NSC209 - HEALTH AND PHYSICAL ASSESSMENT SUMMARY

______ is an essential nursing function which provides foundation for quality nursing care
and intervention.
Health assessment

______ helps to identify the strengths of the clients in promoting health.

Health assessment

An accurate and thorough _______ reflects the knowledge and skills of a professional nurse.
Health assessment

An accurate and thorough health assessment reflects the ______ and skills of a professional
nurse.
Knowledge

An accurate and thorough health assessment reflects the knowledge and skills of a______.
Professional nurse

The focus of _______ care is attainment, sustenance, and recovery of health.

Nursing

The focus of _______ is attainment, sustenance, and recovery of health.

Nursing care

The focus of nursing care is attainment, sustenance, and ______of health.

Recovery

The _______ obtained from the nursing history and physical examination is used to
determine the strengths of the client or responses that the client exhibits in response to health
problem.
Information

The information obtained from the nursing history and physical examination is used to
determine the strengths of the client or responses that the client exhibits in response
to______.
Health problem

The purpose of the nursing assessment is to enable you to make a clinical judgment or
diagnosis about a client‟s health status.
True

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_______ is identified as the first step of the nursing process
Assessment

An _______ describes a hand-on data collection process, while a database identifies a

specific list of data to be collected.
Assessment

The ______ is all the health information about a client.

Database

The process of obtaining a health history and performing a physical examination is an

intimate experience for both you and the________.
Client

During the interview and physical examination your scope of focus must be more than
problems presented by the client.
True

Knowledge of the natural and ________ sciences is a strong foundation for you.
Social

Knowledge of the _______ and _________ sciences is a strong foundation for you.
Natural, Social

_______ is a systematic method of collecting data about a client for the purpose of
determining the client‟s current and ongoing health status, predicting risks to health and
identifying health-promoting activities.
Health assessment

A systematic method of collecting data about a client for the purpose of determining the
client‟s current and ongoing health status, predicting risks to health and identifying health-
promoting activities is referred to as_______
Health assessment

The following are the principles of health assessment

1. An accurate and timely health assessment provides foundation for nursing care and
intervention.
2. A comprehensive assessment incorporates information about a client‟s physiologic,
psychosocial, spiritual health, cultural and environmental factors as well as client‟s
developmental status.
3. The health assessment process should include data collection, documentation and
evaluation of the client‟s health status and responses to health problems and intervention.
4. All documentation should be objective, accurate, clear, concise, specific and current.
5. Health assessment is practiced in all healthcare settings whenever there is nurse-client
interaction.
6. Information gathered from health assessment should be communicated to other health care
professionals in order to facilitate collaborative management of clients and for continuity of
care.
7. Client‟s confidentiality should be kept.

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________ includes the interview, physical assessment, documentation, and interpretation of
findings.
Health assessment

Health assessment includes the interview, physical assessment, ______ , and interpretation of
findings.
Documentation

Health assessment includes the interview, physical assessment, documentation, and ______of
findings.
Interpretation

Health assessment includes the interview, physical assessment, documentation, and

interpretation of_______.
Findings

The data collected during an interview comes from _______and secondary sources.
Primary

The data collected during an interview comes from primary and _______sources.
Secondary

_______ is information that the client experiences and communicates to the nurse.
Subjective data

Subjective data is information that the client experiences and communicates to the________.
Nurse

Subjective data is usually referred to as_______ or symptom

Covert data

________ is usually referred to as covert (hidden) data or as a symptom, when it is perceived

by the client and cannot be observed by others.
Subjective data

The purpose of client interview is to________

Obtain a health history about the client’s past and present health state

An effective _______is a key factor in interview process

Communication

Effective communication is a key factor in ______process.

Interview
Creating a climate of trust and respect is critical to establishing a _______relationship.
Therapeutic

The purpose of _______ is to obtain information about the client‟s health in his or her own
words and based on the client‟s own perceptions.

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Health history

The________ provides cues regarding the client‟s health and guides further data collection.
Health history

The most important aspect of the assessment process is ________

Health history

The amount of time you need to complete a nursing history may vary with the format used
and your________.
Experience

The _______ interview enables you to clarify points, to obtain missing information, and to
follow up on verbal and nonverbal cues identified in the health history.
Focused

________is hand-on examination of the client.

Physical assessment

_______ is observed or measured by the professional nurse.

Objective data

Objective data is observed or measured by the_______.

Professional nurse

_______ is also known as overt data or a sign once it is detected by the nurse.
Objective data

_______ data can be seen, felt, heard, or measured by the professional nurse.
Objective data

Data that can be observed by one person and verified by another person observing the same
patient are known as_______
Objective data

_______ of data from health assessment creates a client record or becomes an addition to an
existing health record.
Documentation

Documentation must be accurate, confidential, appropriate, complete, and_______.

Detailed

_______ means that documentation is limited to facts or factual accounts of observations.

Accuracy

______ can be defined as making determination about all of the data collected in the health
assessment process.
Interpretation of findings

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_______ are used by nurses to gather information about a patient's condition.
Health assessments

The role of nurses in health assessment include the following

 Nursing Diagnoses and Care Planning
 Managing Problems
 Evaluation
 Discharge Teaching
 Advocate

A _______ takes note of actual or potential problems her patient may have during a health
assessment.
Nurse

_______ of a patient's health status is done through health assessments.

Evaluation

_______ determine if a patient has responded to nursing care sufficiently enough to be

recommended for discharge.
Evaluations

______is the first step of the nursing process

Assessment

The first step of the nursing process is known as______

Assessment

An _______describes a hands-on data collection process.

Assessment

A ______includes a detailed health history and physical examination of one body system or
many body systems
comprehensive assessment

A comprehensive or complete health assessment usually begins with obtaining a thorough

health history and ______exam.
Physical

A ________ is a more abbreviated assessment used to evaluate the status of previously

identified problems and monitor for signs of new problems.
Focused assessment

The advantage of an abbreviated assessment is that_______

It allows you to thoroughly assess your patient in a shorter period of time

The report of pain is a ________

Social transaction

The report of _______is a social transaction

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Pain

Pain is essential in comprehensive health assessment.

True

Pain can be acute and chronic, severe or mild

________ is a complex multidimensional experience.

Pain

Pain is a complex multidimensional_______.

