Advanced health assessment St. Thomas University Florida NUR 504

Which of the following is an example of subjective data that may be collected during a health assessment? a. Height and weight b. A patient's recall of his or her past health conditions c. Results from an abdominal CT scan d. Complete blood count - ANS-- b. A patient's recall of his or her past health conditions 1. Which of the following is true regarding the data taken in a health history? a. Most health history data are objective and measurable. b. Objective data are error-free, quantifiable data. c. Subjective data, being inherently less accurate, are of less value than objective data. d. A successful individualized plan of care must incorporate subjective data. - ANS-- d. A successful individualized plan of care must incorporate subjective data. 1. What do Coulehan and Block define as "listening to the total communication . . . and letting the patient know that you are really hearing"? a. Cultural competence b. Patience c. Empathy d. Top-tier communication - ANS-- c. Empathy 1. The provider is preparing to take a health history for a new patient. He takes the patient to a private room and asks the patient to don a hospital gown. After stepping outside to give the patient sufficient time to change, he then comes back in and asks permission to conduct the history. He sits next to the patient at eye level, discreetly observes the patient for any sensory deficits, and asks the patient if he may take brief notes of the conversation. During the conversation, he gives the patient time to answer questions fully. He makes sure that his questions do not contain technical terms and quietly observes the patient's nonverbal behaviors throughout. Which mistake did the provider make? a. He should have allowed the patient to remain fully clothed in their own clothing for their comfort. b. He should not have omitted technical terminology. Patients like having a chance to learn. c. He should have seated - ANS-- a. He should have allowed the patient to remain fully clothed in their own clothing for their comfort. 1. Which of the following is true of both comprehensive and focused health histories? a. They both include identifying data. b. They both include a social history. c. They both include a family history. d. They are both conducted in emergency situations. - ANS-- a. They both include identifying data. 1. In the mnemonic devise PQRST, which of the following includes describing the location of the symptoms? a. Precipitating factors b. Quality c. Radiation d. Severity - ANS-- b. Quality 1. What is the current mnemonic device for taking a health history? a. PQRST b. CLIENT OUTCOMES c. PRACTICE d. GOOD MEDICINE - ANS-- b. CLIENT OUTCOMES 1. When taking a PMI, which of the following is correct? a. Do not take the statement "I'm allergic to. . . " at face value. b. Ask the patient for a very brief summary of their current health. c. If a patient states that they have been vaccinated with BCG, make sure to administer a PPD test. d. CAM documentation is no longer a requirement. - ANS-- a. Do not take the statement "I'm allergic to. . . " at face value. 1. Which of the following is a first-degree relative to the patient who has experienced premature onset of CVD? a. Sister at 62 b. Cousin at 62 c. Aunt at 59 d. Grandfather at 44 - ANS-- a. Sister at 62 1. Recording the patient's occupation falls under which category? a. PHI b. FH c. SH d. ROS - ANS-- c. SH 1. A focused ROS: a. involves a wider range and shallower level of questions than a comprehensive ROS. b. includes questions directed toward the systems most likely to be involved in the patient's symptoms. c. includes questions seeking significant positives to narrow down the body systems affected. d. covers all body systems. - ANS-- b. includes questions directed toward the systems most likely to be involved in the patient's symptoms. 1. A patient comes to the clinic complaining of repeated headaches and lightheadedness. As the provider takes a health history, he or she should: a. perform a comprehensive ROS. b. skip the social history in order to focus on the current issue. c. focus her interest and questions on the patient's neurologic system. d. spend a good deal of time assessing the reliability of the information she is getting. - ANS-- c. focus her interest and questions on the patient's neurologic system. A patient's recall of his or her current health needs and past health is subject to error and is also a critical component in the caregiving process? - ANS-- True Ethnocentrism, belief in the superiority of one's own beliefs and values, is a major barrier to establishing effective patient-provider relationships? - ANS-- True A 58-year-old man at risk of diabetes, with a sedentary lifestyle and unhealthy diet, is unwilling to follow his provider's recommendations to modify his routine. Because he has not yet experienced the negative health consequences of his actions, he cannot be classified as resistant? - ANS-- False 1. When taking a patient's chief complaint, rephrase the stated reason using standard medical terminology for clarity. - ANS-- False Family history should include both parents and grandparents, if information is known. - ANS-- True Social history includes a detailed diet history, best performed as a record of food and beverage intake by the patient for a typical week, that includes things like use of salt and oil in food preparation and methods of cooking - ANS-- True What does PQRST stand for? - ANS-- 1. Precipitating factors, quality, radiation, severity, and timing 1. What are 10 body systems that compose a comprehensive review of systems? - ANS-- general/constitutional, skin, eyes, ears, nose, mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, breast, musculoskeletal, neurologic, mental/psychiatric, lymphatic, hematologic, and endocrine 1. What are the two main general considerations of physical examinations listed in the text? a. Preparation and sequence b. Medical and financial c. Patient interaction and scope d. Inspection and palpation - ANS-- c. Patient interaction and scope 1. The physician has begun her first physical examination on a new patient who has come to the clinic for a well-patient visit. Which of the following is true? a. The first thing the physician will do as part of the physical examination is perform the history. b. This will likely be a head-to-toe examination. c. As a first exam, this will likely be brief and focused. d. The patient, on his first visit, will likely be disoriented and unaware of the physician's tone and expressions. - ANS-- b. This will likely be a head-to-toe examination. 1. The physician records a sound as "tympanic." The physician has just performed which assessment technique? a. Palpation b. Auscultation c. Percussion d. Compression - ANS-- c. Percussion 1. A physician is listening to a patient's heart, but something has negatively impacted the sound. Which of the following has most likely caused this? a. Indirect rather than direct percussion b. A double-lumen stethoscope c. Lack of palpation d. Loose-fitting ear tips - ANS-- d. Loose-fitting ear tips 1. Which of the following is included on the list of basic equipment needed for a physical examination? a. Syringe b. Measuring tape c. Occult blood testing materials d. Culture media - ANS-- b. Measuring tape 1. What does a physician use the Weber and/or Rinne tests for? a. Assessing the lungs b. Performing an abdominal fluid wave text c. Testing hearing d. Observing posture and balance - ANS-- c. Testing hearing 1. The red reflex is a test of: a. the abdomen. b. the spine. c. the eyes. d. the mouth. - ANS-- c. the eyes. 1. If the physician is evaluating thoracic expansion, percussing the kidneys, and inspecting the skin for lesions, the patient is in which position? a. Patient seated and facing examiner b. Patient seated and facing away from examiner with back exposed c. Patient standing d. Patient supine with chest exposed - ANS-- b. Patient seated and facing away from examiner with back exposed 1. Which position is only performed on female patients? a. Reclining 45 degrees b. Lithotomy position c. Leaning forward reaching for toes d. Supine with abdomen exposed - ANS-- b. Lithotomy position 1. Which part of the body of a neonate should be studied first? a. Abdomen b. Chest c. Hands and feet d. Head - ANS-- d. Head 1. Which of the following assessments is specific to the geriatric patient? a. Functional b. General c. Physical d. Developmental - ANS-- a. Functional A functional assessment includes which of the following components? a. Abdominal assessment b. Visual assessment c. Assessment of flaccidity, tension, and spasticity d. Assessment of mental status and mood impairment - ANS-- d. Assessment of mental status and mood impairment The history should be performed separately from the physical examination - ANS-- False When the patient is already under the ongoing care of the clinician and presents with a specific problem-oriented complaint, the physician performs a focused physical examination. - ANS-- True Indirect percussion involves touch by instrument or object and requires no physical contact between the physician and patient. - ANS-- False The physical exam begins as the patient enters the room. - ANS-- True Jugular venous pressure is measured when the patient is reclining 45 degrees. - ANS-- True The kidneys should be examined both while the patient is supine and while the patient is seated facing away from the examiner. - ANS-- True 1. What are the positions that all adult patients will be asked to assume during a physical examination? - ANS-- Seated and facing examiner (without chest exposed and with chest exposed); seated facing examiner while reclining 45 degrees; seated and facing away; supine (with chest exposed, with abdomen exposed, with legs exposed); standing What methods are mentioned in the text to win cooperation of pediatric patients of different ages? - ANS-- Take a few minutes to establish a relaxed environment. Give a 1-year-old an object to hold in his hands. With a toddler, use a gentle pat, pleasing words, or interactive play. Allow children to touch the equipment used during the examination. Which of the following is true of healthcare institutions regarding documentation? a. To comply with HIPAA regulations, institutions must ensure that computer monitors with sensitive patient data are not left unattended. b. All institutions must follow a standard policy for posting abbreviations in documentation drawn from the AMA. c. Institutions consider drawings a fairly inaccurate way to represent a patient's systems or picture of the patient's condition. d. As of 2003, faxes may no longer be used to share patient medical information between institutions - ANS-- a. To comply with HIPAA regulations, institutions must ensure that computer monitors with sensitive patient data are not left unattended. SOAP