Health Assessment General Survey Quiz

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Questions and Answers

Which of the following is NOT a component of the general survey?

Body structure

Mobility

Cognitive function (correct)

Physical appearance

What is the first step to ensure a safe environment during health assessment?

Use specialized medical instruments

Clean the equipment (correct)

Perform auscultation

Take patient history

What should be done first in the assessment techniques?

Auscultation

Percussion

Inspection (correct)

Palpation

What does proper inspection require?

Comparing symmetry of body sides Signup and view all the answers

Which of the following instruments is used in the inspection assessment technique?

Penlight Signup and view all the answers

What should nurses do to maintain medical asepsis when changing bed linen?

Keep soiled linen away from their uniform Signup and view all the answers

What is one of the main purposes of a general survey in health assessment?

To assess a patient’s physical and psychological status Signup and view all the answers

Why should bed linens never be shaken during the changing process?

It can spread microorganisms through air currents Signup and view all the answers

Before conducting a physical examination, what data should be collected from the nursing history?

The patient's cultural background and health beliefs Signup and view all the answers

What defines cultural competency in health assessments?

Providing care that is sensitive to the patient’s cultural context Signup and view all the answers

What should nurses do if clean linen touches the floor during bed making?

Immediately discard it Signup and view all the answers

What is the correct positioning of the bed when using the Fowler’s position?

The head of the bed is elevated at least 45 degrees Signup and view all the answers

How should nurses ensure a patient's bed remains comfortable?

Inspect linens frequently for cleanliness and wrinkles Signup and view all the answers

Which of the following is NOT one of the five principles of health promotion?

Focus on individual behavior Signup and view all the answers

What is primary data primarily gathered from?

Client interviews Signup and view all the answers

Which method is used to assess the characteristics of sounds produced in body organs?

Auscultation Signup and view all the answers

What type of data can be found in a client chart?

Laboratory data Signup and view all the answers

Which step in the nursing process focuses on the analysis of patient data?

Assessment Signup and view all the answers

Baseline assessment findings are used for what purpose?

To compare with future assessments Signup and view all the answers

Which method involves using parts of the hand to detect physical characteristics?

Palpation Signup and view all the answers

What approach is utilized when conducting a comprehensive nursing assessment?

Problem-oriented approach Signup and view all the answers

What is the first step in making an occupied bed?

Slide the client up the mattress Signup and view all the answers

What technique is used to apply clean linen to the near side of the bed?

Fan fold technique Signup and view all the answers

Which type of bed is prepared in a hospital room before a new patient is admitted?

Closed bed Signup and view all the answers

What modification is made to the top linen in a surgical, recovery, or postoperative bed?

Top sheets are folded to one side or bottom third Signup and view all the answers

What should be done with the side rails during the process of making an occupied bed?

Keep them up at all times Signup and view all the answers

When is it appropriate to remove gloves during the process of making an occupied bed?

After tucking in dirty linen Signup and view all the answers

What is the primary purpose of making an open bed?

To ensure easy access for patients Signup and view all the answers

What should be done to ensure client comfort when making an occupied bed?

Adjust their pillow and side rails Signup and view all the answers

What is the purpose of using the fingertips during palpation?

To discriminate fine tactile details Signup and view all the answers

Which percussion sound is typically associated with hollow structures?

Tympany Signup and view all the answers

What does the dorsa of the hands best assess?

Temperature Signup and view all the answers

In auscultation, which endpiece of the stethoscope is preferred for high-pitched sounds?

Diaphragm Signup and view all the answers

What characteristic does indirect percussion involve?

A stationary hand and a striking hand Signup and view all the answers

Which technique is best for detecting organ position and consistency?

Palpation Signup and view all the answers

What does a vibratory sensation during palpation indicate?

Normal function of organs Signup and view all the answers

What is the primary goal when beginning to auscultate sounds?

Achieving comfort in identifying normal sounds Signup and view all the answers

Which of the following is NOT a purpose of physical examination?

