Calamba Doctors' College: Virborough Subdivision, Parian, Calamba City, Laguna

CALAMBA DOCTORS’ COLLEGE
Virborough Subdivision, Parian, Calamba City, Laguna
Health Assessment
BSN 1
Home Activity No.1

Direction: Write all your works/answers (handwritten) on short bond paper and send via email –
diosdadomanalotojr@yahoo.com or submit after quarantine period.
Case study 1
Summarize the case study of Jonathan Miller (JM), a 22-year-old college student (Chapter 18) using the
nursing health history format
1. Biographic Data:
2. Chief Complain
3. History of Present Health Concern
4. Past Health History
5. Family History
6. Lifestyle and Health Practices
7. Physical Assessment
8. 3 Nursing Diagnoses
Case Study 2
Trudy Neinto is a 25-year-old Native American (Navajo) female who was brought to the clinic by her sister.
The following data are collected by the nurse during an interview and assessment
The patient tells the nurse, “My ear is hurting very badly, and I’m hot.” She adds, “I wanted to go to the
clinic yesterday, but my grandmother told me I shouldn’t.” Trudy tells the nurse, “I have been treated many
times for this problem over the last several years by the medicine man. Last night I had drainage from my ears.
Grandmother told me that this was a sign that the illness was being chased from my body. I did not know.
what it was, but I felt scared.”
General survey:
Healthy-appearing adult female, temperature: 101.8° F (38.8° C), typical position of ears bilaterally, left
ear pinna is red. Dried purulent drainage noted on left external ear and in left external canal. Grimaces when
left ear is touched. The right ear unremarkable, dried drainage noted in left ear canal. Tympanic membrane
perforated, right ear is unremarkable. Whisper test in right ear 80%; whisper test in left ear 0%.
Clinical Reasoning
1. Application of COLDSPA base on above case study.
2. Which data deviate from normal findings and suggesting a need for further investigation?
3. Based on the data, which risk factors for hearing loss does the client have?
4. Provide at least 3 nursing diagnoses
5. With which additional health care professionals should you consider collaborating to meet her health
care needs?
Health Assessment
BSN 1
Home Activity No.2
Read - Health Assessment Procedure
A. Collecting Subjective and Objective data. (Chapter 19 ; Page 374-377 and 380-390)
 Dyspnea (difficulty breathing)
 Chest pain
 Cough and Sputum
 Nasal flaring and Pursed lip breathing
 Chest palpation
o Crepitus
o Fremitus
 Chest percussion
 Chest Auscultation/Breath sound (Normal/ Adventitious)
 Auscultate voice sounds.
o Bronchophony
o Egophony
o Whispered pectoriloquy
 Respiration patterns
Clinical Application
1. Client has a viral infection or upper respiratory allergies when the patient describes the sputum as being:
A. White or mucoid C. Rusty color
B. Excessive, tenacious secretions D. Pink tinged or frothy
2. What is the color of the sputum associated with pulmonary edema?
A. With blood stain C. Rusty color
B. Yellow or green D. Pink tinged or frothy
3. During inspection of the respiratory system the nurse documents which finding as abnormal?
A. Patient leaning forward with arms braced against the knees
B. The client uses his/her trapezius/shoulder muscles to facilitate breathing.
C. Reddish to purple complexion
D. All of the above
4. An increase anteroposterior–transverse diameter of the chest is commonly seen to a client with:
A. Bronchial asthma C. Congestive heart failure
B. Emphysema D. All of the above
5. On auscultation of a patient’s lungs, narrowing of the bronchi creates which adventitious sound?
A. Crackles C. Wheeze
B. Pleural Friction Rub D. Tactile Fremitus
Case Study:
Mrs. Martinez 50 -year-old patient was complaining of shortness of breath, hoarseness, difficulty swallowing, and
chronic cough with rust-colored sputum She has had a breathing problems for past 2 years and getting worse while
doing her daily activities. She says that she can sleep for only a couple of hours at a time. She sleeps best using two
pillows to prop up, but on some nights she just sits in a chair.
Mrs.Martinez has a past medical history of a severe pneumonia and hypertension. The nurse auscultated
inspiratory crackles, blood pressure of 148/96, tachycardia of 120 beats/min, tachypnea of 28 breaths/min, She
admitted smoking average of pack of cigarettes a day for more than 20 years. she is currently using anti-hypertensive
drug
She is alert and slightly anxious, sitting slightly forward, skin is pale with slight cyanosis around the lips and in nail
beds. She has had a recent “weight loss of 20 pounds for past 2 months. After bronchoscopy and series examination she
was diagnosed of lung cancer and advice by physician to undergo chemotherapy.
Clinical Reasoning
1. Based on above data, What is the contributing factor associated with lung cancer
2. Provide at least 3 nursing diagnoses base on the above data.
Health Assessment
BSN 1
Home Activity No.3

