Exam Study Guide – Practice
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Demographic Data - Answer✔✔-1. Date
2. Biographical information
3. client as a reliable historian
4. age, sex, marital status (single, married, widowed, divorced, partnered,
separated)
5. reason for seeking healthcare (chief complaint)
6. history of present illness/condition
Past Health History - Answer✔✔-1. Medical history (disease
processes/conditions, treatment, compliance)
2. Surgical history (any procedures and try to get the year; complications)
3. Meds - prescribed and OTC
,4. Any communicable diseases or in the past
5. Allergies (food, drug, environmental, seasonal, etc.)
6. Disabilities/handicaps - diagnosed and temporary
7. Injuries or accidents
8. Hx of blood transfusions and reactions
9. Hx of childhood illness (example: chicken pox)
10. Immunizations (up to date or need any; see CDC)
Family Health History - Answer✔✔-compile a genogram; ask about familial and
genetic diseases
Social History - Answer✔✔-alcohol, tobacco, drugs, travel, current work
environment (loud noises, etc.), what is the home environment, hazards (lead
paint, etc.), where they sleep, stressors (home, work, other), what they do for
fun, current/highest education level, economic status, religious preference,
military status, roles/relationships, culture, sexual history, patterns of daily
living
Health Maintenance - Answer✔✔-sleep (hours/night; consistency), diet (24
hour recall); exercise (how much, frequency); current safety measures
(seatbelts or sunscreen); stress management; patterns of health care (when
they go to the doctor; PCP or ED); review of symptoms
Purpose of the Physical Assessment - Answer✔✔-1. Assess the client's current
health status
2. Interpret physical data
3. Decide on interventions based on data obtained
(Data is both subjective and objective)
, Materials needed for physical assessment - Answer✔✔-ophthalmascope,
tuning fork, cotton swabs, Snellen eye chart, thermometer, penlight, tongue
depressor, ruler/tape measurer, safety pins, balance scale, gloves, nasal
speculum, vaginal speculum (vaginal exam - not part of routine care unless
specified)
Order of examination for general assessment - Answer✔✔-1. Inspection
2. Palpation
3. Percussion
4. Auscultation
Order of examination for abdominal assessment - Answer✔✔-1. Inspection
2. Auscultation
3. Percussion
4. Palpation
Inspection (what to look for) - Answer✔✔-size, shape, color, texture,
symmetry, position
ballottement - Answer✔✔-push fluid-filled tissue towards palpating hand so
object floats against fingertips
What to look for when using palpation - Answer✔✔-masses, pulsation, organ
size, tenderness or pain, swelling, tissue fullness or elasticity, vibration,
crepitus, temperature, texture, moisture