stands for: a. standard operating and admitting procedures. b. sanitation, observation, auscultation, palpation. c. surgeons, officials, administrators, patients. d. subjective, objective, assessment, plan, - ANS-- d. subjective, objective, assessment, plan, Which of the following is recorded in documentation as direct patient quotes? a. The chief complaint and follow-up responses b. The chief complaint only c. Nothing; everything is written in precise medical terminology d. The objective information - ANS-- b. The chief complaint only 1. A patient is examined according to __________, and documentation is recorded according to __________. a. PQRST, CLIENT OUTCOMES b. body region, system c. subjective data, objective data d. the institution's system, the physician's system - ANS-- b. body region, system Which of the following is true of reporting history of present illness? a. If a patient describes having pain in the arm and numbness in the fingertips, the physician should examine these as a single unit. b. The opening sentence should contain the results from pertinent test results and test dates. c. All recent pertinent diagnostic tests and the outcomes of recent pertinent interventions should be summarized and included in the HPI. d. Medical tests that are unrelated to their current complaint should be included in the HPI. - ANS-- a. If a patient describes having pain in the arm and numbness in the fingertips, the physician should examine these as a single unit. Which is the preferred order of taking down a patient's subjective information? a. Family history, physical exam, diagnostic tests, assessment b. SOAP c. HPI, past medical history, family history, social history d. HPI, family history, physical exam, assessment - ANS-- c. HPI, past medical history, family history, social history What is a genogram? a. A genetic test performed in a doctor's office b. A visual representation or chart of a patient's family history c. A biometric monitor worn during a physical exam d. A computer report correlating information from the patient's history, exam, and diagnostic tests - ANS-- b. A visual representation or chart of a patient's family history In a physical examination, the physician spends the most attention on the patient's musculoskeletal and neurological systems. What can we deduce from this? a. The same systems were likely not explored in the review of systems. b. This is a comprehensive examination. c. Documentation from the subjective component of the patient's visit has pointed the physician to these systems. The diagnosis will be firmly established after assessment of both systems. - ANS-- c. Documentation from the subjective component of the patient's visit has pointed the physician to these systems. 1. Which of the following is the last component of gathering objective data? a. Review of systems b. Physical examination c. Assessment d. Diagnostic tests - ANS-- d. Diagnostic tests 1. Which of the following is true of a problem list that is created during the final assessment? a. It outlines the educational needs of the patient. b. It includes additional findings that are directly related to the history of present illness. c. It may include other issues that are not true diagnoses. d. Items on the problem list typically cannot be treated. - ANS-- c. It may include other issues that are not true diagnoses. 1. In the "Plan" section, the text singles out which component of the plan as critical for legal reasons? a. Education b. Nonpharmacological interventions c. "Rule outs" d. Follow-up - ANS-- a. Education 1. Which component of the treatment plan is typically reserved for hospitalized patients? a. Pharmacological interventions b. Referrals c. Nonpharmacological interventions d. Follow-ups - ANS-- c. Nonpharmacological interventions Documentation that just indicates that the healthcare provider found "no problems" is unacceptable because of lack of precision and clarity of what was asked and what was assessed - ANS-- True HIPAA regulations permit healthcare institutions to share a patient's information without their consent, but only to other accredited healthcare institutions and only if strict security measures are in place. - ANS-- False The format and extent of information gathered are different for each subclassification of the SOAP approach - ANS-- False If the patient reports that 5 years ago she had a "heart attack," it is important for the physician to note this using the patient's own terminology. - ANS-- False "Patient holds an M.A. in art history and curates a small museum; occupation calls for standing 6-7 hours a day" is an example of documentation of a patient's social history - ANS-- True The assessment plan for all patients will contain new diagnoses, differential diagnoses, and a problem list. - ANS-- False Explain what each step of SOAP stands for and why they appear in the particular order they do. - ANS-- Subjective: Any information or facts that the patient presents or that the chart provides. Objective: Data and information obtained by the examiner with his or her eyes, ears, and hands. Assessment: Pulls together the findings presented in the subjective and objective sections to form a diagnosis. Plan: Outlines the treatment plan. Each step builds chronologically on the previous one. What are the five broad categories usually explored in a patient's family history? - ANS-- Cancer Diabetes Cerebrovascular accidents Myocardial infarctions Genetic defects