NR 509 MIDTERM EXAM STUDY GUIDE WITH EXPERT
FEEDBACK/NEWEST UPDATE
Focused Assessment - (ANSWER)-Addresses focused concerns or symptoms
-Used for established clients during routine or urgent care visits
-Health history and physical exams are focused on the problem
-Includes:
• brief history of the present illness
• only the system related to the problem in the review of systems
Comprehensive Assessment - (ANSWER)-Used for new clients
-Provides personalized information about the client
-Strengthens the clinician-client relationship
-Provides a baseline for future assessments
-Provides an opportunity for health promotion education and counseling
-Includes:
• extended history of the present illness
• at least two areas of past medical history, family history, and social history
• at least 10 systems in the review of systems
Subjective data - (ANSWER)includes symptoms that the client describes such as a
sore throat, headache, or pain. It also includes the client's feelings, perceptions,
and concerns
Information obtained from the client during any part of the health history
,Examples of Subjective Data:
-Lower back pain
-Fatigue
-Stomach cramps
-Immunization history
Objective data - (ANSWER)includes the physical examination findings or signs
observed
All physical examinations, laboratory information, and test data
Examples of Objective Data:
-Heart rate
-Blood pressure
-Lung sounds
-Wound appearance
-Ambulation description
-Weight
Clinical Encounter Sequence (detailed) - (ANSWER)Initiate Encounter
-Review the clinical record
-Ensure the client is comfortable
-Clarify the goals/agenda for the encounter; balance provider and client goals
-Establish rapport
,-Identify the client's preferred title, name, and gender pronouns
-Use "people first" language (i.e., a person with hearing loss, a person who uses a
wheelchair)
Gather Information
-ID the client's chief complaint or reason for seeking care
-Invite the client's story using an open-ended approach
-Gather information about the client's perspective of the illness using the
mnemonic FIFE
-Conduct the health history interview
-Gather information about past medical history, medications and allergies, family
history, personal and social history, and ROS
Perform the Physical Exam
-Conduct the exam based on the information obtained from the health history
-Maintain client's comfort and privacy throughout the exam
Explain and Plan
-Assess and respond to the client's needs for information
-Negotiate and make decisions together
-Utilize teach-back to ensure the client understands the plan
Close the Encounter
, -Leave time for the client to ask questions
-Summarize the plans for future evaluation, treatments, and follow up
The general sequence of a clinical encounter is to: - (ANSWER)-initiate the
encounter
-gather information
-perform a physical exam
-develop a shared plan
-close the encounter
FIFE mnemonic - (ANSWER)Feelings
Ideas
Function
Expectations
-A mnemonic for the patient's perspective on the illness
• The patient's Feelings, including fears or concerns, about the problem
• The patient's Ideas about the nature and the cause of the problem
• The effect of the problem on the patient's life and Function
• The patient's Expectations of the disease, of the clinician, or of health care,
often based on prior personal or family experiences
FEEDBACK/NEWEST UPDATE
Focused Assessment - (ANSWER)-Addresses focused concerns or symptoms
-Used for established clients during routine or urgent care visits
-Health history and physical exams are focused on the problem
-Includes:
• brief history of the present illness
• only the system related to the problem in the review of systems
Comprehensive Assessment - (ANSWER)-Used for new clients
-Provides personalized information about the client
-Strengthens the clinician-client relationship
-Provides a baseline for future assessments
-Provides an opportunity for health promotion education and counseling
-Includes:
• extended history of the present illness
• at least two areas of past medical history, family history, and social history
• at least 10 systems in the review of systems
Subjective data - (ANSWER)includes symptoms that the client describes such as a
sore throat, headache, or pain. It also includes the client's feelings, perceptions,
and concerns
Information obtained from the client during any part of the health history
,Examples of Subjective Data:
-Lower back pain
-Fatigue
-Stomach cramps
-Immunization history
Objective data - (ANSWER)includes the physical examination findings or signs
observed
All physical examinations, laboratory information, and test data
Examples of Objective Data:
-Heart rate
-Blood pressure
-Lung sounds
-Wound appearance
-Ambulation description
-Weight
Clinical Encounter Sequence (detailed) - (ANSWER)Initiate Encounter
-Review the clinical record
-Ensure the client is comfortable
-Clarify the goals/agenda for the encounter; balance provider and client goals
-Establish rapport
,-Identify the client's preferred title, name, and gender pronouns
-Use "people first" language (i.e., a person with hearing loss, a person who uses a
wheelchair)
Gather Information
-ID the client's chief complaint or reason for seeking care
-Invite the client's story using an open-ended approach
-Gather information about the client's perspective of the illness using the
mnemonic FIFE
-Conduct the health history interview
-Gather information about past medical history, medications and allergies, family
history, personal and social history, and ROS
Perform the Physical Exam
-Conduct the exam based on the information obtained from the health history
-Maintain client's comfort and privacy throughout the exam
Explain and Plan
-Assess and respond to the client's needs for information
-Negotiate and make decisions together
-Utilize teach-back to ensure the client understands the plan
Close the Encounter
, -Leave time for the client to ask questions
-Summarize the plans for future evaluation, treatments, and follow up
The general sequence of a clinical encounter is to: - (ANSWER)-initiate the
encounter
-gather information
-perform a physical exam
-develop a shared plan
-close the encounter
FIFE mnemonic - (ANSWER)Feelings
Ideas
Function
Expectations
-A mnemonic for the patient's perspective on the illness
• The patient's Feelings, including fears or concerns, about the problem
• The patient's Ideas about the nature and the cause of the problem
• The effect of the problem on the patient's life and Function
• The patient's Expectations of the disease, of the clinician, or of health care,
often based on prior personal or family experiences
