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Questions and Answers
Match the following assessment types with their corresponding descriptions:
Match the following assessment types with their corresponding descriptions:
Initial assessment = Performed within a specified time after admission to a health care agency. Problem-focused assessment = Ongoing process integrated with nursing care. Emergency assessment = During any physiological or psychological crisis of the client. Time-lapsed reassessment = Several months after initial assessment.
What are the two main categories of data collected during health assessments?
What are the two main categories of data collected during health assessments?
Which of the following is NOT a purpose of health assessment?
Which of the following is NOT a purpose of health assessment?
Open-ended questions encourage conversation and allow for detailed responses.
Open-ended questions encourage conversation and allow for detailed responses.
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Closed questions are typically used to:
Closed questions are typically used to:
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Leading questions should always be used during health assessments to ensure accurate information gathering.
Leading questions should always be used during health assessments to ensure accurate information gathering.
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What is the primary purpose of the "Weber" test in ear assessment?
What is the primary purpose of the "Weber" test in ear assessment?
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What is the primary purpose of the Snellen chart?
What is the primary purpose of the Snellen chart?
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What does the "pulse deficit" indicate?
What does the "pulse deficit" indicate?
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Auscultation for adventitious breath sounds involves listening for normal breath sounds.
Auscultation for adventitious breath sounds involves listening for normal breath sounds.
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The "Rinne" test assesses air conduction vs bone conduction.
The "Rinne" test assesses air conduction vs bone conduction.
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A normal pupil is black, round, and 1-3 mm in size.
A normal pupil is black, round, and 1-3 mm in size.
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What is the purpose of the "Romberg" test?
What is the purpose of the "Romberg" test?
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A positive "Chvostek" sign indicates tetany, a condition characterized by muscle spasms.
A positive "Chvostek" sign indicates tetany, a condition characterized by muscle spasms.
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'Murphy's Sign,' when positive, suggests which condition?
'Murphy's Sign,' when positive, suggests which condition?
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What is the most common sign of hypoglycemia?
What is the most common sign of hypoglycemia?
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Which of the following is NOT a common symptom associated with hypersecretion of adrenal glands (Cushing's disease)?
Which of the following is NOT a common symptom associated with hypersecretion of adrenal glands (Cushing's disease)?
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The 'Glasgow Coma Scale' is a neurological assessment tool used to evaluate the severity of head injuries.
The 'Glasgow Coma Scale' is a neurological assessment tool used to evaluate the severity of head injuries.
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Which of the following is a type of involuntary muscle contraction associated with hyperparathyroidism?
Which of the following is a type of involuntary muscle contraction associated with hyperparathyroidism?
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The "PQRST" approach is a standardized method for assessing a patient's pain history.
The "PQRST" approach is a standardized method for assessing a patient's pain history.
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Which type of ROM (Range of Motion) evaluation uses assistance from an external force?
Which type of ROM (Range of Motion) evaluation uses assistance from an external force?
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What is the primary purpose of "Arthrocentesis" in joint assessment?
What is the primary purpose of "Arthrocentesis" in joint assessment?
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Arthrocentesis is a therapeutic procedure that can be used to remove excess fluid from a joint.
Arthrocentesis is a therapeutic procedure that can be used to remove excess fluid from a joint.
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Which of the following diagnostic tests is considered non-invasive?
Which of the following diagnostic tests is considered non-invasive?
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Arthrocentesis is a non-invasive procedure that can be used to diagnose and treat joint infections.
Arthrocentesis is a non-invasive procedure that can be used to diagnose and treat joint infections.
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Which diagnostic test is used to visualize the internal structures of a joint using a thin fiber-optic viewing instrument?
Which diagnostic test is used to visualize the internal structures of a joint using a thin fiber-optic viewing instrument?
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The "muscle strength scale" is used to assess the strength of a patient's muscles.
The "muscle strength scale" is used to assess the strength of a patient's muscles.
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Which of the following is considered a sign of a severely dysfunctional kidney?