Experience

Pain is one of the major reasons that people seek health care.
True

The International Association for the Study of Pain (IASP) defines ______ as “an unpleasant
sensory and emotional experience associated with actual or potential tissue damage or
described in terms of such damage”.
pain

IASP means_______
International Association for the Study of Pain

_______ is defined as an unpleasant sensory and emotional experience associated with actual
or potential tissue damage or described in terms of such damage
Pain

The intensity of pain is most accurately assessed with_______.

pain rating scales

Quality of pain is assessed by _______

Asking the client to apply an adjective to the pain

The ______of pain refers to the onset and duration of the pain experience.
Pattern

The following are factors which precipitate pain

 Activity
 Exercise
 Temperature
 Climatic Changes

The _______ provides information about the patient‟s prior state of health.
Past health history

________ is the systematic assessment of the physical and mental status of a patient, and
findings are considered objective data.
Physical examination

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________ is the process of obtaining information about patient‟s health status through
communication.
Nursing history

The four major techniques used in performing the physical examination are

 Inspection
 Palpation
 Percussion
 Auscultation

________ is the visual examination of a part or region of the body to assess normal
conditions and deviations from normal.
Inspection

_______ is the examination of the body through the use of touch.

Palpation

Palpation is the examination of the _______ through the use of touch.

Body

Palpation is the examination of the body through the use of________.

Touch

_______ is an assessment technique involving the production of sound to obtain formation

about the underlying area.
Percussion
Percussion is an assessment technique involving the production of _______ to obtain
formation about the underlying area.
Sound

_______ is listening to sounds produced by the body to assess normal conditions and
deviations from normal.
Auscultation

The process used for the assessment of hyperresonance over inflated lung tissue in a patient
with emphysema is_______
Auscultation

_______is usually performed with a stethoscope.

Auscultation

Auscultation is usually performed with a_______.

Stethoscope

_______ is particularly useful in evaluating sounds from the heart, lungs, abdomen and
vascular system.
Auscultation

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Auscultation is particularly useful in evaluating sounds from the______, lungs, abdomen and
vascular system.
heart

Auscultation is particularly useful in evaluating sounds from the heart, ______, abdomen and
vascular system.
lungs

Auscultation is particularly useful in evaluating sounds from the heart, lungs, ______and
vascular system.
abdomen

Auscultation is particularly useful in evaluating sounds from the heart, lungs, abdomen
and_______.
Vascular system

The _______ of the stethoscope is more sensitive to low-pitched sounds

Bell

The bell of the _______ is more sensitive to low-pitched sounds

Stethoscope

The _______ of the stethoscope is more sensitive to hig-pitched sounds.

Diaphragm

The diaphragm of the stethoscope is more sensitive to _______sounds.

hig-pitched

The bell of the stethoscope is more sensitive to_______ sounds

low-pitched

The integumentary system comprises of the skin, hair, and ______

nails

The ______ for the integumentary system concerns data related to the structures and
functions of that system.
Focused interview

Physical assessment of the ear consists of ______ parts

Three

Physical assessment of the ear consists of three parts

 Auditory screening
 Inspection and palpation of the external ear
 Otoscopic assessment

The general approach to heart assessment

 Explain to the patient what you are going to do
 Ensure that the room is warm, quite, well lit

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  Expose the patient‟s chest only as much as is needed for the assessment
 Position the patient in supine or sitting position
 Stand to the patient‟s right side

The cardiovascular physical assessment has two major components

 Assessment of the pericardium
 Assessment of the periphery

Behaviors indicative of ______ include facial grimace, moaning, crying or screaming,

guarding or immobilization of a body part, tossing and turning, and rhythmic movements.
Pain

The nails should have a _______undertone and lie flat or form a convex curve on the nail bed
Pink

When viewed laterally, the angle between the skin and the nail base should be
approximately______ degrees.
160

The process used for the assessment of hyperresonance over inflated lung tissue in a patient
with emphysema is_______
Auscultation

Using eleven functional health patterns, the processes of ingestion, digestion, absorption, and
metabolism are assessed in________
Nutritional Metabolic Pattern

Types of assessment that are used to obtain information about a client are comprehensive,
focused, and_______
Emergency

The purpose of the nursing assessment is to make a ______about a client‟s health status.
clinical judgment

Data that can be observed by one person and verified by another person observing the same
patient are known as________
objective data

The bell of the stethoscope is used for ______sounds

low-pitched

The pulmonic area is the second intercostals space (ICS) to the_________

right of the sternum

ICS stands for_______

second intercostals space

Percussion has limited usefulness in the______ because X rays and other diagnostic tests
provide the same information in a much more accurate manner

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cardiovascular assessment

In Asian cultures, breast selfexamination may be considered a form of_______

Masturbation

In ______ cultures, breast selfexamination may be considered a form of masturbation

Asian

In Asian______, breast selfexamination may be considered a form of masturbation

cultures

Physical assessment of the ear consists of auditory screening, inspection and palpation of the
external ear and______
otoscopic assessment

Assessment of the eyes should be carried out in an orderly fashion, moving from the
extraocular structures to the______
intraocular structures

______ is used to determine exact ROM in joints with limited ROM

Goniometer

Physical assessment of the neurologic system proceeds in a_______ and distal to proximal
pattern
Cephalocaudal

Physical assessment of the neurologic system begins with assessment of the client‟s_______
mental status

Schamroth techniques are used to assess_______

Clubbing

Localized hot, red, swollen painful areas indicate the presence of_______ and possible
infection.
Inflammation

_______ is produced when bacterial waste products mix with perspiration on the skin surface.
Body odor

Gray hair can occur as a result of decreased melanin,_______ or aging.

