Health Assessment Documentation Exam

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84 Terms

1
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<p><span>What is the affected side showing?</span></p><p></p>

What is the affected side showing?

Effusion of the knee

2
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<p>How would you document the spinal curvature?</p>

How would you document the spinal curvature?

Scoliosis

3
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<p><span>Which spinal curvature do these patients have?</span></p><p></p>

Which spinal curvature do these patients have?

Kyphosis

4
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<p><span>Which spinal curvature do these patients have?</span></p><p></p>

Which spinal curvature do these patients have?

Lordosis

5
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<p><span>Which angular deformity does this patient have?</span></p><p></p>

Which angular deformity does this patient have?

Genu Normal

6
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<p><span>Which angular deformity does this patient have?</span></p><p></p>

Which angular deformity does this patient have?

Genu Varum

7
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<p><span>Which angular deformity does this patient have?</span></p><p></p>

Which angular deformity does this patient have?

Genu Valgum

8
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<p><span>Which joint deformity is shown here?</span></p><p></p>

Which joint deformity is shown here?

Swollen Joints

9
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<p><span>What range of motion is the patient doing with their TMJ (temporomandibular joint)?</span></p><p></p>

What range of motion is the patient doing with their TMJ (temporomandibular joint)?

Extension of the temporomandibular joint (TMJ)

10
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<p><span>Which shoulder range of motion is shown here?</span></p><p></p>

Which shoulder range of motion is shown here?

Rotation of the shoulders

(Left: internal, Right: external)

11
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<p>Which neck range of motion is this?</p>

Which neck range of motion is this?

Flexion

12
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<p>Which neck range of motion is this?</p>

Which neck range of motion is this?

Hyperextension

13
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<p>Which neck range of motion is this?</p>

Which neck range of motion is this?

Lateral Flexion

14
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<p>Which neck range of motion is this?</p>

Which neck range of motion is this?

Rotation

15
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<p><span>Which hip range of motion is shown here?</span></p><p></p>

Which hip range of motion is shown here?

Flexion of the hip

16
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<p><span>How would you document the color in each test tube?</span></p><p></p>

How would you document the color in each test tube?

  1. Clear

  2. Pale yellow

  3. Straw yellow

  4. Dark yellow

  5. Amber

  6. Brown

  7. Red

17
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<p><span>How would you document this finding in a urine sample?</span></p><p></p>

How would you document this finding in a urine sample?

Sediment in pale yellow urine

18
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<p><span>How would you document the characteristics and color of this urine?&nbsp;</span></p><p></p>

How would you document the characteristics and color of this urine? 

Cloudy straw yellow urine

19
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<p><span>How would you document the characteristic of this urine?</span></p><p></p>

How would you document the characteristic of this urine?

Hematuria

20
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<ul><li><p><span>What is this image showing?&nbsp;</span></p></li><li><p><span>How do you assess this item?</span></p></li><li><p><span>Do you or do you not want a bruit and thrill to be present?</span></p></li></ul><p></p>

  • What is this image showing? 

  • How do you assess this item?

  • Do you or do you not want a bruit and thrill to be present?

AV (arteriovenous) fistula. Assess for a thrill (vibration) and bruit (whooshing sound). We want BOTH of these items to be present when assessing an AV fistula. This tells us that the AV fistula is working. 

21
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<p><span>How would you document the shape of this abdomen?</span></p><p></p>

How would you document the shape of this abdomen?

Round, obese abdomen

22
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<p><span>How would you document the shape of this abdomen?</span></p><p></p>

How would you document the shape of this abdomen?

Flat abdomen

23
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<p><span>How would you document the shape of this abdomen?</span></p><p></p>

How would you document the shape of this abdomen?

Concave abdomen

24
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<p><span>How would you document the finding of this abdomen?</span></p><p></p>

How would you document the finding of this abdomen?

Portrusion of the umbilicus

25
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<p><span>What artery is each line pointing to in this picture?</span></p><p></p>

What artery is each line pointing to in this picture?

  1. Aorta

  2. Renal

  3. Illiac

  4. Femoral

26
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<ul><li><p>Which assessment is being performed for this patient?</p></li><li><p>What does it assess for?</p></li></ul><p></p>

  • Which assessment is being performed for this patient?

  • What does it assess for?

Murphy’s punch

Kidney issues: infections, kidney stones

27
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<p>What stools are considered constipated, normal, or lacking fiber/inflammation?</p>

What stools are considered constipated, normal, or lacking fiber/inflammation?

Constipated: types 1 & 2

Normal: types 3 & 4

Laking fiber/inflammation: types 5,6,& 7

28
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<p><span>How would you document this assessment finding?</span></p><p></p>

How would you document this assessment finding?