Which of the following is considered a sign of a severely dysfunctional kidney?
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Study Notes
Types of Assessment
- Initial assessment: Performed within a set time after admission to a healthcare facility.
- Problem-focused assessment: An ongoing process integrated with nursing care.
- Emergency assessment: Performed during a physiological or psychological crisis.
- Time-lapsed reassessment: Occurs several months after the initial assessment.
Collecting Data
-
Subjective (Symptom):
- Verbal statements from the patient (e.g., nausea, pain, fatigue, itching).
-
Objective (Signs):
- Observations that can be measured according to standard procedure (e.g., what the patient says vs. what can be seen).
Purpose of Health Assessment
- Obtain baseline physical and mental health data.
- Supplement, verify, or question data documented in the nursing history.
- Obtain data that helps establish nursing diagnoses and plan patient care.
- Evaluate the appropriateness of the nursing actions.
- Evaluate the physiological outcomes of care.
- Help nurses identify deviations from normal and potential health problems.
- Serve as a foundation for developing a patient-centered care plan.
Open Questions
- Begin with open-ended questions (e.g., "What," "Why," "When," "How," "Which").
- Encourage conversation.
- Allow the respondent to provide details.
- Can take longer, so active listening skills are necessary.
Closed Questions
- Use short, yes/no, or don't know answers.
- Short answers (e.g, what is your name?).
- Used to gather clarification
- Misplaced questions can stop conversation and lead to silence.
Leading Questions
- Based on assumptions; leading the patient towards a specific answer.
- Should not be used, especially in legal cases.
- Can bias results
- Biased leading questions render data unusable.
Components of Health History
-
Menstrual and obstetrical history (if applicable):
- Cycle length and duration.
- Pain and other symptoms.
- Number of children and childbirth type.
- Any ante-, intra-, or post-natal complications.
-
Personal history:
- Hygienic habits.
- Smoking/substance abuse.
- Dietary pattern and preferences.
- Frequency and amount of food intake.
- Allergies/Food allergies.
- Functional history (rest and sleep, intestinal and bladder habits).
Development of Empathy
- Nurses must be receptive to patients' feelings and perceptions.
- Nurses should try to understand the patient's place and communication.
Some Examples of Subjective & Objective Data
- Subjective (S): nausea, pain, fatigue and shortness of breath.
- Objective (O): Tachycardia, hyperthermia, wheezing, vomiting.
Light Palpation
- Lightly place the dominant hand over the surface of the structure being examined (less than 1-cm depression).
- Circulation, pulses, tenderness, textures, temperature.
Auscultation
- Diaphragm: detects high-pitched sounds (breath sounds, normal heart sounds, bowel sounds).
- Bell: detects lower-pitched sounds (abnormal heart sounds/murmurs).
Legal and Ethical Aspects of Health Assessment
- Maintain patient confidentiality.
- Follow HIPAA recommendations.
- Obtain informed consent.
- Adhere to professional boundaries and ethical conduct.
- Respect patient rights and cultural differences.
Assessment Sequencing
- Head-to-toe examination.
- System-wise examination (e.g., cardiovascular, respiratory).
- Emergency assessment/ABCs (airway, breathing, circulation).
Pulse (Heart Rate)
- Tachycardia: More than 100 beats per minute.
- Bradycardia: Fewer than 60 beats per minute.
- Factors affecting pulse: age, gender, exercise, fever, medications, hypovolemia/dehydration, and stress.
Pulse Rates/assessment
- Absent: Cannot be detected.
- Weak/Thready: difficult to palpate;
- Diminished: Difficult to palpate; easily obliterated with pressure.
- Full: Easily palpable; difficult to obliterate.
- Strong/Bounding: Easily palpable; cannot easily be obliterated.
- Methods: use three fingers; count heart rate (for 30 seconds and multiply by two if regular, or count for 1 full minute if irregular).
Types of Pulses
- Primary pulse: Radial pulse from inside of the wrist.
- Apical pulse: From the apex of the heart.