Genetics

Hair color is determined by the amount of_______

Melanin

The________ is sensitive to touch and temperature

skin

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In physical assessment of the integumentary system, the techniques of inspection and______
will be used
Palpation

Listening to sounds produced by the body to assess normal conditions and deviations from
normal is done through_______
Auscultation

_______ of the stethoscope is more sensitive to high-pitched sounds.

The diaphragm

Auscultation is usually performed with a________

Stethoscope

The usual percussion sound in the right lower quadrant of the abdomen is________
Tympany

________ is an assessment technique involving the production of sound to obtain formation

about the underlying area
Percussion

The tips of the fingers can be used to palpate________

lymph nodes

The dorsa (back) of the hands and fingers can be used to assess________
Temperatures
_______ is the visual examination of a part or region of the body to assess normal conditions
and deviations from normal
Inspection

________ is observed or measured by the professional nurse

Objective data

_________ is hand-on examination of the client

Physical assessment

Perception of pain, nausea, dizziness, itching sensations, or feeling nervous are examples
of_______
Subjective data

_______is information that the client experiences and communicates to the nurse
Subjective data

The primary source from which data is collected is________

The client

Assessment is_______ step of nursing process

First

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Objective data is obtained through________ to determine the patient‟s physical status,
limitations, and assets.
physical examination

Functional health patterns format includes an initial collection of important health

information followed by assessment of______ areas of health status or function
Eleven

Functional health patterns format for taking Nursing history was developed by________
Gordon

Subjective data is gathered during________

Interview

The nursing health assessment is used to support the identification of a________

Nursing diagnosis

________ is a systematic data collection

Health assessment

This part of the body is more sensitive to vibrations_______

Palmar surface

The „gold standard‟ for assessing the existence of pain is_______

Client selfreport

The part of the body that is more sensitive to vibrations is________

Palmar surface

The „gold standard‟ for assessing the existence of pain is_______

Client selfreport

The step of the nursing process that includes data collection by health history, physical
examination, and interview is_________
Assessment

________ is used for head-to-toe assessment.

Comprehensive Assessment

________ includes an assessment related to a specific problem

Focused Assessment

Detailed assessment that focuses on one or more body systems, including those not directly
involved in presenting problem or admission diagnosis is_______
Comprehensive Assessment

_______ determine if a patient has responded to nursing care sufficiently enough to be

recommended for discharge
Evaluations

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Blood pressure, pulse rate, blood counts, and age are examples of________
Variable data

_______ is information that does not change over time such as race, sex, or blood type
Constant data

A _______ is used as a guide for establishing a comprehensive nursing database.

systems approach

Health assessment is an essential nursing function which provides foundation for quality
nursing _______ and intervention.
care

Health assessment is an essential nursing function which provides foundation for quality
nursing care and______.
intervention

Health assessment helps to identify the ______ of the clients in promoting health.
strengths

Health assessment helps to identify the strengths of the _______ in promoting health.
clients

Health assessment helps to identify the strengths of the clients in promoting_______.

health

An accurate and thorough ______ reflects the knowledge and skills of a professional nurse.
health assessment

An accurate and thorough health assessment reflects the _______ and skills of a professional
nurse.
knowledge

An accurate and thorough health assessment reflects the knowledge and _______ of a
professional nurse.
skills

An accurate and thorough health assessment reflects the knowledge and skills of a ______
nurse.
professional

An accurate and thorough health assessment reflects the knowledge and skills of a
professional_______ .
nurse

An accurate and thorough health assessment reflects the knowledge and skills of a_______.
professional nurse

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The focus of ______ is attainment, sustenance, and recovery of health.
nursing care

The focus of nursing care is______, sustenance, and recovery of health.

attainment

The focus of nursing care is attainment, _______, and recovery of health.

sustenance

The focus of nursing care is attainment, sustenance, and_______.

recovery of health

The focus of nursing care is attainment, sustenance, and recovery of_______.

health

The _______ of nursing care is attainment, sustenance, and recovery of health.

focus

The information obtained from the nursing history and physical examination is used to
determine the strengths of the client or responses that the client exhibits in response
to______.
health problem

The information obtained from the ______ and physical examination is used to determine the
strengths of the client or responses that the client exhibits in response to health problem.
nursing history

The information obtained from the nursing history and ______ is used to determine the
strengths of the client or responses that the client exhibits in response to health problem.
physical examination

The _______ obtained from the nursing history and physical examination is used to
determine the strengths of the client or responses that the client exhibits in response to health
problem. information

The purpose of the nursing assessment is________

to enable you to make a clinical judgment or diagnosis about a client’s health status

The purpose of the nursing assessment is to enable you to make a _______ judgment or
diagnosis about a client‟s health status.
clinical

The purpose of the nursing assessment is to enable you to make a clinical judgment or
_______ about a client‟s health status.
diagnosis

The purpose of the nursing assessment is to enable you to make a clinical judgment or
diagnosis about a client‟s_______.
health status

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The purpose of the nursing assessment is to enable you to make a clinical judgment or
diagnosis about a client‟s health_______.
status

_______ is identified as the first step of the nursing process

Assessment

_______ is performed continuously throughout the nursing process to validate nursing

diagnoses, evaluate client‟s response to nursing interventions, and determine the extent to
which client outcomes and goals have been met.
Assessment

________ describes a hand-on data collection process

An assessment

A ________ identifies a specific list of data to be collected.

database

The ______ is all the health information about a client.

database

The database is all the _______ information about a client.

health

The database is all the health ______ about a client.

information

The database is all the health information about a_______.

client

_______ includes the nursing history and physical examination, the medical history, and
physical examination, results of laboratory and diagnostic tests, and information contributed
by other health professionals.
Database

The process of obtaining a health history and performing a physical examination is an

intimate ________ for both you and the client.
experience

During the interview and physical examination, you need to be ______ to issues of eye
contact, space, modesty, and touching.
sensitive

During the interview and physical examination, you need to be sensitive to issues of_______,
space, modesty, and touching.
eye contact

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During the interview and physical examination, you need to be sensitive to issues of eye
contact, _______, modesty, and touching.
space

During the _______ and physical examination, you need to be sensitive to issues of eye
contact, space, modesty, and touching.
interview

During the interview and physical examination, you need to be sensitive to issues of eye
contact, space, modesty, and________.
touching

During the interview and physical examination, you need to be sensitive to issues of eye
contact, space, _______, and touching.
modesty

During the interview and_______, you need to be sensitive to issues of eye contact, space,
modesty, and touching.
physical examination

Your scope of focus must be more than problems presented by the client.
True

________ of the natural and social sciences is a strong foundation for you.
Knowledge

Knowledge of the _______ and social sciences is a strong foundation for you.
natural

Knowledge of the natural and ______ sciences is a strong foundation for you.
social

Knowledge of the natural and social sciences is a strong _______ for you.
foundation

