSWER-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
Family Health Hx - CORRECT ANSWER-Are completed across three generations
looking specifically for patterns in genetic issues that negatively impact quality of life
Health Hx - CORRECT ANSWER-gives a picture of patient's current health and
documentation must be completed for each visit and or assessment
How to measure height less than 2 years of age - CORRECT ANSWER-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.
BRAINSCAPE1
, BRAINSCAPE1
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.
Height children 2-3 and older - CORRECT ANSWER-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 and feet flat on the floor, and the patient is asked to look straight ahead.
The flat surface of the stadiometer is lowered until it touches the crown of the head,
compress the hair. A measuring rod attached to a weight scale should not be used.
Measuring weight: - CORRECT ANSWER-1. Balance beam or digital scales should be
used to weigh patients of all ages. Spring type
scales are not acceptable. CDC recommends that all scales should be zero balanced
and calibrated. Scales must be checked for accuracy on an annual basis and calibrated
in accordance with manufacturer's instructions.
2. Prior to obtaining weight measurements, make sure the scale is "zeroed".
Weight infants, children, and teens and adults - CORRECT ANSWER-3. Weigh infants
wearing only a dry diaper or light undergarments. Weigh children after removing
outer clothing and shoes. Weigh adolescents and adults with the patient wearing
minimal
clothing.
4. Place the patient in the middle of the scale. Read the measurement and record
results
immediately. Plot measurements on age and gender specific growth charts and
evaluate
accordingly
Measuring head circumference - CORRECT ANSWER-Obtain measurement on
children from birth to 36 months of age by extending a non stretchable measuring tape
around the broadest part of the child's head For greatest accuracy the tape is placed 3
times with a reading taken at the right side at the left side and at the mid forehead and
the greatest circumference is plotted. The tape should be pulled adequately compress
the hair
Should be measured each visit
Chest circumference - CORRECT ANSWER-This is measured at the nipple line
BRAINSCAPE1