- Pulse deficit: Different heart beat rates from apical and radial.
Abnormal Skin Conditions
- Jaundice: Yellowing of skin and eyes due to elevated bilirubin levels, can indicate liver dysfunction.
- Paronychia: Inflammation of tissue surrounding the nail.
- Rash: Change in skin texture/color (redness, bumps or itching).
- Lesion: Area of abnormal tissue (flat or raised, varying) in size, shape, and color.
- Vesicle: Fluid-filled blister on the skin.
Visual Acuity
- Snellen chart: Progressively smaller characters, used to assess distance vision.
- Normal vision is 20/20.
Pupillary Reaction
- Normal pupils are black, round and equal in size (2-6mm).
- Pupil checked using penlight.
Cranial Nerve Testing - Extraocular Muscles
- Examiner observes all eye movements (in all directions).
- Patient asked to follow object moved 12-14 inches away from the nose.
- A stationary object is traced in an imaginary "H" shape.
Techniques & Tools for Ear Assessment
- Tuning Fork Tests: Weber & Rinne for lateralisation of sound.
- Whisper Voice Test: To assess hearing acuity by asking patient to repeat whispered words.
- Otoscopic Examination: To observe internal ear structures.
Normal Breath Sounds
- Bronchial Breathing: Higher-pitched, louder sounds (inspiration shorter than expiration).
- Bronchovesicular Breathing: Equal inspiration and expiration, no pause.
- Vesicular Breathing: Lower-pitched, gentler sounds (inspiration longer than expiration, no pause).
Adventitious Breath Sounds
- Crackles: Discontinuous, popping/bubbling sounds heard on inspiration.
- Wheezes: Continuous, high-pitched sounds heard on inspiration or expiration (asthma).
- Rhonchi: Continuous, low-pitched, snoring sounds (e.g. mucus).
- Pleural Friction Rub: Grating, creaking sound during inspiration and expiration.
- Stridor: Continuous, high-pitched crowing sound, common in upper airway obstruction.
Laboratory Investigations
- ECG: Records heart's electrical activity, used to assess rate, rhythm, and electrical strength and timing.
- Echocardiogram: Ultrasound images of the heart, used to assess blood flow and valve function.
- Cardiac markers: Troponin T/I, CK-MB, Myoglobin to diagnose heart attack-like events.
Vital Signs Measurements
- Pulse: Heart rate, assessed with the use of one or two fingers.
- Blood pressure: Pressure of blood through the blood vessels, assessed with a sphygmomanometer.
PSOAS
- Used in assessing lower abdomen (to detect inflammation from the appendix).
- Ask for pain elicited during movement.
Review or Chief Complaint
- Document patient's current complaints (e.g., pain, nausea, vomiting) related to GI system.
- Collect health history related to GI systems, surgeries, medications, family history.
- Dietary habits and food intolerances.
- Assess bowel habits, laxatives and stool consistency, and frequency.
Evaluating Nutritional Disorders
- Symptoms of common nutritional disorders (weakness and fatigue, dry scaly skin, poor turgor, etc) and their impact on the body, and the diagnosis of different types of nutritional deficiency
Laboratory Studies
- Plasma glucose (normal: 60-110mg/dL) used for diagnosis of various conditions, including dehydration and anemia.
- Hemoglobin and hematocrit (M: 14–18 g/dL; F: 12–16 g/dl) are used to measure the number of red blood cells or the measurement of iron status in the blood.
- Cholesterol (120–200 mg/dL) used to assess heart and vessel disease.
- Triglycerides (normal: 150mg/dL) used to screen for hyperlipidemia.
- Serum protein and albumin (3.5–5.5 g/dL) are sensitive indicators of protein malnutrition.
- Various vitamin and mineral levels (Serum transferrin) measure overall nutritional status.
Mid Upper Arm Circumference (MUAC)
- Estimates skeletal muscle mass and fat stores for body assessment and detection of acute malnutrition.
- Normal MUAC for 20-year-old females is 23-34 cm and 27.2-37.2 cm for males.
