NUR 3065 - exam 1 Questions With Complete Solutions
1. biographic data Correct Answers name, address, phone #,
age/DOB, marital status, occupation, etc.
source of history: judge the reliability
10 interview pitfalls Correct Answers false reassurance, giving
unwanted advice, authority, avoidance language, distancing,
biased Q "you don't smoke, do you", professional jargon, why
Q, talking too much, interrupting
2. reason for seeking care Correct Answers signs/symptoms;
quick quote or paraphrased sentence on why pt is seeking care
-in pt's own care
3. present health or history of present illness Correct Answers -
provide short sentence ab general health
-if ill, ask PQRSTU
4 inner factors for interview Correct Answers liking others,
empathy, ability to listen, self-awareness
-having a general liking towards people, optimistic, assumption
for strength/tolerance for weakness
-empathy: seeing pt in their perspective, while still keeping your
own
-ability to listen: active listening is key; look at not only what
they say but how they say it
-self-awareness: know your vales/bias/responses well...your
unintentional responses can negatively impact communication
with pt
,4 types of patient data: 2. focused/problem-centered database
Correct Answers aka episodic database
-"mini", smaller scope, concerns mainly one problem, one body
system, or one-cue complex
-used in all settings
ex. 2 days post-op, a hospitalized pt has a congested cough,
shortness of breath, fatigue...history and exam focus primarily
on respiratory and cardiovasc system
ex. outpatient clinic has a pt with a rash...history follows the
direction of this concern
4 types of patient data: 3. follow-up Correct Answers -already
know the patient, evaluate at regular, appropriate intervals
-think ab questions like what changes have occurred? problem
better or worse? which coping strats used?
-used in all settings to follow up both short-term and chronic
health pts
ex. heart failure pt: follow up with primary practitioner to re-
eval. meds, identify changes in symptoms, coping strats
4 types of patient data: 4. emergency database Correct Answers
urgent, rapid collection of data while simultaneously taking
lifesaving measures
-diagnosis is swift and sure
-ask Q while assessing ABCs, LOC, disability
-get info ASAP before pt bc unresponsive (if they are...rely on
family and friends for answers)
once person is stable, get a complete database
ex. ED, ask "what did you take, when, how much?"
,4 types of patient data: complete 1. (total health) database
Correct Answers -pt may have many issues or unknown
pathology
-complete health history (current and past health status) and full
physical exam
-often in primary care settings (college health services,
peds/family practice clinics, community health agencies)...where
healthcare provider is the only one seeing the patient
-a complete database helps establish and strengthen bond with
the patient
-must screen pathology for all well and ill pts and find ways to
respond to pathology
-acute hospital care: complete database is performed once pt is
admitted
-data specific to pathology collected by physician
4. past history Correct Answers -childhood & chronic
illnesses/injuries
-hospitalizations
-obstetric Hx
-immunities
-medications
-last exam and results
4. past history: allergies Correct Answers record allergies in
food, drugs (only list true drug allergies...not ones with
unpleasant side effects, environment)
-note the allergy and the type of reaction it causes
NKA = no known allergies
NKDA = no known drug allergies
, 4. past history: medicine Correct Answers look at rx, OTC,
herbal meds, supplements
-remember 5 rights: right pt, right drug, right dose, right route,
tight time
(patient, drug, dose, route, time)
4. past history: obstetric Hx Correct Answers GTPAL
G (gravida # pregnancies) T (to term) P (preterm) A (abortions,
miscarriages) L (living)
if GP first... G # pregnancies P para # to full term
G4P2022 (4 pregnancies, 2 full term, 0 preemies, 2 abortions, 2
living)
5. family history (FHx) Correct Answers record all conditions
for all relatives, their relationship to the parent, if they're alive or
deceased, how long?