Read - Health Assessment Procedure - Breasts and Lymphatic system
B. Collecting subjective and objective data.
C. Self-breast examination
D. Assessment Procedures
 Female Breasts
o Inspect size and symmetry, superficial venous pattern, areolas, nipples, retraction and dimpling
o Palpate for texture and elasticity, tenderness and temperature, masses, nipples, mastectomy or
lumpectomy site
o Palpate axilla
 Male Breasts
o Inspect and palpate the breasts, areolas, nipples, and axillae
1. Ms. Cruz a 20-year-old college student visits the school clinic because she discovered small, painless, non-tender,
firm and mobile lumps in her right breast. What is the most common cause of breast lumps?
A. Breast cancer C. Fibroadenomas
B. Fibrocystic breast disease D. Intraductal Papilloma
2. A 50 year-old female client seeks consultation at the center for breast mammography examination. The examination
yields negative findings. When will the nurse ask her to return for the next breast examination?
A. After a year C. After 3 years
B. After 2 years D. After 5 years
3. Which of these signs and symptoms is NOT an indication of breast cancer?
A. Orange-peel appearance C. Asymmetric venous pattern
B. Recent retract nipples D. Dark brown nipple discharges
4. Which quadrant of the breast is the most common site for malignant tumors?
A. Upper outer quadrant C. Lower outer quadrant
B. Upper inner quadrant D. Lower inner quadrant
5. Mrs X, 23-year-old has a benign fibrocystic cyst of the left breast. Which of the following is associated with
fibrocystic breast disease?
A. Immobile C. Hard consistency
B. Tender D. Irregular shape
6. Jane, aged 50, a mother of 4 children has discovered a lump in her right breast. As you obtain her health history, you
identify risk factors for breast cancer. Which factor increases the risk for breast cancer?
A. History of fibrocystic breast changes C. Multiparity
B. Breast fed her children D. Her age of 50
7. When palpating patient’s breast, its prepare to used:
A. The whole palm C. Index finger and middle finger
B. Three middle finger D. Thumb, index, and middle finger
8. Normal changes in the breast of a premenstrual woman include:
A. A single hard, fixed mass C. Redness on nipple and breast dimpling
B. Tenderness, firm and mobile cysts D. Redness and scaling over the portion of the breast
9. Mrs Y, aged 55, you are reviewing BSE with her. At what time of the month should she perform BSE?
A. First of every month C. Last day of the month
B. Middle of the month D. Same time every month
10. What is the reason for palpating axillary lymph nodes during a clinical breast examination?
A. Axillary node tenderness is the most common initial sign of breast cancer
B. Axillary nodes are tender in response during monthly menstrual cycle
C. Lymph network in the breast toward the axillary lymph nodes.to detect infections and malignancy
D. This is a matter of convenience because of the close proximity of the axillae to the breasts.
Case Study:
Julie is a 46-year-old woman who came to the clinic because she had discovered a lump in her left breast. The
following data are collected during an interview and examination.
She tells the nurse that she first noticed the lump about 9 months ago. Because it seemed small and didn’t hurt, she
didn’t worry about it that much. Recently she noticed that the lump felt bigger and decided that she should have
someone look at it. She tells the nurse, “I just know it’s not cancer because I’m much too young and healthy. And if it is,
I’m not about to let some doctor mutilate me with a knife. I’d rather die than have my breast cut off.” The nurse asks her
if she has noticed any redness or dimpling of the breast. She tells the nurse, “No, not really, but I don’t pay attention to
those things.” She tells the nurse that she started having regular menstrual cycles at age 11 and has not reached
menopause. She has never been married and has no children.
General survey:
She is alert, well-nourished female; hesitant to expose her breast for examination. Breast Inspection reveals breasts
of typical size with right and left breast symmetry. The skin of both breasts is smooth with even pigmentation. The
nipples protrude slightly with no drainage noted. The left nipple is slightly retracted. Significant dimpling is noted on left
breast in upper outer quadrant when arms are raised over her head. Right breast is firm, smooth, elastic, without lumps
or tenderness. Palpation of the left breast reveals a large, hard lump in the upper outer quadrant. No lumps or masses
are noted in the right breast. The left nipple produces a serosanguineous discharge when squeezed; the right nipple is
unremarkable
Clinical Reasoning
3. Which of the above data requires validation and needs further assessment?
4. Based on above data, What is the contributing factor associated with breast cancer
5. Provide at least 3 nursing diagnoses base on the above data.
Health Assessment
BSN 1
Home Activity No.4

