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NUR 3094C Health Assessment Exam 1
Questions with Correct and Verified Answers
100% Rated (Score A)-Florida State College
What does the health history provide? Subjective and objective data What is subjective data? what is an example? SD is what the patient tells you Example: headache, chest pain What is objective data? what is an example? OD are the signs perceived by the examiner through physical examination during assessment Example: rash seen by a nurse, or temp taken with a thermometer In what order are skills performed during a typical assessment?
- Inspection
- Palpation
- Percussion
- Auscultation If a patient has abdomen pain, what order do you do the assessment? Why?
- Inspection
- AUSCULTATION
- Palpation
- Percussion Because of pain, don't touch or tap the tender area first. Start by inspecting and then listening before you feel the area. What occurs during inspection, the first step?
- ALWAYS COMES FIRST
- begins when you first meet a person w/ a general survey
- you should start assessment of each body system with inspection
- requires: good lighting, adequate exposure, use of instruments including otoscope, opthalmoscope, penlight, or specula
During palpation, what should the base of fingers or the ulnar surface of hand be used for?
- best for vibration **-vibrations are felt on the ulnar side of hand During palpation, what type of palpation should you start with and why? What steps are next?
- start with LIGHT palpation to detect surface characteristics and accustom person to being touched
- then deeper palpations when needed
- intermittent pressure better than one long continuous palpation
- 5 to 8 cm or 2-3 in ALSO: bimanual palpation- requires use of both hands to envelop or capture certain body parts or organs such as kidneys, uterus or adnexa for precise delimitation What occurs during percussion, the third step?
- consists of tapping a person's skin with short, sharp strokes to assess underlying structures
What uses does percussion have?
- mapping location and size of organs
- signaling density of a structure by a characteristic note
- detecting a superficial abnormal mass
- percussion vibrations penetrate about 5 cm deep
- deeper mass would give no change in percussion
- eliciting pain if underlying structure is inflamed
- eliciting deep tendon reflex using percussion hammer HOLLOW (AIR-FILLED) ORGANS SOUND DIFFERENT THAN SOLID ORGANS What are the two methods of percussion?
- Direct, or immediate, which is when the striking hand directly contacts body wall
- Indirect, or mediate, is when you use both hands and the striking hand contacts stationary hand fixed on person's skin In regards to percussion, what is resonance and where does it occur? Resonance is low pitch and it occurs over normal lungs
What is the single most important step in decreasing microorganism transmission? WASH YOUR HANDS
- before physical contact with each patient
- after inadvertent contact with blood, body fluids, secretions, and excretions
- after contact with any equipment contaminated with body fluids
- after removing gloves What else should you do in health care in addition to washing your hands? WEAR GLOVES
- any time there is contact with body fluids The nurse is performing an assessment of the abdominal region. What is the appropriate sequence for the examination?
- Palpation, percussion, inspection, auscultation
- Inspection, palpation, auscultation, percussion
- Inspection, auscultation, percussion, palpation 3 Are vital signs subjective or objective data?
Objective because they can be measured by a health care professional What are the 5 vital signs?
- Temperature
- Pulse
- Heart rate
- Respirations
- Blood pressure What are the benefits of taking temperature orally?
- It is accurate and convenient
- The oral sublingual site has a rich blood supply from the carotid arteries that quickly responds to changes in inner core temperature What is a normal oral temperature range? 98.6 degrees F (37 degrees C) with a range of 96.4 degrees F to 99.1 degrees F (35.8 to 37.3 degrees C) What is a normal rectal temperature range? Rectal measures 0.7 to 1 degrees F (0.4 to 0.5 degrees C) higher
What should you do before inserting the thermometer probe in the rectum?
- Put on gloves
- Use lube How should temperature be recorded?
- In celsius unless agency uses fahrenheit What is the conversion for Fahrenheit to Celsius? Celsius to Fahrenheit? F to C: C = 59(F-32) or C = F-32+1. C to F: F = (95 x C) + 32 or F = 1.8(C) + 32 Know both Fahrenheit and Celsius scales and normal ranges *** What is stroke volume? What is normal in adults? The amount of blood every heart beat pumps into aorta
- 70 mL
Regarding pulse as a vital sign, what does palpating the peripheral pulse do? It gives rate and rhythm of heartbeat, as well as local data on condition of artery When is the radial pulse usually palpated? When vital signs are measured What should you use and where should you palpate the radial pulse?