Russell’s sign

29
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<p><span>How would you document the assessment findings of the tragus?</span></p><p></p>

How would you document the assessment findings of the tragus?

Inflamed with erythema and swelling

30
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<p><span>Which assessment technique is shown here?</span></p><p></p>

Which assessment technique is shown here?

Pulling pinna up to assess ear canal

31
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<p><span>How would you document the assessment findings of this patient’s eyes?</span></p><p></p>

How would you document the assessment findings of this patient’s eyes?

Exophthalmos

32
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<ul><li><p><span>How would you document the assessment findings of this patient’s eyes?</span></p></li><li><p><span>How would you assess for this disorder?</span></p></li></ul><p></p>

  • How would you document the assessment findings of this patient’s eyes?

  • How would you assess for this disorder?

Strabismus (ocular misalignment)

Assessed by testing the corneal light reflex.

33
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<ul><li><p><span>How would you document the assessment finding?</span></p></li><li><p><span>Which part of the eye is affected?</span></p></li></ul><p></p>

  • How would you document the assessment finding?

  • Which part of the eye is affected?

Jaundice of the sclera

34
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<p><span>How would you document the assessment findings of this patient’s conjunctiva?</span></p><p></p>

How would you document the assessment findings of this patient’s conjunctiva?

Pale conjunctiva

35
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<p><span>How would you document this patient’s pupils?</span></p><p></p>

How would you document this patient’s pupils?

Anisocoria

36
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<p><span>How would you document the patient's left eye?</span></p><p></p>

How would you document the patient's left eye?

Ptosis (drooping) of the left eye lid

37
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<p>Interpret and document results of a snellen test</p>

Interpret and document results of a snellen test

38
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Left eye abbreviation

OS

39
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Right eye abbreviation

OD

40
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Both eyes abbreviation

OU

41
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<p>What facial sinus is being assessed?</p>

What facial sinus is being assessed?

Frontal sinus

42
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<p>What facial sinus is being assessed?</p>

What facial sinus is being assessed?

Maxillary sinus

43
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term image

Deviated septum

44
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<p>How would you document the size of this patient’s tonsils?</p>

How would you document the size of this patient’s tonsils?

+4

45
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<p>How would you document the white spots found in this patient’s mouth?</p>

How would you document the white spots found in this patient’s mouth?

Fungal infection

46
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<ul><li><p><span>How would you document the red spots found in this patient’s mouth?</span></p></li></ul><ul><li><p><span>How would you grade these tonsils?</span></p></li></ul><p></p>

  • How would you document the red spots found in this patient’s mouth?

  • How would you grade these tonsils?

Red spots: Infection such as strep throat

Tonsil size: +2

47
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<p>Which cranial nerve is not intact for this patient?</p>

Which cranial nerve is not intact for this patient?

Facial nerve (VII)

48
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<p>Which cranial nerve is responsible of the function of clenching your jaw?</p>

Which cranial nerve is responsible of the function of clenching your jaw?

Trigeminal nerve (XII)

49
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<p><span>Which type of posturing does this patient have?</span></p><p></p>

Which type of posturing does this patient have?

Decerebrate

50
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<p><span>Which type of painful stimuli is the nurse assessing?</span></p><p></p>

Which type of painful stimuli is the nurse assessing?

Supraorbital pressure

51
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<p><span>Which type of painful stimuli is the nurse assessing?</span></p><p></p>

Which type of painful stimuli is the nurse assessing?

Trapezius squeeze

52
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<p><span>Which reflex is being tested on this patient?</span></p><p></p>

Which reflex is being tested on this patient?

Plantar reflex (assessing for a Babinski sign)

53
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<p><span>Which reflex is the nurse assessing?</span></p><p></p>

Which reflex is the nurse assessing?

Patellar reflex

54
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<p><span>Which reflex is being assessed by the nurse?</span></p><p></p>

Which reflex is being assessed by the nurse?

Achilles reflex

55
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<p><span>Which pulse is the nurse assessing?</span></p><p></p>

Which pulse is the nurse assessing?

Popliteal pulse

56
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<p><span>Be able to complete a Glascow coma scale on a patient</span></p><p><span>When completing a Glascow Coma Scale, how do you document the verbal response of a patient that is intubated?</span></p><p></p>

Be able to complete a Glascow coma scale on a patient

When completing a Glascow Coma Scale, how do you document the verbal response of a patient that is intubated?

Put the letter “t” after the score to indicate intubation.

57
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<p><span>Which pulse is the nurse assessing?</span></p><p></p>

Which pulse is the nurse assessing?