To entertain patients Signup and view all the answers

What is the primary focus during a successful health history interview?

Orienting the interview to the patient Signup and view all the answers

What type of assessment is critical for forming a definitive nursing or medical diagnosis?

Comprehensive health assessment Signup and view all the answers

Which assessment type is typically performed in situations requiring immediate action?

Emergent assessment Signup and view all the answers

What is necessary for a nurse to provide effective patient care?

Recognizing changes in patient status Signup and view all the answers

Which component is NOT included in a complete health assessment?

Financial assessment Signup and view all the answers

What role does critical thinking play in developing nursing diagnoses?

It aids in analyzing patient information comprehensively Signup and view all the answers

How do nurses demonstrate accountability for their nursing care?

Through evaluating patient responses to care Signup and view all the answers

Study Notes

Nurse's Role in Health Assessment & Bedmaking

Objectives:
- To explain the process of making occupied and unoccupied beds.
- To outline the role of a nurse in health assessments.
- To describe the components of a general survey.
- To outline the differences in assessment types and frequencies.
- To discuss frameworks for collecting health assessment data.
- To explain the purposes of physical assessment & a General Survey.
- To describe cultural diversity, cultural competency, and cultural safety relating these to culturally competent health assessments and improved patient outcomes.
- To identify the data to collect from the nursing history before a physical examination.
- To describe the necessary environmental preparations prior to a physical examination.
- To list techniques needed to prepare a patient physically and psychologically before and during an examination.

Bedmaking

Principles of medical asepsis:
- Keep soiled linen away from uniforms.
- Place soiled linen in special bags before discarding it.
- Avoid shaking bed linens to prevent the spread of microorganisms.
- Do not place soiled linen on the floor.
- Immediately discard clean linen that touches the floor.

Bedmaking - Occupied Bed Procedures

Equipment: Assemble all required equipment.
Prepare: Hand hygiene, body mechanics, adjust bed height.
Bed: Position client according to needs, and adjust pillow and ensure comfort.
Comfort: Offer necessary items (bedpan, privacy).
Asepsis: Apply gloves before handling any dirty linens, remove linens carefully.
Prepare: Loosen top linens, assess what is clean and dirty, remove dirty linens and place into the hamper or beside table.
Cover: Cover client with a clean sheet or blanket, making sure to tuck correctly and provide cleanliness and comfort.
Dispose: Place soiled linen in the laundry hamper.

Bedmaking - Occupied Bed - Continued

Slide up: Instruct on placing the soiled linen correctly under the client and replacing with a new one while sliding up.
Position: Positioning client, ensuring comfort.
Be/Gloves: Gloves removal, and comfort checks.
Make: Make half the bed, tuck dirty linen under, put clean linen on the side and fold correctly.
Roll: Roll client to other side and readjust side rails, pillow, etc
Make (full bed): Make other half of the bed, apply appropriate covers/pillows and ensure comfort.
Ask: Ask client if they are comfortable, ensuring a pleasant experience.
Side: Side rails up and call bell in position

Bedmaking - Unoccupied Beds

Open bed: Fold back top coverings to allow easy entry.
Closed bed: Draw top sheet, blanket, and bedspread up to the head of the mattress and under pillows.

Terms you should know

Fowler's: HOB elevated at least 45 degrees
Semi-Fowler's: HOB elevated at 30 degrees
Trendelenburg: Entire frame tilted, HOB down
Reverse Trendelenburg: Entire frame tilted, FOB down
Flat: Bed & frame horizontal and parallel to floor

General Survey

General health state: Observe and document any obvious physical characteristics.
General impression: Provide an overarching impression of the patient's overall state.
First encounter: Start the general survey as soon as you encounter the patient.
Four areas: Focus on physical appearance, body structure, mobility, and behaviour.