________ techniques and use of critical thinking skills are essential in helping you to gather
detailed, complete, relevant, objective, subjective, and measurable data needed to formulate a
plan of care to meet the needs of the client.
Effective communication

_________ communication techniques and use of critical thinking skills are essential in
helping you to gather detailed, complete, relevant, objective, subjective, and measurable data
needed to formulate a plan of care to meet the needs of the client.
Effective

Effective _______ techniques and use of critical thinking skills are essential in helping you to
gather detailed, complete, relevant, objective, subjective, and measurable data needed to
formulate a plan of care to meet the needs of the client.
communication

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Ask appropriate _______ when conducting a comprehensive health history to elicit data that
will be used to guide a physical examination
questions

Ask appropriate questions when conducting a comprehensive ______ history to elicit data
that will be used to guide a physical examination
health

Ask appropriate questions when conducting a comprehensive health ______ to elicit data that
will be used to guide a physical examination
history

Ask appropriate questions when conducting a comprehensive health history to elicit data that
will be used to guide a _______ examination
physical

List the components of the comprehensive physical examination and review of systems based
on ______ flags identified in the patient history
red

Collect _____ data about the client.

objective

Collect objective _____ about the client.

data

Collect ______ about the client.

objective data

Collect objective data about the_______.

client

_______ are observable or measurable pieces of information.

Objective data

Objective data can be______, heard, touched, or smelled.

seen

Objective data can be seen, _______, touched, or smelled.

heard

Objective data can be seen, heard, _______, or smelled.

touched

Objective data can be seen, heard, touched, or______.

smelled

_______ data can be seen, heard, touched, or smelled.

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Objective
Examples of objective data are________
color of urine, vital signs, moisture on skin and breath color

________ data are experiences only the client can describe

Subjective

Collect ______ data from the client.

subjective

Examples of subjective data are _______

nausea, pain, and itching

Collect information about the client‟s ________

family, community, culture, ethnicity, and religion

Identify past and present client ______ that support health or increase the risk of illness.
behaviors

Identify past and present client behaviors that support health or increase the risk of_______.
illness

Identify ______ and______ client behaviors that support health or increase the risk of illness.
past and present

Identify _____ that suggest risk for or actual health problems.

data

Identify past and present client behaviors that support health or increase the______.
risk of illness

A systematic method of collecting data about a client for the purpose of determining the
client‟s current and ongoing health status, predicting risks to health, and identifying health-
promoting activities is called______
Health assessment

During nursing history, interview and physical examination, you will obtain data to support
the _______ of a nursing diagnosis.
identification

During nursing history, interview and physical examination, you will obtain data to support
the identification of a nursing_______.
diagnosis

During nursing______, interview and physical examination, you will obtain data to support
the identification of a nursing diagnosis.
history

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During nursing history, ______ and physical examination, you will obtain data to support the
identification of a nursing diagnosis.
interview

During nursing history, interview and_____, you will obtain data to support the identification
of a nursing diagnosis.
physical examination

During nursing history, interview and physical examination, you will obtain data to support
the identification of a ______ diagnosis.
nursing

During nursing history, interview and physical examination, you will obtain data to support
the identification of a______.
nursing diagnosis

The health status will include _______

wellness behaviors, illness signs and symptoms, client strengths and weakness, and risk
factors

All ______ should be objective, accurate, clear, concise, specific and current.
documentation

All documentation should be ______

objective, accurate, clear, concise, specific and current

All documentation should be objective, accurate, clear, concise, specific and_______.

current

_______is practiced in all healthcare settings whenever there is nurse-client interaction.

Health assessment

Health assessment is practiced in all ______ settings whenever there is nurse-client

interaction.
healthcare

Health assessment is practiced in all healthcare settings whenever there is ______ interaction.
nurse-client

Information gathered from ______ should be communicated to other health care

professionals in order to facilitate collaborative management of clients and for continuity of
care.
health assessment

______ confidentiality should be kept.

Client’s

Client‟s ______ should be kept.

confidentiality

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Health assessment includes the______, physical assessment, documentation, and
interpretation of findings.
interview

Health assessment includes the interview, ______, documentation, and interpretation of

findings.
physical assessment

Health assessment includes the interview, physical assessment, ______, and interpretation of
findings.
documentation

Health assessment includes the interview, physical assessment, documentation, and______.

interpretation of findings

Health assessment includes the following

 interview
 physical assessment
 documentation
 interpretation of findings

The primary source from which data is collected is the_______

client

_______ is information that the client experiences and communicates to the nurse
Subjective data

Perception of pain, nausea, dizziness, itching sensations, or feeling nervous are examples
of_______.
subjective data

Perception of pain, nausea, dizziness, itching sensations, or feeling nervous are examples of
_______ data.
subjective

_______ of pain, nausea, dizziness, itching sensations, or feeling nervous are examples of
subjective data.
Perception

_______ is usually referred to as covert (hidden) data or as a symptom, when it is perceived

by the client and cannot be observed by others.
Subjective data

The purpose of _______ is to obtain a health history about the client‟s past and present health
state.
client interview

The purpose of client interview is______

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to obtain a health history about the client’s past and present health state

______ communication is a key factor in interview process.

Effective

Effective ______ is a key factor in interview process.

communication

_______ is a key factor in interview process.

Effective communication

Effective communication is a key factor in_______.

interview process

Creating a climate of ______ and respect is critical to establishing a therapeutic relationship.

trust

Creating a climate of trust and ______ is critical to establishing a therapeutic relationship.

respect

Creating a climate of trust and respect is critical to establishing a ______ relationship.

therapeutic

Creating a _______of trust and respect is critical to establishing a therapeutic relationship.

climate

_______ and______ are critical to establishing a therapeutic relationship.

Trust and respect

In addition to understanding the principles of effective communication, you need to develop a

_______ style of relating to clients.
personal

The purpose of the ______ is to obtain information about the client‟s health in his or her own
words and based on the client‟s own perceptions.
health history

The purpose of the health history is _______

to obtain information about the client’s health in his or her own words and based on the
client’s own perceptions

Biographical data, perceptions about health, past and present history of illness and injury,
family history, a review of systems, and health patterns and practices are the types of
information included in the______.
health history

The ______ provides cues regarding the client‟s health and guides further data collection.
health history

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The _______ is most important aspect of the assessment process.
health history

The health history is most important aspect of the ______ process.