Common Symptoms of Urinary Disorders
- Dysuria: Pain or discomfort during urination.
- Urinary frequency: Increased need to urinate.
- Urinary urgency: Sudden, compelling urge to urinate.
Diagnostic Investigations:
- Urinalysis: Screen for various conditions, including infections and kidney disease.
- Culture and Sensitivity: Identification of pathogens and their susceptibility to antibiotics.
- Imaging Studies: (e.g., Ultrasound, CT scans): Non-invasive & detailed visualization of kidney size, structure, stones, tumors or structural issues.
- Cystoscopy: Direct visualization of the bladder and urethra for diagnosis (biopsy if needed).
- Post-Void Residual Measurement: Assess bladder emptying efficiency.
Percussion
- Percussion of the Bladder: Assess for dullness in the suprapubic area.
- Costovertebral Angle (CVA) Tenderness: Tap the area where kidneys are located for tenderness, that may indicate inflammation or infection.
How to assess a patient's pain history
- P- Provokes and Palliates
- Q- Quality
- R- Region and Radiation
- S- Severity
- T- Time
ROM Evaluation Types
- Passive ROM: Movement produced entirely by an external force.
- Active-Assistive ROM: Manual or mechanical assistance needed.
- Active ROM: Movement without assistance.
-
Equipment Use:
- Goniometer: Measures joint angle.
- Inclinometer: Measures cervical, thoracic, and lumbar spine angles.
Diagnostic Tests
- Arthrocentesis: Aspiration of synovial fluid from a joint for analysis.
- Arthroscopy: Internal inspection of a joint using an arthroscope for diagnosis or treatment.
- DEXA: Bone density examination for osteoporosis
- Skeletal X-Ray, CT and MRI: Identification of fractures, dislocations, and bone disorders (osteoporosis, fractures, etc).
Muscle Strength Scale
- Muscle strength assessed on a scale from 0–5
- (0—no muscular contraction, 1—trace contraction, 2—movement only with elimination of gravity, 3—movement against gravity but no resistance, 4—movement against gravity and some resistance and 5—movement against gravity and full examiner resistance).
Glasgow Coma Scale
- Assesses the severity of brain injury.
- Evaluates responses to stimuli (e.g., eye opening, verbal response and motor response). 3 (deep coma) to 15 (fully awake).
Pupillary Assessment
- Direct pupillary reflex: Responds to light coming through the same pupil.
- Consensual pupillary reflex: Responds to light coming through the other pupil.
- Reflexes graded & examined against expected responses and findings.
Romberg Test
- Test for assessing balance and proprioception.
- Patient stands with feet together and eyes closed.
- Positive sign if the patient loses balance.
Hyper-Parathyroid Disorders
- Tetany: General muscle tremor, contractions and involuntary muscle spasms, often caused by low calcium levels.
- Symptoms: Muscular tremors, contractions, and involuntary muscle spasms.
- Chvostek Sign: Facial spasm, caused when facial nerve is tapped.
Hypoglycaemia
- Blood sugar below 70mg/dL.
- Symptoms: cold skin, rapid heartbeat, headache, nervousness, tremors, faintness, dizziness, hunger, vision fluctuations.
Hypersecretion of Adrenal glands
- Includes symptoms such as moon face, buffalo hump, edema, thin extremities and increased risk of fractures due to osteoporosis.
- Cushing syndrome from prolonged exposure to high cortisol levels.
Diabetes Mellitus (Symptoms)
- Polyuria: Excessive urination.
- Polydipsia: Increased thirst
- Polyphagia: Excessive hunger.
- Glucosuria: Sugar in urine
- Weight loss: Loss of body weight
- Anorexia, nausea and vomiting: loss of appetite, upset stomach
- Blurring of vision: Eye problems, difficulty seeing.
- Acetone breath odor: Fruity smell on breath
- Kussmaul's Respiration: Rapid, deep breathing.
- CNS Depression: leading to coma, neurological impairment
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