Advanced Health Assessment Midterm Study Guide

Advanced Health Assessment
Midterm Study Guide With
Correct Answers
 S O A P note - correct-answers-a method of documentation employed by health
care providers to write out notes in a patient's chart
Subjective, Objective, Assessment and Plan
 A B C D skin lesion assessment - correct-answers-Asymmetry
Border irregularity
Color isn't uniform
Diameter >6cm (pencil eraser)
Evolving size, shape and color
 Preferred qualities of a first impression - correct-answers-honesty, candor,
openness, flexibility, eager, explanatory, open to questions
 patient centered care - correct-answers-providing care that is respectful of and
responsive to individual patient preferences, needs, and values and ensuring
that patient values guide all clinical decisions
 4 C's of effective communication - correct-answers-courtesy
comfort
connection
confirmation
 Open ended questions goal - correct-answers-patient's description of answer
 direct question goal - correct-answers-seeking specific information
 Leading question goal - correct-answers-Limiting information to one focus /
subject
 Reasons patients avoid the full story of the illness - correct-answers-dementia,
alcoholism, illness, sexual uncertainties, domestic violence, child abuse
 Potential Barriers to Communication - correct-answers-- Curiosity about you
o Anxiety
o Silence

, o Depression
o Crying and Compassionate Moments
o Seduction
o Anger
o Financial Considerations
 2 goals of a patient history - correct-answers-1. identify what the patient's
problem is
2. establish reliability of the patient
 Why is it important to complete a review of systems after a history? - correct-
answers-to identify complementary or symptoms that may seem unrelated
 Tips when discussing a sensitive topic - correct-answers-provide privacy, direct
& firm, no apologies, no judgement, avoid confrontation, no jargon, document
carefully
 4 steps in approaching the examination of sensitive areas - correct-answers-1.
introduction & why
2. open ended questions to explore pt's feelings
3. repeat what's been said & give feedback
4. take questions from pt
 TACE questions - correct-answers-Does it *T*ake more than two drinks to get
you drunk?
Have people *A*nnoyed you by criticizing your drinking?
Have you ever felt you ought to *C*ut down on your drinking?
Have you ever had a drink first thing in the morning to steady your nerves (*E*ye
opener)?
 Partner Violence Screen - correct-answers-Have you been hit, kicked, punched
or otherwise hurt by someone within the past year?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is making you feel unsafe
now?
 HITS tool - correct-answers-Hurt
Insult

, Threaten
Scream
 *for intimate partner violence
 FICA tool for spiritual assessment - correct-answers-Faith, belief, meaning
Importance & influence
Community
Action in care
 Sexuality History Goal - correct-answers-identify risk factors for unintentional
pregnancy or STIs
 5 P's of sexual history - correct-answers-Partners
Prevention of pregnancy
Protection from STIs
Practices
Past history of STIs
 Functional Assessment - correct-answers-screens the safety of independent
living and ability to perform ADLs, the need for home health services, and quality
of life
 Functional assessment questions - correct-answers-mobility, upper extremity
function, housework, instrumental ADLs
 pediatric triad - correct-answers-practitioner, parent & child
 Consent by proxy - correct-answers-process by which people with legal right to
consent to a medical treatment for themselves or for a minor/ward delegates that
right to another person
 developmental milestone examples - correct-answers-holds head erect, stands
alone, rolls over, walks alone, sits alone, uses words, talks in sentences, dresses
self, age of potty training, dentition, pubertal development
 HEEADSSS TOOL - correct-answers-Home
Education and employment
Eating
Activities
Drugs