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ysi
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dEd
iti
onJ
arv
isTe
st
Ba
nk
Chap
ter05:TheComp
leteHeal
thHi
sto
ry
Ja
rvi
s:Physic
alEx
amina
tion&Heal
thAss
ess
men
t,3r
dCa
nad
iane
dit
ion
MUL
TIPL
ECHOI
CE
Th
en u
rseispre
parin
gtoc onductah eal
thhist
ory.Whichofthesest
ateme
ntsbe
st
des
cri
besthepurposeofah ealt
hh i
stor
y?
Toprov
ideanop por
tuni
tyfori
n t
eract
ionbetweenthep at
ien
ta n
dthenur
se
Toprovi
deaformf orobtai
ningthepa t
ien
t’sbi
o gr
aphicinf
ormati
on
Todocumentthenormal a
nda bnormalfi
nding
sofap hys
icalas
sessment
Toprovi
dead a
tabaseo fsubj
ectiv
ein f
ormati
ona boutthepati
ent
’s
pastandcurr
enth e
alth
ANS:
D
Thepur
poseoftheh
e a
lthhist
oryi
stocol
le
ctsub
ject
iv
edata
—whatthe
pe
rsonsay
sab ou
thimselforher
sel
f.Th
eothe
ropti
onsar
enotc
orre
ct.
DI
F:Cogni
ti
veLe
vel
:Unde
rst
andi
ng(Compre
hensi
on)
MSC:Cl
i
entNee
ds:Saf
eandEff
ect
iv
eCa r
eEnvi
ron
ment:
Man
age
men
tofCa
re
.Wh
2 ent
hen
urs
eise
val
uat
ingt
her
eli
abi
li
tyofap
ati
ent
’sr
esp
ons
es,
whi
chof
t
hes
estat
eme nt
swou l
dbec or
rec
t?Thepati
ent
:
.Ha
a sahist
o r
yofdrugabuseandth
eref
oreisnotr
eli
abl
e.
.P
b rov
ide
dc onsi
ste
ntinf
ormati
onandther
efor
eisrel
iab
le.
.S
c mil
edthr
ou gh
outint
erv
iewandther
efor
eisassumedrel
ia
ble
.
.Wo
d u
ldn
ota
nswe
rqu
est
ion
scon
cer
nin
gst
res
san
dth
ere
for
eisn
otr
eli
abl
e.
ANS:
B
Areli
abl
epe
rsona
lwaysgi
vesth
esameanswer
s,e
venwhenques
ti
onsar
e
r
e p
hrase
dorar
erepe
atedl
ateri
nth
ein
ter
vi
e w.
Theot
hers
tate
me nt
sar
enot
cor
rect
.
DI
F:Cogni
ti
veLe
vel
:Appl
yi
ng(
Appli
cat
ion)
MSC:Cl
i
entNee
ds:Saf
eandEf
fec
ti
veCa r
eEnv
ir
onme
nt:
Man
age
men
tofCa
re
A5
9-y
ear
-ol
dpa
tie
ntt
ell
sth
enu
rset
hath
eha
sul
cer
ati
vec
oli
ti
s.Heh
asb
eenh
avi
ng“
bla
ck
s
too
ls”f
ort
hep
ast24h
our
s.Ho
wwou
ldt
hen
urs
ebe
std
ocu
men
thi
sre
asonf
ors
eek
ingc
are
?
J
.M.i
sa5 9-
year
-ol
dma nse
eki
ngtr
eatmentf
orul
cer
ati
vecoli
ti
s.
J
.M.camein
tothecli
ni
ccompl
aini
ngofhavi
ngbl
ackst
oolsfort
hepast2
4hou
rs.
J
.M.i
sa5 9-
year
-ol
dma nwhost
ate
sthath
eh asu
lcer
ati
vecoli
ti
sand
want
sitche
cked.
J
.M.i
sa5 9-
year
-ol
dma nwhost
ate
sthathehasbee
nh av
ing“bla
ck
st
ools
”fort
hep as
t24hour
s.
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Ther
eas
onf
ors
ee kin gc a rei sab r i
e fs p o nta ne ou ss ta te me n tint h ep
ers
on’
sownwo
rdst
hat
d
escr
ibesth
ereas
onfort
hevis
it
. I
tsta
tesone(p
oss
ibl
ytwo)s
ign
sorsymptomsandt
hei
r
d
ura
tion.Thes
ymptomdesc
ript
ionisencl
osedi
nquot
ati
onmarkst
oin
d i
catet
he
p
ers
on ’
s
e
xac
twor
ds.