Read - Health Assessment Procedure - Heart
A. Auscultating Heart Sounds
B. Assessing symptoms: Chest pain, tachycardia, palpitation, fatigue, dyspnea, dizziness, pulmonary
congestion and edema
C. Assessment of the neck vessels
D. Assessment of the heart
E. Abnormal Arterial Pulse and Pressure Waves
1. This refers to area, wherein the examiners auscultate the patient’s heart at the left sternal border (LSB) at the
second intraclavicular space (ICS).
A. Erb’s point
B. Mitral area
C. Aortic area
D. Pulmonic area
2. The Apex of the heart is referring to:
A. Aortic area
B. Mitral area
C. Pulmonic area
D. Tricuspid area
3. A patient complains of chest pain when at rest. Which question should the nurse ask for further data?
A. “Does your chest pain accompanied by gastrointestinal pain after meal when this pain occurs
B. “Do you feel dizzy when the pain occurs?”
C. “Does the pain go away when you have light activity?”
D. None of the above
4. Which patient has the greatest risk for the development of heart diseases such as coronary artery diseases?
A. Overweight and lack of physical activity
B. With family history of hypertension
C. Stress and high cholesterol diet
D. Female with age above 60 year old
5. When a patient complains of chest pain, which question should first to gain additional data?
A. “What medication did take when pain first occurred?”
B. “What does the pain feels like?”
C. “Do you have episodes of shortness of breath and gastrointestinal pain
D. “Has anyone in your family ever had a similar pain?”
6. The appropriate procedure to determine jugular vein pulsations.
A. Looks the jaw line as the patient turns from supine to a side-lying position
B. Looks the sternocleidomastoid muscle as the head of the bed is slightly lowered
C. Looks above the clavicle as the head of the bed is slightly elevated
D. Look for jugular vein pulsation and positions the patient supine and asks to cough
7. The appropriate procedure to palpate the carotid.
A. Palpate at the jaw line as the patient’s head turn to side
B. Palpate the sternocleidomastoid muscle as the head of the bed is slightly lowered
C. Palpate the sternocleidomastoid muscle with patient supine with torso elevated 30-45 degree.
D. Palpate above the clavicle as the head of the bed is slightly elevated
8. On auscultation of the heart, which of the following is expected as normal finding?
A. The S4 heart sound is a low-pitched blowing sound is heard over the abdominal aorta.
B. The S3 heart sound is a high-pitched vibration is heard over the base of the heart.
C. The S1 heart sound is louder at the apex of the heart.
D. The S2 heart sound is commonly heard at the beginning of the diastole
9. A murmur is a swishing sound caused by turbulent blood flow through the heart valves or great vessels. Auscultate
murmurs with the client on left lateral position, use the bell of the stethoscope and listen at the apex of the heart. A
pathologic murmurs are common to patient with:
A. Congenital heart defect such as aortic valve stenosis, patent ductus arteriosus
B. Rheumatic heart disease
C. Endocarditis
D. All option are correct
10. This refers to heart beat, which is either too fast during inspiration and slow down while on expiration.
A. Sinus Tachycardia
B. Respiratory sinus arrhythmia
C. Premature ventricular contraction
D. Premature atrial contraction
Case Study
Mr. T is a 59-year-old man business man brought to emergency and complaining of shortness and difficulty
breathing. Upon assessment he is alert, anxious, cooperative, well-groomed male
Initial data.
Mr T has labored breathing at 36 breaths/min and tachycardia at 112 beats/min, BP, 142/112 mm Hg, right arm;
144/110 mm Hg, left arm; temperature, 98.8° F (37.1° C). His pulse oximetry is 90% on 40% oxygen via a face mask.
Crackles are heard throughout his lungs. Jugular venous distension (JVD) and pulsation noted with patient in supine
position. : Skin warm and dry, without cyanosis. Even hair distribution. 2+ pitting edema noted bilaterally. No lesions
present. Based on Mr T’ admission assessment, he is exhibiting clinical manifestations of coronary artery disease, and
hypertension
Interview Data
Mr. T does not know exactly when his breathing difficulty started, but it has gotten noticeably worse the last couple
of days. His father died of a heart attack at age 60. Mr. T plays golf once a week or has light exercise; however, he tells
the nurse that this last week he has “just felt too tired to do anything.” He says that he has not been able to sleep very
well at night because of his breathing difficulty. He adds, “I keep coughing out this bubbly-looking phlegm.” He denies
hypertension and taking any medications. He says that he eat food in well balance diet and he does not smoke or drink
alcoholic beverages.
Clinical Reasoning
7. Based on above data, what is the contributing factor associated to the above health condition?
8. Provide at least 3 nursing diagnoses with nursing plan based on the above data.
Health Assessment
BSN 1
Home Activity No.5

