HLTENN003 Performing Clinical Assessment And Contribute To Planning Nursing Care


1. Nursing assessment is the first stage of the nursing process. State four reasons why a nursing history is performed on admission?
2. Part A
    Explain why it is important to involve your client and/or their family whilst conducting nursing assessments?
    Part B
    What is meant by holistic care?

3. List 4 points relating to the documentation guidelines that you must comply with when recording any information.

4. You are asked to take vital signs on a client. State 4 indications to complete vital signs

5. Match the appropriate term with the correct temperature range



36.2 -37.5 0C



35.0        36.0 0C




37.5 – 39.0 0C


It is recommended to take a confused person’s temperature via the oral route




 Explain your answer
7. ___________________is an abnormal pulse rate greater than 100 beats/minute
8. List 4 factors that affect body temperature
9. When taking a client’s pulse, what 3 characteristics must be assessed?
10. List the 4 most common sites for taking a pulse measurement.
11. The term for a pulse rate below 60 beats per minute is a ____________________________
12. When taking a client’s respirations, what 3 characteristics must be assessed?
13. A normal respiratory rate for a child is ________________________breaths per minute.
14. List four factors which may affect pulse oximetry
15. List the normal range of pulse oximetry in a healthy adult.
16. Define systolic blood pressure.
17. Define diastolic blood pressure
18. An elderly client has a blood pressure of 184/102.  The client is
19. A client has a urinary tract infection.  The client will have an increased level of _________ present in his urine.
20. Outline the normal characteristics of urine.
21. The medical term for shortness of breath is _________________________________
22. A client’s blood glucose level prior to breakfast was 3.1mmol/l, this result is a 
23. The correct formula to calculate the body mass index (BMI) is which of the following
24. A client with a BMI of 33.4 is considered to be ____________________________________
25. Blood glucose target ranges may differ depending on age, duration of diabetes and medications.  Normal blood glucose levels are between
26. Individual human development is a lifelong continuous process beginning at conception and ending with death and is perceived as involving a series of orderly and            predictable changes, which can be classified as physical, social, emotional and intellectual.  Complete the following referring to Erikson’s eight stages of development


Conflict to be resolved


Oral-Sensory (birth to 1 year)





(1-3 Years)





(3-5 Years)





(6 -11 Years)





(12-18 Years)




Young Adulthood

(19-35 Years)




Middle adulthood (40 to 65 years)




Maturity (65 to death)



27. Outline the specific assessment technique(s) you would use to assess the following clients:

     A client who has fallen and is suspected of having a head injury

     A client who is dyspneic

     A client with diabetes

     A client who is complaining of pain on micturition

     A person who has a plaster cast on their arm post a recent fracture

28. A fluid balance chart has been ordered for Mr. Leech (UR 0123456789) DOB: 30/06/1949. Complete FBC on the following page below using the following information:

0730 hrs — orange juice 150 mL, milk 140ml

1350 hrs — cup of tea 250 mL, water 100 mL

1030 hrs — cup of tea 180 mL

1430 hrs — voided 250 ml

1115 hrs — water 120 mL

1630 hrs — vomited 150ml, bile stained fluid

1230 hrs — cup of tea 120 mL jelly 200 mL

1800 hrs — Bowels open – loose, approximately 100mls

1230 hrs — voided 150 mL urine



The Total intake for the day is


The total output for day is


Is Mr Midler in a positive or negative fluid balance?  


29. The urinalysis is another common test routinely taken in almost all acute hospitals as an admission lab screening test. What can a urinalysis reveal?
30. Provide a definition for the following terms





31. Provide a definition for the following terms





32. When completing a nursing assessment, data that is the client’s perception, ideas and sensations is known as                                        ______________________________________________________

33. What is a holistic assessment?

34.What are the 3 characteristics of a Glasgow Coma scale  

35. Part A

You are asked to undertake an admission assessment of a 4 year old who is admitted with vomiting and diarrhea. Explain the strategies you would use and why to achieve an accurate assessment

Part B

While undertaking the nursing admission, you note that the General Practitioner has stated in the referral that the child is allergic to a medication, however the Medical Officer has written up a stat dose.  What are your actions?

36. You are asked to create a discharge care plan for Mrs Marjorie White who is an 83 year old lady who was admitted for a hip replacement. Outline what is required in the discharge plan.

37.  Part A

You have just completed a blood pressure measurement of your client. It was 185/105. List the steps you would take;

Part B

List 2 likely causes of this high reading 

38. You are caring for Jess, a 19yr old male who had been recently admitted for asthma.

Explain how you could assist in the health education of Jess prior to discharge.     

39. The mother of a 7 month old Zoe asks you if Zoe should reach the same milestones at the same time as her older siblings.  What would be an appropriate response?

40. Mrs Joan Smith is a 61 year old lady (UR 333666) was admitted to your ward for day surgery.

Document the following admission observations accurately on the graph observation chart provided.

1400 hrs    T – 36.7,          P – 100,          R – 22,            B/P – 140/90.  

Weight is 68 kg

Urinalysis reveals a ph  of 8.0, positive for leucocytes and SC 1015

No other abnormalities

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