NUR 643E Final Physical Exam Assessment With complete solution Newest 2025

NUR 643E Final Physical Exam
Assessment With complete solution
Newest 2025
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Initial Approach and History Taking
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Hi, my name is Samantha. I am the registered nurse that will be completing your physical
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exam. I am just going to gather my supplies and then we will get started.
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Perform hand hygiene. I I I I I I I I I I

Needed supplies: gloves, alcohol swabs, cotton ball, cotton swab, tongue depressor,
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ophthalmoscope, otoscope, reflex hammer, stethoscope
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Initial Approach and History Taking I I I

Obtain patient identification information.
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Can you tell me your name and date of birth?
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How old are you?
Gender?
Race? I I I I

Initial Approach and History Taking
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What brings you in today? Are you having any pain or other issues?
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Can you tell me more about the pain.
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Use OPQRST I I I I I I I I I I I

Onset: when did the symptoms first begin? Was it gradual or sudden? I I I I I I I I I I I I I

Provocative or Palliative: What were you doing when the symptoms started? what makes it
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better? I I I I I I I

Quality and Quantity: Can yo describe the pain?
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Region or Radiation: can you point to where the pain is at? Does it radiate anywhere?
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Severity: how bad is the pain right now on a scale of 0-10? what is the worst it has been?
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Timing and Treatment: how long do the symptoms last? Are they intermittent or does it come
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and go? Is there anything you are doing for the pain?
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Past Medical History I I I

Must complete by memory! I I I I I I I I I I I I I I I

-General Health: when was your last physical exam? Do you know the date? Were there any
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concerns?
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-Chronic Illnesses: do you have any chronic medical conditions? If so, when did they start
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and how were/are they being treated?
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-Do you have a known history of any infectious diseases? If so, what and how were/are they
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treated?
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-Do you have any allergies? To medication, food or environmental?
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-Have you ever had surgery? If so, what surgery? Were there complications? Did they use

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anesthesia?
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-Have you ever had any injuries?
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-Have you ever been hospitalized? If so, for what?
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-Are all of your immunizations up to date? Including your childhood, Tdap, Influenza and
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COVID vaccines?
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-If female, do you see a gynecologist? When was your last well woman exam? When was
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your last PAP Smear? Do you complete monthly self breast exams? When was your last
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period?
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-If male, do you complete monthly testicular exams?
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Sexual History: The 5 Ps I I I I I I I I I I I I I I

Partners: Are you currently having sex? How many partners do you currently have? Are you
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or your partner having sex with others?
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Practices: What kind of sex do you participate in? Oral, genital or anal?
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Protection: Do you and your partner(s) use protection? What kind? Have you received the
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HPV or Hepatitis A/B vaccines? If applicable, do you use pre-exposure prophylactic
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medications or PrEp?
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Past STIs: Have you ever been tested for STIs or HIV? Have you ever been diagnosed with
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an STI or HIV? If so, did you get treatment? Do your partner(s) have STIs?
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Pregnancy: Do you have intentions of getting pregnant? If not, are you using measures to
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prevent it? I

Family History
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Can you please tell me the health status, age, and if applicable the cause of death for the
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following family members: I

-Paternal grandparents I

-Maternal grandparents
-Mother
-Father
-Siblings
-Children I I I

Family History Disease Presence
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Next, I am going to name some diseases. Please tell me if there is a presence of the named
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disease in your grandparents, parents, siblings or children.I I I

-Cancer or Bleeding Disorders I

-Neurological Disease
-Seizures I I

-Mental/Emotional Health Disorders I

-Substance Abuse

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-Endocrine Disease I

-Cardiovascular Disease I

-Pulmonary Disease
-Obesity
-Osteoporosis I

Social History I I I

-Where were you born? I I I

-What is your nationality? I I I I

-What is your marital status?
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-Do you have children?
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-Do you feel safe at home?
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-Do yo have any concerns for your safety? -Are you ever exposed to violence?
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-Do you have military history? I I I

-What is your occupation? I I I I

-What is your living arrangements?
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-How well do you sleep at night?
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-How would your describe your current emotional state? I I I

Mnemonic for Social History I I I I I I

Brave - Born (Where were you born)
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New - Nationality/race (What is your nationality) I I I I I I I I

Mothers - Marital Status (What is your marital status) I I I I I I

Carefully - Children (Do you have children)
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Shield - Safe (Do you feel safe at home) I I I I I I I

Children - Concerns (Any concerns for your safety) I I I I I

Viewing - Violence (Exposed to violence) I I I I I I

Military - Military History (Any military history) I I I I I I

Occupations - Occupation (What is your occupation)
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Like - Living Arrangements (Current living arrnagements)
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Safe - Sleep (How is your sleep) I I I I I I I I

Environments - Emotional State (how is your emotional state)
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Social History - Habits I I I I I I I I I I I I I I

-Next, lets review any habits that you may have. How would you describe the following: I I I I I I I

-Diet/nutrition (Do you eat a well balanced diet) I I I I I I I I I

-Hydration (How much water do you drink in a day) I I I I I I I I I I

-Exercise (How much activity do get in a day or week) I I I I I I I I I I I I

-Laxative use (Do you use laxatives to help you go to the restroom) I I I I I I I I

-Caffeine (How much caffeine do you drink a day)
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Do you use any of the following: I I I I I I

-Tobacco (Do you smoke or chew tobacco) I I I I I I

-Nicotine (Do you use any nicotine products)
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-Vape (Do you use vape) I I I I

-Alcohol (Do you drink alcohol) I I I I I I I

-Recreational drugs (Do you use any recreational drugs)
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If so, how frequently and what kind?