assessment

The amount of time you need to complete a ______ may vary with the format used and your
experience.
nursing history

The amount of time you need to complete a nursing history may vary with the ______ used
and your experience.
format

The amount of time you need to complete a nursing history may vary with the format used
and your______.
experience

When a client is unable to provide the necessary data (e.g., unconscious or aphasic), you ask
the ______ to provide as much information as possible.
caregiver

Inform clients that ______ affects the electronic exchange, privacy, and security of an
individual‟s health information.
federal legislation

You need to judge the ______ of the client as a historian.

reliability

You need to judge the reliability of the ______ as a historian.

client

You need to judge the reliability of the client as a_______.

historian

You need to _____ the reliability of the client as a historian.

judge

An older adult may give a false impression about his or her mental status because________
of a prolonged response time or visual and hearing impairments

It is important for you to determine the client‟s ______concerns and expectations.

priority

It is important for you to determine the client‟s priority concerns and______.

expectations

Occasionally there is a lack of _____ between your priorities and those of the client.
congruency

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The ______ enables you to clarify points, to obtain missing information, and to follow up on
verbal and nonverbal cues identified in the health history.
focused interview

You need not use a prepared set of questions for the_______.

focused interview

You need not use a prepared set of questions for the focused interview.
True

The ______ provides the means and opportunity to expand the subjective database regarding
specific strengths, weaknesses, problems, or concerns expressed by the client or required by
the nurse to begin to make reliable judgments about information and observations as part of
planning care.
focused interview

_______ is hand-on examination of the client.

Physical assessment

Components of physical assessment are the ______ and examination of systems.

survey

Components of physical assessment are the survey and______.

examination of systems

_______ gathered during physical assessment, when combined with all other reliable sources
of information, provides a sound database from which care planning may proceed.
Objective data

Objective data gathered during______, when combined with all other reliable sources of
information, provides a sound database from which care planning may proceed.
physical assessment

_______ is observed or measured by the professional nurse.

Objective data

_______ data is observed or measured by the professional nurse.

Objective

Objective data is observed or measured by the professional_______.

nurse

Objective data is observed or measured by the_______.

professional nurse

The objective data observed or measured by the professional nurse is also known as______
overt data

Page 23
Both subjective and objective data may further be categorized as ______ or variable.
constant

Both subjective and objective data may further be categorized as constant or_______.
variable

_______ is information that does not change over time such as race, sex, or blood type.
Variable data may change within minutes, hours, or days.
Constant data

Blood pressure, pulse rate, blood counts, and age are examples of_______.
variable data

______ of data from health assessment creates a client record or becomes an addition to an
existing health record.
Documentation

The ______ is a legal document used to plan care, to communicate information between and
among healthcare providers, and to monitor quality of care.
client record

The ______ provides information used for reimbursement of services, is often a source of
data for research, and is reviewed by accrediting agencies to determine adherence to
standards.
client record

Documentation must be_______

accurate, confidential, appropriate, complete, and detailed

When______, you must use standard and accepted abbreviations, symbols, and terminology
and must reflect professional and organizational standards.
documenting

______ means that documentation is limited to facts or factual accounts of observations.

Accuracy

Accuracy means that ______

documentation is limited to facts or factual accounts of observations

Accuracy means that _______ is limited to facts or factual accounts of observations.

documentation

When recording subjective data, it is important to use ______ and quote a client exactly
rather than interpret the statement.
quotation marks

In______, accuracy requires the use of accurate measurement and location of symptoms and
physical findings.
health assessment

Page 24
In health assessment, ______ requires the use of accurate measurement and location of
symptoms and physical findings.
accuracy

_______ can be defined as making determination about all of the data collected in the health
assessment process.
Interpretation of findings

______ must be systematically obtained and organized in such a manner that you can readily
analyze and make a judgment about the client‟s health status and any health problems.
Assessment data

______ are used by nurses to gather information about a patient's condition.

Health assessments

A ______ takes note of actual or potential problems her patient may have during a health
assessment.
nurse

A nurse takes note of actual or potential problems her patient may have during a_____.
health assessment

_______ of a patient's health status is done through health assessments.

Evaluation

_______ determine if a patient has responded to nursing care sufficiently enough to be

recommended for discharge.
Evaluations

You should regularly perform ______ assessments in response to client needs.

focused

The ______ needs to obtain client‟s consent prior to health assessment.

nurse

The nurse needs to obtain client‟s ______ prior to health assessment.

consent

The nurse needs to obtain client‟s consent prior to______.

health assessment

_______ is a systematic, deliberative and interactive process by which nurses use critical
thinking to collect, validate, analyze and synthesize the collected information in order to
make judgments about the health status and life processes of individuals, families and
communities.
Health assessment

_______ is the first step of the nursing process.

Page 25
Assessment

_______ is the orderly collection of information concerning the patient‟s health status.
Assessment

_______ describes a hands-on data collection process.

An assessment

A ______ includes a detailed health history and physical examination of one body system or
many body systems
comprehensive assessment

A ______ or complete health assessment usually begins with obtaining a thorough health
history and physical exam.
comprehensive

A comprehensive or ______ usually begins with obtaining a thorough health history and
physical exam.
complete health assessment

A ______ is a more abbreviated assessment used to evaluate the status of previously

identified problems and monitor for signs of new problems.
focused assessment
The advantage of an abbreviated assessment is that______
it allows you to thoroughly assess your patient in a shorter period of time

_______ in a hospital inpatient setting demands a high degree of consistency among different
health care professionals.
Assessment

Assessment in a ______ inpatient setting demands a high degree of consistency among

different health care professionals.
hospital

At any time during the assessment the client may report a ______ such as pain, fatigue, or
weakness.
symptom

_______ provides foundation for quality nursing care and intervention.

Health assessment

Health assessment provides foundation for quality nursing care and_______.

intervention

Health assessment provides foundation for quality ______and intervention.

nursing care

_______ helps to identify the strengths of the clients in promoting health.

Health assessment

Page 26
An assessment describes a ______data collection process.
hands-on

An assessment describes a hands-on_______ collection process.

data

An assessment describes a hands-on data ______ process.

