Study Questions and Answers 100% Correct
Grade A - Chamberlain
1. Focused Assessment
Answer> -Addresses focused concerns or symptoms
-Used for established clients during routine or urgent care visits
-Health history and physical exams are focused on the problem
-Includes
• brief history of the present illness
• only the system related to the problem in the review of systems
2. Comprehensive Assessment
Answer> -Used for new clients
-Provides personalized information about the client
-Strengthens the clinician-client relationship
-Provides a baseline for future assessments
-Provides an opportunity for health promotion education and counseling
-Includes
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,extended history of the present illness
• at least two areas of past medical history, family history, and social history
• at least 10 systems in the review of systems
3. Subjective data
Answer> includes symptoms that the client describes such as a sore throat,
headache, or pain. It also includes the client's feelings, perceptions, and
concerns
Information obtained from the client during any part of the health history
Examples of Subjective Data
-Lower back pain
-Fatigue
-Stomach cramps
-Immunization history
4. Objective data
Answer> includes the physical examination findings or signs observed All
physical examinations, laboratory information, and test data
Examples of Objective Data
-Heart rate
-Blood pressure
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,-Lung sounds
-Wound appearance
-Ambulation description
-Weight
5. Clinical Encounter Sequence (detailed)
Answer> Initiate Encounter
-Review the clinical record
-Ensure the client is comfortable
-Clarify the goals/agenda for the encounter; balance provider and client goals
-Establish rapport
-Identify the client's preferred title, name, and gender pronouns
-Use "people first" language (i.e., a person with hearing loss, a person who uses a
wheelchair)
Gather Information
-ID the client's chief complaint or reason for seeking care
-Invite the client's story using an open-ended approach
-Gather information about the client's perspective of the illness using the mnemonic
FIFE
-Conduct the health history interview
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, -Gather information about past medical history, medications and allergies, family
history, personal and social history, and ROS
Perform the Physical Exam
-Conduct the exam based on the information obtained from the health history
-Maintain client's comfort and privacy throughout the exam
Explain and Plan
-Assess and respond to the client's needs for information
-Negotiate and make decisions together
-Utilize teach-back to ensure the client understands the plan
Close the Encounter
-Leave time for the client to ask questions
-Summarize the plans for future evaluation, treatments, and follow up
6. The general sequence of a clinical encounter is to
Answer> -initiate the encounter
-gather information
-perform a physical exam
-develop a shared plan
-close the encounter
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