NR 509 PHYSICAL ASSESSMENT COMPLETE
STUDY GUIDE QUESTIONS AND VERIFIED
ANSWERS
●● 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 present illness, only the system related to the
problem in the ROS
●● 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 area of
PMhx, family hx, social hx, at least 10 ROS
●● subjective data
,Answer: Subjective data includes symptoms that the client describes
such as a sore throat, headache, or pain. It also includes the client's
feelings, perceptions, and concerns
●● objective data
Answer: Objective data includes the physical examination findings or
signs observed. Information obtained from the client during any part of
the health history is considered subjective data. All physical
examinations, laboratory information, and test data are considered
objective data
●● initial encounter
Answer: -review the clinical record
-ensure the client is comfortable
-clarify the goals/agenda for the encounter
-establish rapport
-identify client's preferred title, name, and gender pronouns
-use "people first" language (i.e. hearing loss, wheelchair)
-identify the c/o
-open-ended approach for client's story
-gather information about the client's perspective of the illness using the
FIFE (feelings, ideas, function, expectations)
-conduct health history interview
,-gather information about PMHx, meds, allergies, family, personal and
social, ROS
●● "How would you describe your sexual identity?"
"How would you describe your gender identity?"
"What is the sex on your original birth certificate?"
Answer:
●● Basic Interviewing Skills
Answer: -active listening-closely attending to what the pt is
communicating, connect to pt's emotional state, use verbal and
nonverbal skills
-empathy- the capacity to identify with the pt and feel the pt's pain as
your own
-guided questioning- allows for interviewer to facilitate full
communications
-validating- affirm legitimacy of pt's emotional experience
-empowerment; encourage pt to ask questions
-partnering; express your commitment to ongoing relationship
-transitioning; inform your pt when you are changing directions
-reassuring; help the pt feel that their problems have been heard
- summarizing; giving a summary of the pt's story to communicate that
you have been carefully listening
-nonverbal communication
, -people first language --> ex. patient with diabetes instead of diabetic
●● history of present illness
Answer: The history of the present illness is a concise, clear, and
chronological description of the chief complaint which prompted the
client's visit. A symptom analysis guided by the mnemonic OLD CARTS
will reveal information regarding the onset, location, duration,
characteristics, aggravating factors, relieving factors, treatments, and
severity of the symptoms. There are other mnemonics and variations of
OLD CARTS that may also be used to guide in gathering information
about the chief complaint.
●● personal and social history
Answer: The Five P's:
-partners
-practices
-protection from STIs
-Past hx of STIs
-Pregnancy plans
-Plus-- assess for trauma, violence, sexual health concerns, provide
support for sexual orientation and gender identity
●● assessment questions with the related symptom attribute
STUDY GUIDE QUESTIONS AND VERIFIED
ANSWERS
●● 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 present illness, only the system related to the
problem in the ROS
●● 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 area of
PMhx, family hx, social hx, at least 10 ROS
●● subjective data
,Answer: Subjective data includes symptoms that the client describes
such as a sore throat, headache, or pain. It also includes the client's
feelings, perceptions, and concerns
●● objective data
Answer: Objective data includes the physical examination findings or
signs observed. Information obtained from the client during any part of
the health history is considered subjective data. All physical
examinations, laboratory information, and test data are considered
objective data
●● initial encounter
Answer: -review the clinical record
-ensure the client is comfortable
-clarify the goals/agenda for the encounter
-establish rapport
-identify client's preferred title, name, and gender pronouns
-use "people first" language (i.e. hearing loss, wheelchair)
-identify the c/o
-open-ended approach for client's story
-gather information about the client's perspective of the illness using the
FIFE (feelings, ideas, function, expectations)
-conduct health history interview
,-gather information about PMHx, meds, allergies, family, personal and
social, ROS
●● "How would you describe your sexual identity?"
"How would you describe your gender identity?"
"What is the sex on your original birth certificate?"
Answer:
●● Basic Interviewing Skills
Answer: -active listening-closely attending to what the pt is
communicating, connect to pt's emotional state, use verbal and
nonverbal skills
-empathy- the capacity to identify with the pt and feel the pt's pain as
your own
-guided questioning- allows for interviewer to facilitate full
communications
-validating- affirm legitimacy of pt's emotional experience
-empowerment; encourage pt to ask questions
-partnering; express your commitment to ongoing relationship
-transitioning; inform your pt when you are changing directions
-reassuring; help the pt feel that their problems have been heard
- summarizing; giving a summary of the pt's story to communicate that
you have been carefully listening
-nonverbal communication
, -people first language --> ex. patient with diabetes instead of diabetic
●● history of present illness
Answer: The history of the present illness is a concise, clear, and
chronological description of the chief complaint which prompted the
client's visit. A symptom analysis guided by the mnemonic OLD CARTS
will reveal information regarding the onset, location, duration,
characteristics, aggravating factors, relieving factors, treatments, and
severity of the symptoms. There are other mnemonics and variations of
OLD CARTS that may also be used to guide in gathering information
about the chief complaint.
●● personal and social history
Answer: The Five P's:
-partners
-practices
-protection from STIs
-Past hx of STIs
-Pregnancy plans
-Plus-- assess for trauma, violence, sexual health concerns, provide
support for sexual orientation and gender identity
●● assessment questions with the related symptom attribute
