NUR 305 ASSESSMENT EXAM 1 STUDY GUIDE
Name the phases of the interview process - Answer -1. Preinteraction phase
2. Beginning pahse
3. Working phase
4. Closing phase
Preinteraction phase - Answer -you collect data from the medical record, including the
previous history of medical illness or surgeries, current medication list, and problem list
in the preinteraction phase.
Beginning phase - Answer --introduce yourself by name and state the purpose of the
interview.
-ask the patient how he or she would like to be addressed
-discussion of some neutral areas, such as weather
Working phase - Answer -you collect data by asking specific questions.
Closed-ended questions are best used for... - Answer -specific information that yields a
yes or no answers
Open-ended questions are best used for... - Answer --require patient's to provide more
information than yes or no.
-they are broad and yield responses for the patient to answer in their own words.
What kind of questions should you avoid in the working phase? - Answer -"why"
questions, they could confusion the patient or the patient could find them difficult to
answer.
Closing phase - Answer --you end the interview by summarizing and stating what the
two or three most important patterns or problems might be
-for example, "it seems that you are most concerned about the control of your pain.
Would you agree?
Primary data - Answer -the individual patient is considered the primary data source
Secondary data - Answer -charts and information from family members are considered
secondary data sources
Reliable historian - Answer -provides information that is consistent with existing records
and is comprehensive in scope
Inaccurate historian - Answer -if information differs from past descriptions, or if details
change each time, the patient may be unreliable
, Components of health history - Answer -1. Demographic data
2. Reason for seeking care (aka chief complaint)
3. HPI
4. Past Health History
5. Current Medications
6. Allergies
7. Family History
8. Functional Assessment
9. Review of Systems
10. Psychosocial
11. Sexual History
In what order should you collect the components of health history? - Answer -collect
demographic data first and then elicit from the patient a complete description of the
reason for seeking health care
Demographic data - Answer -name, date of birth, address, and billing information
Reason for seeking care - Answer -brief statement, usually in the patient's own words,
about why he or she is making the visit
Emergency health history components - Answer -care focuses on gathering information
so that interventions can resolve the immediate problem. Assessment and interventions
are concurrent
Purpose of emergency health history - Answer -nurses collect the most important
information and defer obtaining details until patients are stable. They elicit reason for
seeking care along with current health problems, medications, and allergies.
Focused health history purpose - Answer -the focused health history involves questions
that relate to the current situation
Focused health history components - Answer -example: patient visits primary care
provider about cough. Nurse asks about length, severity, and timing of cough, and other
related factors. Nurses do not perform a complete review of systems.
Comprehensive health history purpose - Answer -takes place during an annual physical
examination, for sports participation screening, and during a hospital admission
Comprehensive health history components - Answer -includes demographic data, full
description of the reason for seeking care, individual health history, family history,
functional status, and history in all physical and psychological areas.
OLDCARTS - Answer -Onset, Location, Duration, Character, Associated/Aggravating
factors, Relieving Factors, Timing, Severity
Name the phases of the interview process - Answer -1. Preinteraction phase
2. Beginning pahse
3. Working phase
4. Closing phase
Preinteraction phase - Answer -you collect data from the medical record, including the
previous history of medical illness or surgeries, current medication list, and problem list
in the preinteraction phase.
Beginning phase - Answer --introduce yourself by name and state the purpose of the
interview.
-ask the patient how he or she would like to be addressed
-discussion of some neutral areas, such as weather
Working phase - Answer -you collect data by asking specific questions.
Closed-ended questions are best used for... - Answer -specific information that yields a
yes or no answers
Open-ended questions are best used for... - Answer --require patient's to provide more
information than yes or no.
-they are broad and yield responses for the patient to answer in their own words.
What kind of questions should you avoid in the working phase? - Answer -"why"
questions, they could confusion the patient or the patient could find them difficult to
answer.
Closing phase - Answer --you end the interview by summarizing and stating what the
two or three most important patterns or problems might be
-for example, "it seems that you are most concerned about the control of your pain.
Would you agree?
Primary data - Answer -the individual patient is considered the primary data source
Secondary data - Answer -charts and information from family members are considered
secondary data sources
Reliable historian - Answer -provides information that is consistent with existing records
and is comprehensive in scope
Inaccurate historian - Answer -if information differs from past descriptions, or if details
change each time, the patient may be unreliable
, Components of health history - Answer -1. Demographic data
2. Reason for seeking care (aka chief complaint)
3. HPI
4. Past Health History
5. Current Medications
6. Allergies
7. Family History
8. Functional Assessment
9. Review of Systems
10. Psychosocial
11. Sexual History
In what order should you collect the components of health history? - Answer -collect
demographic data first and then elicit from the patient a complete description of the
reason for seeking health care
Demographic data - Answer -name, date of birth, address, and billing information
Reason for seeking care - Answer -brief statement, usually in the patient's own words,
about why he or she is making the visit
Emergency health history components - Answer -care focuses on gathering information
so that interventions can resolve the immediate problem. Assessment and interventions
are concurrent
Purpose of emergency health history - Answer -nurses collect the most important
information and defer obtaining details until patients are stable. They elicit reason for
seeking care along with current health problems, medications, and allergies.
Focused health history purpose - Answer -the focused health history involves questions
that relate to the current situation
Focused health history components - Answer -example: patient visits primary care
provider about cough. Nurse asks about length, severity, and timing of cough, and other
related factors. Nurses do not perform a complete review of systems.
Comprehensive health history purpose - Answer -takes place during an annual physical
examination, for sports participation screening, and during a hospital admission
Comprehensive health history components - Answer -includes demographic data, full
description of the reason for seeking care, individual health history, family history,
functional status, and history in all physical and psychological areas.
OLDCARTS - Answer -Onset, Location, Duration, Character, Associated/Aggravating
factors, Relieving Factors, Timing, Severity
