Advanced Health Assessment Midterm Study Guide Practice Questions Fully Solved.

S O A P note - correct answer a method of documentation employed by health care providers to write out notes in a patient's chart Subjective, Objective, Assessment and Plan A B C D skin lesion assessment - correct answer Asymmetry Border irregularity Color isn't uniform Diameter 6cm (pencil eraser) Evolving size, shape and color Preferred qualities of a first impression - correct answer honesty, candor, openness, flexibility, eager, explanatory, open to questions patient centered care - correct answer providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions 4 C's of effective communication - correct answer courtesy comfort connection confirmation Open ended questions goal - correct answer patient's description of answer direct question goal - correct answer seeking specific information Leading question goal - correct answer Limiting information to one focus / subject Reasons patients avoid the full story of the illness - correct answer dementia, alcoholism, illness, sexual uncertainties, domestic violence, child abuse Potential Barriers to Communication - correct answer - Curiosity about you - Anxiety - Silence - Depression - Crying and Compassionate Moments - Seduction - Anger - Financial Considerations 2 goals of a patient history - correct answer 1. identify what the patient's problem is 2. establish reliability of the patient Why is it important to complete a review of systems after a history? - correct answer to identify complementary or symptoms that may seem unrelated Tips when discussing a sensitive topic - correct answer provide privacy, direct & firm, no apologies, no judgement, avoid confrontation, no jargon, document carefully 4 steps in approaching the examination of sensitive areas - correct answer 1. introduction & why 2. open ended questions to explore pt's feelings 3. repeat what's been said & give feedback 4. take questions from pt TACE questions - correct answer Does it *T*ake more than two drinks to get you drunk? Have people *A*nnoyed you by criticizing your drinking? Have you ever felt you ought to *C*ut down on your drinking? Have you ever had a drink first thing in the morning to steady your nerves (*E*ye opener)? Partner Violence Screen - correct answer Have you been hit, kicked, punched or otherwise hurt by someone within the past year? Do you feel safe in your current relationship? Is there a partner from a previous relationship who is making you feel unsafe now? HITS tool - correct answer Hurt Insult Threaten Scream *for intimate partner violence FICA tool for spiritual assessment - correct answer Faith, belief, meaning Importance & influence Community Action in care Sexuality History Goal - correct answer identify risk factors for unintentional pregnancy or STIs 5 P's of sexual history - correct answer Partners Prevention of pregnancy Protection from STIs Practices Past history of STIs Functional Assessment - correct answer screens the safety of independent living and ability to perform ADLs, the need for home health services, and quality of life Functional assessment questions - correct answer mobility, upper extremity function, housework, instrumental ADLs pediatric triad - correct answer practitioner, parent & child Consent by proxy - correct answer process by which people with legal right to consent to a medical treatment for themselves or for a minor/ward delegates that right to another person developmental milestone examples - correct answer holds head erect, stands alone, rolls over, walks alone, sits alone, uses words, talks in sentences, dresses self, age of potty training, dentition, pubertal development HEEADSSS TOOL - correct answer Home Education and employment Eating Activities Drugs Sexuality Suicide and depression Safety **adolescent screening tool PACES TOOL - correct answer parents / peers accidents cigarettes emotional issues school / sexuality **adolescent screening tool fraility - correct answer 80 y/o;; ^ loss of physical function & independence, decreased physical reserve diagnostics - correct answer tests that need performed or ordered to develop a plan of care PAMI list - correct answer Patient's medical problems Allergies with reaction Medications with doses Instructions of how administered / immunizations OLD CARTS - correct answer Onset Location Duration Characteristics Aggravating and Alleviating Factors Related Symptoms Temporal factors -- frequency & occurance Severity Sensitive Patient health information - correct answer HIV status substance abuse mental health conditions Terms to describe current condition status - correct answer stable uncontrolled resovled cranial nerves - correct answer 12 pairs of nerves that carry messages to and from the brain