Read - Health Assessment procedure - Abdomen
A. Assessment guide – Abdominal structure by quadrant
B. Assessing abdominal pain, indigestion, nausea and vomiting, appetite and bowel elimination
C. Type and characteristic of abdominal pain
D. Assessment procedure -,inspection auscultation, percussion and palpation
E. Test of ascites, appendicitis and cholecystitis
1. Alex 25 year old was diagnosed with pancreatitis and complaining of abdominal pain. What question does a nurse
should be asked to the patient?
A. About the food that aggravate the pain
B. Changes in bowel habit
C. Prescribed medications such as aspirin and antibiotic
D. Description and severity of pain
2. Mr Timbol 20 year old is complaining of flank pain, fever, chills, and pain radiating to the groin. Which examination
technique by the nurse is most appropriate for this patient?
A. Percussion of the costovertebral angle over the ribs
B. Deep palpation of the abdomen
C. Testing for rebound tenderness
D. Assess tone of all quadrants of the abdomen
3. The above assessment technique should be demonstrated such:
A. Placing the non-dominant hand flat over the lower rib cage and use the ulnar of dominant hand and strike
the non-dominant hand
B. Using the palmar surface of the fingers, compress to a maximum depth (5–6 cm).
C. Using the fingers of dominant hand palpate deeply by 90 degree into abdomen then release immediately.
D. Percuss all quadrants by placing the index and middle finger into the abdomen and lightly tap the fingers
systematically.
4. The above patient condition is a potential problem in the:
A. Stomach
B. Gallbladder
C. Kidney
D. Urinary bladder
5. A patient reports a gnawing, burning pain in the epigastric area that is aggravated after taking meals. Which
additional data does the nurse ask for the symptom analysis?
A. Nausea and vomiting
B. Yellow discoloration of the eyes and skin
C. Bowel elimination problems such as constipation or diarrhea
D. All of the above
6. The above patient condition is a potential medical diagnosis for:
A. Gastric ulcer
B. Dyspepsia
C. Appendicitis
D. All of the above
7. The nurse palpates the abdomen to gather data about which organs located in the right upper quadrant?
A. Liver and gallbladder
B. Stomach and spleen
C. Uterus, if enlarged, and right ovary
D. Right ureter and ascending colon
8. Which of the following abdominal assessment finding is an abnormal for a 30 year old woman?
A. Flat or scaphoid
B. Kidneys are non-palpable
C. Bulges observed when coughing
D. Silver-white striae and pigmented line
9. Which is an expected finding of an abdominal examination of an adult?
A. Dull percussion tones over the bladder
B. Venus hum over the epigastrium on auscultation
C. High-pitched gurgles every 5 to 15 seconds on auscultation
D. Swishing sounds over the abdominal aorta on auscultation
10. The nurse suspects that the patient has appendicitis. Which assessment techniques can the nurse use to confirm his
or her suspicion?
A. Gently perform fist percussion over the right costovertebral angle
B. Ask the patient to place her hand on the abdomen while the nurse taps one side of the abdomen and
palpates the other side
C. Palpate the right/ left lower quadrant at a 90-degree angle and quickly release his or her hand
D. With the patient lying supine and flexing her right knee and hip, tap on the sole of the patient’s right
Case Study
Ms K. is a 40-year-old woman complaining of abdominal pain. The following data are collected by the nurse during an
interview and examination
Interview Data
Ms. K tells the nurse that the pain started yesterday evening and has gotten progressively worse. She describes the
pain as “really bad.” It is constant and located in her right lower abdomen, toward her umbilicus. She says that it feels a
little better if she stays curled up and does not move. She tells the nurse that she is in good health and that she has
never had a problem with her stomach.
Ms. K indicates that normally she has a good appetite and can eat anything— except for now. She says that she ate
breakfast and lunch yesterday but by dinnertime she was nauseated and had no appetite. She has not eaten anything
since. She has had no recent weight changes, but she would like to weigh about 5 lbs (2.5 kg) less than she currently
does within a month
Ms. K smokes a half pack of cigarettes daily. She does not drink alcoholic beverages, and she takes no medication.
She denies discomfort or problems with urination, describing her urine as “usual looking.”
Ms K reports that she has been feeling more tired lately and she is having problems with constipation. She has a
history of colon cancer in his immediate family.
On physician assessment, a fecal occult blood test is positive for blood. Laboratory tests are ordered including
scheduled colonoscopy. The physician/surgeon is suspecting a possible colon cancer versus acute appendicitis.
Examination Data
 General survey: Alert and anxious female in moderate distress lying in a fetal position on the examination table,
with her eyes closed. Appears well nourished. Her skin is hot.
 Inspection: Abdomen is flat and symmetric. No lesions or scars are noted. No surface movements are seen
except for breathing.
 Auscultation: Bowel sounds are absent.
 Palpation: Tympany is noted over most of abdominal surface; dullness over liver. Midclavicular liver span is 4
inches (10 cm).
 Light palpation: Demonstrates pain and guarding in right lower quadrant. Unable to palpate deep structures
because of excessive abdominal discomfort. Demonstrates positive rebound tenderness in right lower quadrant.
Clinical Reasoning
A. Colon cancer
B. Appendicitis
Health Assessment
BSN 1
Home Activity No.6