6. social history (SHx) - ADLs Correct Answers ALDs =
activities of daily living
self esteem/self-concept (education, religious practices),
coping/stress mechanisms, drugs/alcohol/tobacco (list pack
years), activity level, nutrition/elimination, relationships, sleep
habits, environmental hazards/occupational health
7. ROS (review of systems) Correct Answers general health
overview, head to toe
-write "pt denies" if not applicable
NOT the physical exam, HH is subjective...what is reported not
what is found through examination (essentially an extension of
the past history)
1. biographic data Correct Answers name, address, phone #,
age/DOB, marital status, occupation, etc.
source of history: judge the reliability
10 interview pitfalls Correct Answers false reassurance, giving
unwanted advice, authority, avoidance language, distancing,
biased Q "you don't smoke, do you", professional jargon, why
Q, talking too much, interrupting
2. reason for seeking care Correct Answers signs/symptoms;
quick quote or paraphrased sentence on why pt is seeking care
-in pt's own care
3. present health or history of present illness Correct Answers -
provide short sentence ab general health
-if ill, ask PQRSTU
4 inner factors for interview Correct Answers liking others,
empathy, ability to listen, self-awareness
-having a general liking towards people, optimistic, assumption
for strength/tolerance for weakness
-empathy: seeing pt in their perspective, while still keeping your
own
-ability to listen: active listening is key; look at not only what
they say but how they say it
-self-awareness: know your vales/bias/responses well...your
unintentional responses can negatively impact communication
with pt
,4 types of patient data: 2. focused/problem-centered database
Correct Answers aka episodic database
-"mini", smaller scope, concerns mainly one problem, one body
system, or one-cue complex
-used in all settings
ex. 2 days post-op, a hospitalized pt has a congested cough,
shortness of breath, fatigue...history and exam focus primarily
on respiratory and cardiovasc system
ex. outpatient clinic has a pt with a rash...history follows the
direction of this concern
4 types of patient data: 3. follow-up Correct Answers -already
know the patient, evaluate at regular, appropriate intervals
-think ab questions like what changes have occurred? problem
better or worse? which coping strats used?
-used in all settings to follow up both short-term and chronic
health pts
ex. heart failure pt: follow up with primary practitioner to re-
eval. meds, identify changes in symptoms, coping strats
4 types of patient data: 4. emergency database Correct Answers
urgent, rapid collection of data while simultaneously taking
lifesaving measures
-diagnosis is swift and sure
-ask Q while assessing ABCs, LOC, disability
-get info ASAP before pt bc unresponsive (if they are...rely on
family and friends for answers)
once person is stable, get a complete database
ex. ED, ask "what did you take, when, how much?"
,4 types of patient data: complete 1. (total health) database
Correct Answers -pt may have many issues or unknown
pathology
-complete health history (current and past health status) and full
physical exam
-often in primary care settings (college health services,
peds/family practice clinics, community health agencies)...where
healthcare provider is the only one seeing the patient
-a complete database helps establish and strengthen bond with
the patient
-must screen pathology for all well and ill pts and find ways to
respond to pathology
-acute hospital care: complete database is performed once pt is
admitted
-data specific to pathology collected by physician
4. past history Correct Answers -childhood & chronic
illnesses/injuries
-hospitalizations
-obstetric Hx
-immunities
-medications
-last exam and results
4. past history: allergies Correct Answers record allergies in
food, drugs (only list true drug allergies...not ones with
unpleasant side effects, environment)
-note the allergy and the type of reaction it causes
NKA = no known allergies
NKDA = no known drug allergies
, 4. past history: medicine Correct Answers look at rx, OTC,
herbal meds, supplements
-remember 5 rights: right pt, right drug, right dose, right route,
tight time
(patient, drug, dose, route, time)
4. past history: obstetric Hx Correct Answers GTPAL
G (gravida # pregnancies) T (to term) P (preterm) A (abortions,
miscarriages) L (living)
if GP first... G # pregnancies P para # to full term
G4P2022 (4 pregnancies, 2 full term, 0 preemies, 2 abortions, 2
living)
5. family history (FHx) Correct Answers record all conditions
for all relatives, their relationship to the parent, if they're alive or
deceased, how long?
6. social history (SHx) - ADLs Correct Answers ALDs =
activities of daily living
self esteem/self-concept (education, religious practices),
coping/stress mechanisms, drugs/alcohol/tobacco (list pack
years), activity level, nutrition/elimination, relationships, sleep
habits, environmental hazards/occupational health
7. ROS (review of systems) Correct Answers general health
overview, head to toe
-write "pt denies" if not applicable
NOT the physical exam, HH is subjective...what is reported not
what is found through examination (essentially an extension of
the past history)