collection

______ types of assessment are used to obtain information about a client.

Three

The types of assessment used to obtain information about a client are_______

comprehensive, focused, and emergency

The ______ of pain is a social transaction

report

The report of ______ is a social transaction

pain

The report of pain is a ______ transaction

social

The highly subjective nature of pain makes pain assessment and management challenges for
every______.
clinician

_______ is essential in comprehensive health assessment.

Pain

Pain is essential in comprehensive_______.

health assessment

_______ is an entirely subjective and personal experience.

Pain

Pain is an entirely _____ and personal experience.

subjective

Pain is an entirely subjective and ______ experience.

personal

______ is a complex multidimensional experience.

Pain

Pain is a _____ multidimensional experience.

complex

Page 27
Pain is a complex ______experience.
multidimensional

Pain is a complex multidimensional______.

experience

_______ is one of the major reasons that people seek health care.
Pain

Pain is one of the major reasons that people seek health care.
True

Pain is categorized as ______ or neuropathic based on underlying pathology.

nociceptive

Pain is categorized as nociceptive or ______ based on underlying pathology.

neuropathic

Most components of a pain assessment involve ______ or observation of the patient.

direct interview

Most components of a pain assessment involve direct interview or ______ of the patient.
observation

______ and physical examination findings complete the initial assessment.

Diagnostic studies

Diagnostic studies and ______ findings complete the initial assessment.

physical examination

Diagnostic studies and physical examination findings complete the_______.

initial assessment

_______ the specific words that the patient uses to describe pain.
Document

Document the specific ______ that the patient uses to describe pain.
words

Document the specific words that the patient uses to describe_______.

pain

Pain assessment consists of ______ phases.

two

Pain assessment consists of two phases: _______and_______

pain history and observation of behaviors and response to pain

Page 28
A ______ includes collection of data about the location, intensity, quality, pattern,
precipitating factors, actions aimed at relief of pain, impact on activities of daily living
(ADLs), coping strategies, and emotional responses.
pain history

You should ask the client to point the specific ______of pain.
location

_______ in which body outlines are depicted are a useful method for children and adults to
accurately identify the site of pain.
Charts
When recording the_____, the body outline chart may be used.
location

When recording the location, the ______outline chart may be used.

body

When recording the location, the body outline ______ may be used.
chart

When recording the location, the ______ chart may be used.

body outline

The ______ of pain is most accurately assessed with pain rating scales.
intensity

The intensity of ______ is most accurately assessed with pain rating scales.
pain

The intensity of pain is most accurately assessed with pain rating_______.

scales

______ accompany the number rating in many scales.

Descriptors

The ______ assist the client to “quantify” the intensity of the pain.
descriptors

The descriptors assist the client to ______ the intensity of the pain.
quantify

The descriptors assist the client to “quantify” the _____ of the pain.
intensity

The descriptors assist the _____ to “quantify” the intensity of the pain.
client

The descriptors assist the client to “quantify” the intensity of the______.

pain

Page 29
_______ accompany each facial expression so that pain intensity can be identified.
Number

________ of pain is assessed by asking the client to apply an adjective to the pain.
Quality

______ is assessed by asking the client to apply an adjective to the pain.

Quality of pain

The _____ refers to the onset and duration of the pain experience.
pattern of pain

The pattern of pain refers to______

the onset and duration of the pain experience

The ______ assesses whether the pain is constant or intermittent.

nurse

If the pain is______, the nurse must assess the length of time without pain or between
episodes of pain.
intermittent

The nurse attempts to identify ______ employed by the client to determine if they are
effective in pain management.
coping strategies

An assessment of the client‟s _______to pain is important.

emotional response

The ______ to pain is often related to the type, intensity, and duration of pain.
emotional response

The ______ phase of pain assessment includes the direct observation of the client‟s behavior
and physiological responses.
observation

Behaviors indicative of pain include______

 facial grimace
 moaning
 crying or screaming
 guarding or immobilization of a body part
 tossing and turning
 rhythmic movements

The site of the pain and the duration of the pain influence _____to pain.
physiological responses

The ______ nervous system is stimulated in the early stage of acute pain.
sympathetic

Page 30
The ______ is stimulated in the early stage of acute pain.
sympathetic nervous system

The sympathetic nervous system is stimulated in the early stage of ______pain.

acute

The sympathetic nervous system is stimulated in the ______ stage of acute pain.
early

______ consists of important health information and client‟s functional health pattern.
Nursing history

The ______ provides information about the patient‟s prior state of health.
past health history

_______ frequently do not consider herbal products and dietary supplements as drugs.
Clients

Clients frequently do not consider _____ and dietary supplements as drugs.

herbal products

Clients frequently do not consider herbal products and ______ as drugs.

dietary supplements

Clients frequently do not consider herbal products and dietary supplements as______.
drugs

Older adult patients, in particular, should be questioned about ______ routines.

medication

Record all ______ along with the date of the event, the reason for the surgery, and the
outcome.
surgeries

Record all surgeries along with the date of the event, the ______ for the surgery, and the
outcome.
reason

Record all surgeries along with the date of the event, the reason for the_____, and the
outcome.
surgery

Record all surgeries along with the date of the event, the reason for the surgery, and
the______.
outcome

______ all surgeries along with the date of the event, the reason for the surgery, and the
outcome.

Page 31
Record

Be sure to ask about and record any ______ products that the client may have received.
blood

_______ may play a role in who the patient selects as the primary health care provider.
Culture

Obtain a _____ dietary recall from the patient.

24-hour

Obtain a 24-hour ______recall from the patient.

dietary

Obtain a _______-hour dietary recall from the patient.