Doralis pedis pulse

58
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<p>Which pulse point is the nurse assessing?</p>

Which pulse point is the nurse assessing?

Brachial pulse

59
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<p>Which pulse is the nurse assessing?</p>

Which pulse is the nurse assessing?

Radial pulse

60
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<p>Which pulse is the nurse assessing?</p>

Which pulse is the nurse assessing?

Posterior tibial pulse

61
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<p>Which test is being shown in this image?</p>

Which test is being shown in this image?

Allen’s test

62
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<ul><li><p><span>What type of edema is shown in the right image?</span></p></li><li><p><span>How would you grade it? The depth and amount of time it takes to resolve would be provided in the exam question. &nbsp;</span></p></li></ul><p></p>

  • What type of edema is shown in the right image?

  • How would you grade it? The depth and amount of time it takes to resolve would be provided in the exam question.  

Pitting edema

63
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<p><span>How would you document the condition of this patient’s skin?</span></p><p></p>

How would you document the condition of this patient’s skin?

Rubor

64
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<ul><li><p><span>How would you document this patient’s veins?</span></p></li></ul><p></p>

  • How would you document this patient’s veins?

Varicose veins

65
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<p><span>What test is being assessed in this patient?</span></p><p></p>

What test is being assessed in this patient?

Homans Sign

66
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<ul><li><p><span>What nail condition is shown in this patient?</span></p></li><li><p><span>What is it indicative of?</span></p></li></ul><p></p>

  • What nail condition is shown in this patient?

  • What is it indicative of?

Nail clubbing. Indicative of poor perfusion and lack of oxygen.

67
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<p><span>How would you document this skin condition?</span></p><p></p>

How would you document this skin condition?

Skin tenting

68
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<ul><li><p><span>Which method is the nurse using to assess the skin?</span></p></li><li><p><span>For which assessments does the nurse use this technique?</span></p></li></ul><p></p>

  • Which method is the nurse using to assess the skin?

  • For which assessments does the nurse use this technique?

Palpating with the dorsal side of the hand to assess the skin temperature. 

69
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<p><span>How would you document the shape of this chest?</span></p><p></p>

How would you document the shape of this chest?

Barrel Chest

70
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<p><span>How would you document each type of sputum?</span></p><p></p>

How would you document each type of sputum?

  1. Clear

  2. Yellow

  3. Green

  4. Dark yellow

  5. Brown 

  6. Bloody

71
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<p><span>Which condition does this patient’s jugular vein have?</span></p><p></p>

Which condition does this patient’s jugular vein have?

Jugular vein distention seen while patient is sitting at 90 degrees

72
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<p><span>How would you document this assessment finding located on the infant’s head?</span></p><p></p>

How would you document this assessment finding located on the infant’s head?

Sunken anterior fontanelle 

73
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<p><span>How would you document the condition this child has?</span></p><p></p>

How would you document the condition this child has?

Hydrocephalus

74
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<p><span>Be able to list the name of each of the lymph nodes on this diagram</span></p><p></p>

Be able to list the name of each of the lymph nodes on this diagram

  1. Posterior auricular

  2. Occipital

  3. Jugulodigastric

  4. Superficial cervical 

  5. Posterior cervical

  6. Supraclavicular

  7. Preauricular

  8. Submandibular

  9. Submental

  10. Deep cervical chain

75
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<p><span>Which condition does this patient have?</span></p><p></p>

Which condition does this patient have?

Enlarged thyroid (goiter)

76
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<p><span>How would you document this skin finding?</span></p><p></p>

How would you document this skin finding?

Lentigo

77
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<p><span>How would you document this skin lesion?</span></p><p></p>

How would you document this skin lesion?

Scale

78
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<p><span>What type of wound does this patient have?</span></p><p></p>

What type of wound does this patient have?

Venous ulcer

79
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<p><span>How would you find this skin finding?</span></p><p></p>

How would you find this skin finding?

Ecchymosis

80
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<p><span>How would you document this skin finding?</span></p><p></p>

How would you document this skin finding?

Petechiae

81
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<p><span>How would you document this skin finding?</span></p>

How would you document this skin finding?

Pustule

82
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<p><span>How would you document this spot on the patient?</span></p><p></p>

How would you document this spot on the patient?

Wheal

83
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<p><span>How would you document this skin lesion?</span></p>

How would you document this skin lesion?

Skin tag (pedunculated lesion)

84
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<p><span>Know how to complete a Braden Scale on a patient given a paragraph of information</span></p><p></p>

Know how to complete a Braden Scale on a patient given a paragraph of information

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