NU 518 – ADVANCED HEALTH
ASSESSMENT | UNIVERSITY OF SOUTH
ALABAMA
EXAM 1: FOUNDATIONS OF HEALTH ASSESSMENT & CLINICAL
REASONING
Keywords
comprehensive health history, chief complaint, HPI, subjective data,
objective data, review of systems, past medical history, family
history, social history, CAGE screening, clinical reasoning, evidence-
based practice, priority setting, cultural competence, health literacy,
,interpreter services, documentation, SOAP note, skin assessment,
pressure ulcers, melanoma detection
Question 1
A 59-year-old patient tells the nurse practitioner that he thinks he
must have ulcerative colitis. He has been having "black stools" for
the last 24 hours. How would the nurse practitioner best document
THE FACTS for his reason for seeking care?
A) JM is a 59-year-old male here for having "black stools" for the
past 24 hours.
B) JM came into the clinic complaining of black stools for the past 24
hours.
C) JM is a 59-year-old male here for "ulcerative colitis."
D) JM, a 59-year-old male, states he has ulcerative colitis and wants
it checked.
Correct Answer: A
Rationale:
✅Correct (A): The chief complaint should be documented using the
patient's own words whenever possible, describing symptoms
rather than diagnostic labels. "Black stools" is a symptom reported
by the patient, while "ulcerative colitis" is a diagnosis the patient is
speculating about. Quoting the patient's exact words maintains
accuracy and prevents premature diagnostic labeling .
✅Incorrect (B): "Complaining of" carries negative connotations;
neutral language is preferred in documentation.
,✅Incorrect (C): The patient has not been diagnosed with ulcerative
colitis; documenting a suspected diagnosis as fact is inaccurate.
✅Incorrect (D): This documents the patient's speculation about a
diagnosis rather than the actual symptom that brought him to care.
Study Tip: "Chief complaint = patient's own words (quote marks),
symptom-focused, not diagnosis."
Question 2
A patient tells the nurse that he is allergic to penicillin. What would
be the nurse's best response to this information?
A) "Are you allergic to any other drugs?"
B) "How often have you received penicillin?"
C) "I'll write your allergy on your chart so you won't receive any."
D) "Please describe what happens to you when you take penicillin."
Correct Answer: D
Rationale:
✅Correct (D): Allergies must be documented with specific
reactions to each medication, such as rash, hives, anaphylaxis, or
nausea. The type and severity of reaction determine clinical
significance and future prescribing decisions. Simply listing
"penicillin allergy" without reaction details is incomplete and
potentially dangerous .
✅Incorrect (A): Asking about other allergies is appropriate but not
the best immediate response to the patient's statement.
, ✅Incorrect (B): Frequency of prior penicillin use is not relevant to
allergy documentation.
✅Incorrect (C): Charting the allergy is necessary, but the reaction
details must be documented first.
Study Tip: "Allergy documentation = drug name + specific reaction
(rash, hives, anaphylaxis)."
Question 3
The following information is recorded in the health history: "Patient
denies chest pain, palpitations, orthopnea, and paroxysmal
nocturnal dyspnea." Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Correct Answer: D
Rationale:
✅Correct (D): The review of systems (ROS) is a systematic
inventory of body systems that documents the presence or absence
of symptoms. Denials of cardiovascular symptoms (chest pain,
palpitations, orthopnea, PND) belong in the cardiovascular section
of the ROS. The ROS helps identify related symptoms the patient
may not have mentioned spontaneously .
ASSESSMENT | UNIVERSITY OF SOUTH
ALABAMA
EXAM 1: FOUNDATIONS OF HEALTH ASSESSMENT & CLINICAL
REASONING
Keywords
comprehensive health history, chief complaint, HPI, subjective data,
objective data, review of systems, past medical history, family
history, social history, CAGE screening, clinical reasoning, evidence-
based practice, priority setting, cultural competence, health literacy,
,interpreter services, documentation, SOAP note, skin assessment,
pressure ulcers, melanoma detection
Question 1
A 59-year-old patient tells the nurse practitioner that he thinks he
must have ulcerative colitis. He has been having "black stools" for
the last 24 hours. How would the nurse practitioner best document
THE FACTS for his reason for seeking care?
A) JM is a 59-year-old male here for having "black stools" for the
past 24 hours.
B) JM came into the clinic complaining of black stools for the past 24
hours.
C) JM is a 59-year-old male here for "ulcerative colitis."
D) JM, a 59-year-old male, states he has ulcerative colitis and wants
it checked.
Correct Answer: A
Rationale:
✅Correct (A): The chief complaint should be documented using the
patient's own words whenever possible, describing symptoms
rather than diagnostic labels. "Black stools" is a symptom reported
by the patient, while "ulcerative colitis" is a diagnosis the patient is
speculating about. Quoting the patient's exact words maintains
accuracy and prevents premature diagnostic labeling .
✅Incorrect (B): "Complaining of" carries negative connotations;
neutral language is preferred in documentation.
,✅Incorrect (C): The patient has not been diagnosed with ulcerative
colitis; documenting a suspected diagnosis as fact is inaccurate.
✅Incorrect (D): This documents the patient's speculation about a
diagnosis rather than the actual symptom that brought him to care.
Study Tip: "Chief complaint = patient's own words (quote marks),
symptom-focused, not diagnosis."
Question 2
A patient tells the nurse that he is allergic to penicillin. What would
be the nurse's best response to this information?
A) "Are you allergic to any other drugs?"
B) "How often have you received penicillin?"
C) "I'll write your allergy on your chart so you won't receive any."
D) "Please describe what happens to you when you take penicillin."
Correct Answer: D
Rationale:
✅Correct (D): Allergies must be documented with specific
reactions to each medication, such as rash, hives, anaphylaxis, or
nausea. The type and severity of reaction determine clinical
significance and future prescribing decisions. Simply listing
"penicillin allergy" without reaction details is incomplete and
potentially dangerous .
✅Incorrect (A): Asking about other allergies is appropriate but not
the best immediate response to the patient's statement.
, ✅Incorrect (B): Frequency of prior penicillin use is not relevant to
allergy documentation.
✅Incorrect (C): Charting the allergy is necessary, but the reaction
details must be documented first.
Study Tip: "Allergy documentation = drug name + specific reaction
(rash, hives, anaphylaxis)."
Question 3
The following information is recorded in the health history: "Patient
denies chest pain, palpitations, orthopnea, and paroxysmal
nocturnal dyspnea." Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
Correct Answer: D
Rationale:
✅Correct (D): The review of systems (ROS) is a systematic
inventory of body systems that documents the presence or absence
of symptoms. Denials of cardiovascular symptoms (chest pain,
palpitations, orthopnea, PND) belong in the cardiovascular section
of the ROS. The ROS helps identify related symptoms the patient
may not have mentioned spontaneously .