- Use your first three fingers
- Palpate it at the flexor aspect of the wrist laterally along radius bone
- Push until strongest pulsation is felt If the heart rhythm is REGULAR, how long should you count the number of beats for?
- 30 seconds and multiply it by 2 Why is 30 seconds used to take the pulse? because it is the most accurate and efficient when heart rates are normal or rapid and when rhythms are regular
- A more RAPID heart rate, over 90 bpm
- occurs with anxiety or with increased exercise to match body's demand for increased metabolism What is bradycardia?
- A SLOWER heart rate, less than 50 bpm
- occurs in well trained athlete What is the force of the pulse? Strength of heart's stroke volume What does a weak, thready pulse reflect? A decreased stroke volume What does a full, bounding pulse indicate? Increased stroke volume
- Such as with anxiety, exercise and some abnormal conditions What kind of scale is pulse recorded on? What do the numbers indicate?
- A three point scale 3+ full, bounding 2+ normal 1+ weak, thready 0 absent
- some agencies use a four point scale "90 bpm 2+" What should someone's breathing be like? How should you monitor respiration?
- relaxed, regular, automatic and silent
- instead of telling someone you are monitoring their respiration, maintain your position of counting radial pulse and count respirations How long should you count respirations?
- Count for 30 seconds or 1 minute if you suspect an abnormality What is the ratio of pulse rate to respiratory rate? 4:
Arm pressure, person may be sitting or lying, with bare arm supported at heart level. What are the steps of taking blood pressure?
- Palpate brachial artery; with cuff deflated, center it about 1 inch above brachial artery and wrap it
- Palpate brachial artery
- Inflate cuff until artery pulsation obliterated and then 20 to 30 mm Hg beyond
- Deflate cuff quickly and completely; wait 15 to 30 seconds before reinflating so blood trapped in veins can dissapate What is a blood pressure cuff called? How many sizes are there? Sphygmomanometer
- 6 sizes What should the dimensions of the rubber bladder on the BP cuff be?
- About 40% the width of the person's arm and the length should be 80% of this circumference
- Should cover 70% of arm from acromion to olecranon If the BP cuff is too narrow/small, what can the reading be?
Falsely high, up to 50 mm Hg If the BP cuff is wrapped too loose, what can the reading be? Falsely high If the BP cuff is too large, what can the reading be? Falsely low When should you not use an automatic BP cuff?
- If systolic < 90 mm Hg, irregular heart rate, shivering, tremors or seizures Orthostatic, or postural vital signs: when should you take serial measurements of pulse and blood pressure?
- you suspect volume depletion
- person known to have hypertension or taking antihypertensive medications
- person reports fainting or syncope How should you take postural vital signs?
How should you measure an infant's body length? Measure it supine by using horizontal measuring board What is the best index of a child's general health? Physical growth*** Arteries, aorta, away, oxygen Study measurement of oxygen saturation What is a normal range of SpO2 for someone with no lung disease and no anemia?
- 97 to 99%
- greater than 95% with normal hemoglobin At lower oxygen saturations, what is more accurate than the pulse oximeter? An earlobe probe is more accurate and less affected by peripheral vasoconstriction
What is a general survey? study of whole person What does a general survey cover? Covers general health state and any obvious physical characteristics You should launch a general survey every moment you first encounter someone or a situation. What are some things you should look for? What leaves an immediate impression?
- Does the person stand promptly as his or her name is called and walk to meet you? Or do they look sick, rising slowly, with shoulders slumped and eyes downcast?
- Is a hospital patient conversing with visitors, involved in reading or television, or lying perfectly still? As you proceed through health history, measurements and vital signs, note following points that will add up to general survey. What are the four areas you should be aware of during a GS?
- physical appearance
- body structure
- mobility
- behavior
