Health Assessment Unit 12

Which of these statements is true regarding the recording of data from the history and physical examination?

• •Use long, descriptive sentences to document findings.

• •Record the data as soon as possible after the interview and physical examination.

• •If the information is not documented, then it can be assumed that it was done as a standard of care.

• •The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the client.

All of the following is required equipment you would use for a complete head to toe assessment except:

• Tuning fork

• Platform scale with height attachment

• Stethoscope with bell and digraph end pieces

• Hoyer lift

The nurse is completing a head to toeassessment on an aging adult client. Which of the following could the nurse do to conserve client energy?

• Arrange the sequence to allow as few position changes as possible

• Rush through the examination

• Complete the examination in one visit

• Maintain a confident manner

A client presents to the ED in acute respiratory distress. How should the nurse proceed with gathering the health history?

• •Collect all the information regardless of client condition

• Collect a mini-database and then complete the assessment once the distress is resolved

• Do not collect any information at this time

• Allow rest periods when needed

After the health history has been obtained and before beginning the physical examination, the nurse should first ask the client to:

• Empty the bladder

• Completely disrobe

• Lie on the examination table

• Walk around the room

Which of the following is a true statement regarding the bedside assessment of the hospitalized client?

• •Hospitalized clients require a complete head to toe screening exam every 24 hours

• •The bedside assessment is a specialized assessment done at least every 12 hour shift

• The bedside assessment is the complete examination done with the first client encounter

• The bedside assessment only focuses on one body system

What should the nurse assess before entering the client’s room on morning rounds?

• Posted conditions, such as isolation precautions

• The client’s input and output chart from the previous shift

• The client’s general appearance

• The presence of any visitors in the room

A client has been in the hospital for 3 days. The nurse performs a bedside assessment in the morning. In the afternoon the client comes back to the floor after an operation. Which type of assessment would the nurse want to perform?

• Focused assessment

• Complete Head-To-Toe Assessment

• Functional assessment

• Bedside assessment

A new graduate nurse asks a more experienced nurse why the initial assessment is done in the early part of the day. The nurse would respond:

• To get your charting done before the physician rounds

• To assess a client following procedures

• To have a more accurate assessment

• To get a baseline for your client so that changes can be detected early

In which of the following ways does the electronic health record (EHR) increase client safety? It:

• Decreases transcription and prescribing errors

• Notifies providers of medication interactions

• Means the provider must be physically present on the floor to write orders

• A & B