24

Assess the impact of ______ factors such as depression, anxiety, and self-concept on
nutrition.
psychological

Assess the impact of psychological factors such as______, anxiety, and self-concept on
nutrition.
depression

Assess the impact of psychological factors such as depression, ______, and self-concept on
nutrition.
anxiety

Assess the impact of psychological factors such as depression, anxiety, and ______ on
nutrition.
self-concept

Assess the impact of psychological factors such as depression, anxiety, and self-concept
on______.
nutrition

Ask the client about the frequency of ______ and bladder activity.
bowel

Ask the client about the ______ of bowel and bladder activity.
frequency

Ask the client about the frequency of bowel and ______ activity.
bladder

The ______ is assessed again in the elimination pattern in terms of its excretory function.
skin

Page 32
The skin is assessed again in the elimination pattern in terms of its ______function.
excretory

The skin is assessed again in the ______ pattern in terms of its excretory function.
elimination

Assess the client‟s usual pattern of______, activity, leisure, and recreation.
exercise

Assess the client‟s usual pattern of exercise, activity, ______, and recreation.
leisure

Assess the client‟s usual pattern of exercise, _______, leisure, and recreation.
activity

Assess the client‟s usual pattern of exercise, activity, leisure, and_______.

recreation

_______ describes the client‟s perception of his or her pattern of sleep, rest, and relaxation in
a 24-hour period.
Sleep-rest pattern

Assessment of _______involves a description of all the senses and the cognitive functions.
cognitive-perceptual pattern

______ describes the client‟s self-concept which is critical in determining the way the person
interacts with others.
Self-perception-self-concept pattern

_______ describes the roles and relationship of client, including major responsibilities.
Role-relationship pattern

Ask the client to describe______, social, and work relationships.

family

Ask the client to describe family, ______, and work relationships.

social

Ask the client to describe family, social, and ______ relationships.

work

Ask the client to describe family, social, and work_______.

relationships

______ describes satisfaction or dissatisfaction with personal sexuality and describes the
reproductive pattern.
Sexuality-reproductive pattern

Page 33
________ describes the client‟s general coping pattern and the effectiveness of the coping
mechanisms.
Coping-stress tolerance pattern

________ describes the values, goals, and beliefs (including spiritual) that guide health-
related choices.
Value-belief pattern

Throughout the______, explore any positive findings using the same criteria as the
investigation of a symptom during the nursing history.
physical examination

A pertinent ______ is the absence of a sign or symptom usually associated with a problem.
negative

A pertinent negative is______

the absence of a sign or symptom usually associated with a problem

During ______ there is direct contact with the patient in attempt to further obtain information
about the patient through the use of senses.
physical examination

The _______ is a statement of general impression of a patient, including behavioral

observations.
general survey

______ major techniques are used in performing the physical examination

Four

The following are the techniques used in performing physical examination

 inspection
 palpation
 percussion
 auscultation

Following the nursing history, make ______ statement.

general survey

The ______ is a statement of general impression of a patient, including behavioral

observations.
general survey

BMI stands for______

body mass index

______ is the visual examination of a part or region of the body to assess normal conditions
and deviations from normal.
Inspection

Page 34
Inspection is the ______ examination of a part or region of the body to assess normal
conditions and deviations from normal.
visual

Inspection is more than just looking.

True

______ technique is deliberate, systematic, and focused.

Inspection

Avoid unnecessary changes in______.

position

The nurse may use ______or open-ended questions to obtain information.

closed

The nurse may use closed or ______questions to obtain information.

open-ended

______ related to the condition of the skin, hair, and nails are gathered during the focused
interview.
Subjective data

A warm, private environment will reduce client ______

anxiety

Maintain the client‟s ______ by using draping techniques.

dignity

Maintain the client‟s dignity by using ______ techniques.

draping

A quick ______ enables the nurse to identify any immediate problem and the client‟s ability
to participate in the assessment.
survey

_______ is a combination of turgor and mobility

Elasticity

Elasticity is a combination of ______and mobility

turgor

Elasticity is a combination of turgor and _____

mobility

Grade any _______ on a four-point scale.

edema

Grade any edema on a _____-point scale.

Page 35
four

Document _____in centimeters.

lesion size

Document lesion size in______.

centimeters

______ the skin in various regions of the body and ask the client to describe the sensations.
Palpate

Palpate the skin in various regions of the body and ask the client to describe the______.
sensations

_______ is influenced by genetics and may begin as early as the late teens in some clients.
Graying

Graying is influenced by ______ and may begin as early as the late teens in some clients.
genetics

When viewed laterally, the angle between the skin and the nail base should be approximately
_______ degrees.
160

The ______ are smooth and flat in healthy nails.

cuticles

The cuticles are ______ and_____ in healthy nails.

smooth and flat

The cuticles are smooth and flat in healthy______.

nails

Physical assessment in neurological examination is guided by _____interview

Focused

Physical assessment requires the use of 3 tools namely________,

Inspection

The nurse gathers _____data

Objective

The patient gives_______ data

Subjective

_______ is for examining the interior structure of the eye

Ophthalmoscope

_______ communication is a key factor in interview process

Page 36
Effective

The _____ history is most important aspect of the assessment process

Health

You need not use a prepared set of questions for the ______ interview
Focused

During______ assessment is done by rapid, specific questioning of a client

Emergency

The subjective nature of ______ makes its assessment and management challenges for every
clinician
Pain

The evaluation of pain should always be______

Multidimensional

The pain ______ is most accurately assessed with pain rating scales
Intensity

______ is the visual examination of a part or region of the body to assess normal conditions
and deviations from normal.
Inspection

Palpation is the examination of the body through the use of_____

Touch

Increase or decrease pigmentation of skin is caused by differences in the distribution

of______ throughout the body
Melanin

We use the _____ surface of fingers and finger pads when palpating for texture.
Palmar

When palpating skin for _______, the client should not report any discomfort from your
touch
Sensitivity

When assessing for hygiene, confirm the ______ are clean and well groomed
Nails

The nurse should assess the _____ health status of a client when meeting him for the first
time
Mental

You are advised to examine the _____ parts of the body first
Non-affected

Page 37
You are required to stand _____ of the patient
In front

While ______the neck, it is important to assess for limitation of motion

Inspecting

Health assessment is an essential nursing function which provides foundation for quality
_______ care
Nursing

Two types of thermometer used in clinical care are electronic and ______
Mercury

When you want to inspect for lymph nodes, you should expose the whole areas of head and
neck for any _____ or inflammation
Enlargement

When you want to inspect for lymph nodes, you should expose the whole areas of head and
neck for any enlargement or______
inflammation

Visual acuity is assessed using ______ chart

Snellen

Inspection and ______ of the external ears is part of the assessment of the ear
Palpation

Crutches are assistive devices use by patients with musculoskeletal problems.

False

The client record is a legal document.