Assessment Techniques

Inspection: -Using sight and smell to observe body systems, be thorough and systematic. -Compare right with left sides; check for symmetry. -Ensure adequate lighting and patient exposure. -Use instruments like otoscopes, ophthalmoscopes, and penlights when required.
Palpation: -Use specific parts of the hand to detect texture, swelling, pulsation, lumps, or the position, shape, and consistency of an organ or mass. -Use different parts of hands for assessing different aspects like the dorsa (back) for temperature, the base of fingers for vibration, etc.
Percussion: -Use short, sharp strokes to assess underlying structures and get sounds like resonance, hyperresonance, tympany, dullness, or flatness. -Distinguish between direct and indirect percussion techniques.
Auscultation: -Use a stethoscope to detect sounds from the body, including heart, blood vessels, lungs and abdomen. -Pay attention to the quality, pitch, and intensity of sounds. -Ensure proper stethoscope fit and seal.

Types of Assessments

Emergent: Quick assessment of immediate needs.
Initial: Comprehensive assessment to understand the overall health status.
Focused: Assessment for a particular problem or injury.
Comprehensive: Detailed overview of the patient's medical history.

Purposes of Physical Examination

Baseline data: Collect starting data.
Supplementary/confirming data: Aid in confirming or refuting data from the medical history.
Identifying nursing diagnoses: Confirm or identify potential nursing problems based on examination findings.
Assessing changing health: Regularly evaluating ongoing shifts in the patient's health.
Evaluating care outcomes: Evaluate the effectiveness of previous treatment and interventions.

Gathering Health History

Comprehensive data collection: Ensuring thoroughness and accuracy.
Relational practice: Establishing a caring and respectful relationship.
Patient-centred approach: Prioritising the patient's concerns rather than solely focusing on the disease itself.

Developing Nursing Diagnoses

Critical thinking: Employ critical thinking skills about the patient's condition and history.
Clinical experience: Apply previous knowledge of similar cases to the current situation.
Objective database: Create a clear picture of the patient's health status based on collected data.
Form a diagnosis: Form a definitive nursing diagnosis requiring all aspects to be understood and reviewed.

Managing Patient Problems

Assessing and intervening: Performing a range of interventions in response to the patient's issues.
Achieving outcomes: Recognizing change in status and making necessary adjustments in interventions, aiming to achieve the most desirable outcomes.

Evaluating Nursing Care

Accountability: Showing responsibility for care provided by confirming the results of nursing interventions.
Physical assessment: Utilizing physical assessment skills to evaluate the patient's response to treatment.

Health Promotion

World Health Organization (WHO) definition: The process of enabling people to increase control over, and improve, their health.
Five principles:
- Involves the population as a whole;
- Directed toward action on the social determinants of health;
- Combines diverse complementary methods;
- Seeks to achieve effective and concrete public participation;
- Nurtured and enabled by health care providers, particularly in primary care.

Types of Data

Primary sources: Information collected directly from the patient.
Secondary sources: Information from patient charts, nursing notes, diagnostic reports, laboratory data and so forth.
Tertiary sources: Relevant literature and nurse experience.

Summary of Findings and Assessment

Baseline summary: Baseline assessment findings are important for comparisons in subsequent assessments.
Inspection: Careful observation using sight and smell to evaluate health status.
Palpation: Using parts of the hand to assess physical characteristics like lumps, swelling and texture.
Auscultation: Using a stethoscope to listen to sounds within the body for a variety of conditions.
History & Body Systems: Patient history aids in understanding areas needing additional evaluation.
Nursing Process: Critical thinking steps involved in diagnosis and treatment of patient problems.
Database Formation: Creating a comprehensive database using a variety of data collection methods.

Lab Requirements

Uniform: Full uniform (scrubs, running shoes, ID, Marker)
Announcements: Regular check for announcements.
Lab groups: Check lab groups for details.
Attendance: Weekly in-person lab attendance.
Absence: Contact Professor; if required.

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Description

Test your knowledge on the components of a general survey in health assessment. This quiz covers critical topics such as safety during assessments, techniques of inspection, and principles of health promotion. Enhance your understanding of nursing practices and cultural competency.