Read - Health Assessment procedure - musculoskeletal system
Case Study
Mrs. X is a 55-year-old Asian woman with rheumatoid arthritis (RA), who has come to her physician complaining of
back pain and joints pain particularly in her hands.
Interview Data
Mrs X says that she has “just learned to live with the pain because it will always be there.” She states that the
stiffness and pain in her joints are always worse in the morning or if she sits for too long. She report to her doctor that
4 weeks ago she developed a mild intermittent low back pain and stiffness and increasing pain intensity over the past 5
days. She rates her pain an 8 on a numerical scale of 0 to 10, with 10 being the highest. Hear back pain worse in the
morning and with certain movements such bending or sudden change of position. Client rates pain rate is 3 – 4 on scale
of 0–10 an hour after taking a Non-steroidal anti-inflammatory Drug
Mrs. X was diagnosed with rheumatoid arthritis at age 30. She denies muscle weakness other than the fact that her
stiffness and soreness prevent her from doing much. She has become more sedentary and has not been eating well since
the pain has begun. She states that her dietary intake has been low and she has started to smoke cigarettes again after
being cigarette free for 6 years. She reports that the RA is progressing to the point at which she is having difficulty doing
her daily activity. Mrs. X admits that she is postmenopausal and not taking any hormone replacement therapy
Mrs X has a family history of hypertension and diabetes on both parents. She denies family history of rheumatoid
arthritis, gout, or osteoporosis. She reports that she tries to walk 30 minutes 2 times weekly and slight difficulty
performing activities of daily livings 1 month ago. Eats balance diet in regular 3 meals a day with in between snacks. She
admits smoking at the ages of 20,
Examination Data
Patient is able to stand, but standing erect is not possible. Gait is slow and purposeful. Significant edema and
tenderness are noted on palpation of wrists, hands, knees, and ankles bilaterally. Hand grips are weak bilaterally.
Subcutaneous nodules are noted at ulnar surface of elbows bilaterally..
Clinical Reasoning
12. Application of COLDSPA (chief complain)
C. Osteoporosis
D. Rheumatoid arthritis
Health Assessment
BSN 1
Home Activity No.7