True

The purpose of ______ assessment is to enable you to make a clinical judgement

Nursing

Objective data are observable or ____ pieces of information about the client
Measurable

Inspiration is part of ______respiration

External

Well-being is declared as a _____perception of vitality and feeling well

Subjective

Tuning fork is for testing _____ function and vibratory sensation

Auditory

Tongue blade is for depressing the ______during assessment

Page 38
Tongue

Body mass index (BMI) of 30.0- 34.9 is regarded as ______

Class I obesity

Normal respiratory rate for children aged 5-10years old is______

20-30 cycles/minute

Which of the following is correct about myopia?

Images are formed in front of the retina

The motility, elasticity and texture of the skin is called_______

Turgor

The following are precipitating factors for pains except______

Symptoms

The following are examples of subjective data except______

Physical wound

Subjective data is also known as_____

Symptoms

The amount of time you need to complete a nursing history may vary depending on
your_______
Experience

The amount of time you need to complete a nursing history may vary depending on
your_______
Experience

Physical assessment of the mouth and throat includes all except

Nostrils

Primary lesions are characterized by all except

Hollowed out crusted areas

Pain exist when patient report it

True

Pain has_______
Intensity

The following are major areas included in general survey except

Food

The following are techniques used in physical assessment except

Skin texture

Page 39
Auscultation is usually done with_____
Stethoscope

In palpating the skin for sensitivity, you need not to bother about clients comfort
False

The following are equipment used in physical examination except

Ears

Adaptation of the physical examination are useful in older adult clients but not children
True

It is important to use a cool, quiet environment to perform physical examination

True

The following are inspected when examining the thorax and lungs except
Pulsations

Respiration is observed for______

Rate

Physical assessment of the peripheral vascular system include all of the following except
S1 to S4 murmurs

In physical examination it is advisable to maintain eye contact so as to make the client fear
you so that he can tell you the truth
False

While assessing the anus, rectum and prostate, you need not to advise the clients to void prior
to assessment
False

The following behaviours are indicative of presence of pain except

Smiling

The following are special equipment used in assessing the neurological system except
Non sterile needle

Normal respiratory rate for adults is______

14-20 cycles/minute

In vagina examination, the nurse does all except

Swab the vulva from back to front with antiseptic

All the following affect pulse except

Laboratory investigation

Nurses use data from health assessment to do all except

Make a diagnosis

Page 40
It is not possible to understand the priority concerns and expectations of the clients
False

Coping strategy for pain include the following except

Fighting

The response to testing of reflexes is______ on a scale of_________

2+, 0 to 4+

Perform the Schamroth techniques to assess______.

clubbing

_______can be used to assess Schamroth techniques

Clubbing

The assessment of asking your client to smile at test indicate what?

cranial nerve VII

_______ is present if your palpation leaves a dent in the skin.

Edema

A wood lamp is shined on the skin to distinguished________

fluorescing lesions

Shine a ______ on the skin to distinguish fluorescing lesions.

wood’s lamp

Auscultation is usually performed with a______.

stethoscope

______ of the skin are changes in normal skin structure.

Lesions

______ develop on previously unaltered skin.

Primary lesions

______ lesion develop on previously unaltered skin

Primary

Lesions that change over time or because of scratching, abrasion, or infection are called
______
secondary lesions

While assessing the overall appearance of the client, what should be noted?
hygiene and odor

Burning, stabbing and piercing indicate which history of pains of the client_______
Quality of pain

Page 41
Margo McCaffery defined pains as_______
whatever the person experiencing the pain says it is, existing whenever the person says
it does

Assessment is ______ step of nursing process.

first

The diaphragm of the stethoscope is more sensitive to_____sounds.

High-pitched

The nails should have a ____undertone and lie flat or form a convex curve on the nail bed
pink

The process used for the assessment of hyperresonance over inflated lung tissue in a patient
with emphysema is______
auscultation

Types of assessment that are used to obtain information about a client are comprehensive,
focused, and_____
emergency

The purpose of the nursing assessment is to make a_______about a client‟s health status.
clinical judgment

Data that can be observed by one person and verified by another person observing the same
patient are known as______
objective data

When assessing the client‟s abdomen,______ should be done first

inspection

The bell of the stethoscope is used for ______sounds

low-pitched

The pulmonic area is the second intercostals space (ICS) to the______

left of the sternum

The aortic area is the second intercostals space (ICS) to the______

right of the sternum

Percussion has limited usefulness in the______ because X rays and other diagnostic tests
provide the same information in a much more accurate manner
cardiovascular assessment

Physical assessment of the ear consists of auditory screening, inspection and palpation of the
external ear and_____
otoscopic assessment

Page 42
Assessment of the eyes should be carried out in an orderly fashion, moving from the
extraocular structures to the_____
intraocular structures

______ is used to determine exact ROM in joints with limited ROM.

Goniometer

Physical assessment of the neurologic system begins with assessment of the client‟s_____
mental status

Schamroth techniques are used to assess______

clubbing

Localized hot, red, swollen painful areas indicate the presence of______ and possible
infection.
inflammation

_____is produced when bacterial waste products mix with perspiration on the skin surface.
Body odor

Hair color is determined by the amount of____

Melanin

The ____is sensitive to touch and temperature

Skin

In physical assessment of the integumentary system, the techniques of inspection and______

palpation

The ______ of the stethoscope is more sensitive to high-pitched sounds.

diaphragm

Auscultation is usually performed with a______

Stethoscope

The usual percussion sound in the right lower quadrant of the abdomen is______
Tympany

______ is an assessment technique involving the production of sound to obtain formation

about the underlying area
Percussion

The tips of the fingers can be used to palpate_____

lymph nodes

The dorsa (back) of the hands and fingers can be used to assess_____
temperatures

Palpation is the examination of the body through the use of______

Page 43
Touch

______ is the visual examination of a part or region of the body to assess normal conditions
and deviations from normal
Inspection

Functional health patterns format for taking Nursing history was developed by______
Gordon

The part of the body that is more sensitive to vibrations is_____

Palmar surface

The „gold standard‟ for assessing the existence of pain is______

Client selfreport

The step of the nursing process that includes data collection by health history, physical
examination, and interview is______
Assessment

_____ is used for head-to-toe assessment.

Comprehensive Assessment

Subjective data is gathered during______

Interview

The nursing health assessment is used to support the identification of a_____

Nursing diagnosis

_____ is a systematic data collection

Health assessment

The expression of hopelessness or loss of control by the client frequently reflects in which
pattern?
Self-Perception-Self-Concept Pattern

Page 44