Read - Health Assessment procedure – Neurologic system
Case Study
Pamela is a 54-year-old female who was brought to the emergency department (ED) by ambulance after her
husband noticed her having difficulty walking and dragging her left leg. Her husband tells the nurse that she was fine
until this morning, when she suddenly had a dizziness and severe headache. She had trouble in speaking and could not
understand her
Vital signs are obtained, an intravenous (IV) line is inserted, and Pamela is quickly sent for a non-contrast computed
tomographic (CT) scan and results from the CT scan revealed. She was admitted to medical ward with a diagnosis of
acute cerebrovascular accident (Ischemic stroke - is a sudden loss of function resulting from disruption of the blood
supply to a part of the brain)
She has a history of hypertension, myocardial infarction, peripheral vascular disease, type 2 diabetes and obesity. . She
stopped smoking last year.
Examination Data
Neurologic examination: Awake, alert, unable to talk but able to follow commands. Cries and avoids eye contact
with his husband and nurse.
Cranial nerves III, IV, V, VI, and VIII are intact bilaterally. Patient has asymmetry and unequal movements of face,
with a drooping of the left side of face. He has asymmetry of shoulder shrug, with weakness noted on left side.
She has supination and pronation of right hand and is unable to perform with left hand. Light touch with sharp and
dull sensation is present on right arm and leg; there is no sensation on left arm or leg. Right arm and leg muscle strength
is 5, left arm muscle tone 0, left leg 1. He is unable to move around in bed unassisted at this time. Assessment of balance
is deferred.
Clinical Reasoning
1. Which data deviate from expected findings, suggesting a need for further investigation?
2. Based on the data, which risk factors for cerebrovascular accident?
3. Provide at least 3 nursing diagnoses with nursing plan based on the above data
4. Provide 3 nursing interventions with rationale for every nursing care plan
6.

Calamba Doctors' College: Virborough Subdivision, Parian, Calamba City, Laguna

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CALAMBA DOCTORS’ COLLEGE

Virborough Subdivision, Parian, Calamba City, Laguna

Home Activity No.1

Home Activity No.3

Home Activity No.4

Home Activity No.5

Home Activity No.6

Home Activity No.7

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