DI
F:Cogni
ti
veLe
vel
:Appl
yi
ng(
Appli
cat
ion)
MSC:Cl
i
entNee
ds:Saf
eandEf
fec
ti
veCa r
eEnv
ir
onme
nt:
Man
age
men
tofCa
re
Down
loa
dedb
yma
rlonma
rlonJ
uni
or(
ben
kig
och
i@g
mai
l
.com)
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Ph
ysi
cal
Exa
min
ati
ona
ndHe
alt
hAs
ses
sme
ntCANADI
AN3
rdEd
iti
onJ
arv
isTe
st
Stuvia.com - The Marketplace to Buy and Sell your Study Material
Ba
nk
Ap
ati
entte
ll
sthen ur
sethatsheh ashada bdomina
lpai
nfort
hep
astwe
ek.
Wha
t
wouldbethenu r
se’sbestresponse
?
“Canyoupointtowh e
reithurts?”
“We’l
ltal
kmo reaboutthatla
terintheint
e r
vie
w.”
“Whathaveyouh adtoeatinth epast24h o
urs?”
“Haveyoueverhada nysurgeriesonyourabdomen?”
ANS:
A
Afi
nalsu
mma r
yofanysympt
omtheper
sonhassh
oul
dincl
ude
,al
ongwi
ths
evenoth
er
cr
it
ica
lchar
act
eri
sti
cs,
“Loc
ati
on:Bes
peci
fi
c.”Thep
ers
onisask
edtop
oin
ttothel
oca
tio
n.
DI
F:Cogni
ti
veLe
vel
:Appl
yi
ng(
Appli
cat
ion)
MSC:Cl
i
entNee
ds:Saf
eandEf
fec
ti
veCa r
eEnv
ir
onme
nt:
Man
age
men
tofCa
re
A2
9-yea
r-o
ldwo mantel
lsthen ur
sethatshehas“excr
uci
ati
ngpai
n ”i
nher
back.Whichwo u
ldbethen urse
’sappr
op r
iat
erespons
etothewoma n
’s
stat
eme nt
?
“Howd oesyourfami
lyreacttoyourpai
n?”
“Thepainmu stbete
rri
ble.Youp r
obabl
yp i
nchedanerve
.”
“I’
vehadb ac
kp ai
nmy se
lf,anditcanbeexcruci
ati
ng.
”
“Howwo uldyousaythepa i
naffect
syourabil
it
ytodoyourdai
lyact
ivi
ti
es?
”
ANS:
D
Thesymptomofpaini
sdif
fi
cul
ttoquant
if
ybecaus
eofindi
vi
duali
nte
rpr
etat
ion.
Wit
hp ai
n,adj
ecti
vessh
ouldbeavoid
ed,andth
ep at
ie
ntshoul
dbea sk
edh ow
th
ep aina f
fec
tsh i
so rherdail
ya ct
iv
it
ie
s.Theot he
rresponse
sa ren ot
appr
opri
ate.
DI
F:Cog
nit
iv
eLe
vel
:Ap
ply
ing NU(Application)RSI
NGTB.
COM
MSC:
Cli
entNe
eds
:Sa
fea
ndE
ffe
cti
veCa
reE
nvi
ron
men
t:Ma
nag
eme
ntofCa
re
I
nreco
rdi
n gthechi
ldhoodil
lnesse
sofap atie
ntwh odeni
eshavi
nghada
ny,
whi
ch
not
ebyt henurs
ewou ldbemos taccur
ate?
Pat
ien
td eni
esus u
alchil
dhoodill
nesse
s.
Pat
ientstat
eshewa sa“ve r
yhe a
lth
y”ch i
ld.
Pat
ien
ts t
ateshissi
sterhadme asl
es,buthedidnot.
Pat
ien
td eni
esha v
inghadme asl
es,mump s,r
ub el
l
a,chi
cke
npox,
pertus
sis,a
nds tr
epthroat
.
ANS:
D
Chi
ldh
oodil
lnes
sesincl
udemeasl
es,
mu mps,r
ubel
la
,chi
cken
pox,p
ertus
sis
,an
d
st
repthr
oat
.Avoidre
cordi
ng“usu
alchi
ldh
oodill
ness
es”beca
useanil
lnes
s
co
mmo ninthepers
on’schi
l
dhoodmaybeu n
usualt
oday(
e.g
.,measl
es)
.
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DI
F:Cogni
ti
veLe
vel
:Reme
mberi
ng(Knowl
edge)
MSC:Cl
i
entNee
ds:Saf
eandE
ffe
cti
veCareEn
vir
onme
nt:
Man
age
men
tofCa
re
Af
ema l
ep atie
ntte l
l
st h
en urs
et hatshehashadsixpr
egnan
cies
,wit
hfourli
ve
bir
thsa tter
ma n dt wospontaneousabor
ti
ons.He
rfourc
hil
dre
na r
esti
l
lli
vi
ng.
Howwou l
dt henurserecordthi
sinfor
mati
on?
P-6,B-
4, (
S)Ab-2
Grav6,Te r
m4 ,(S)Ab -
2,Li
vi
ng4
Pati
e n
th ashadfou rli
vi
ngb abi
es
Down
loa
dedb
yma
rlonma
rlonJ
uni
or(
ben
kig
och
i@g
mai
l
.com)
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Ph
ysi
cal
Exa
min
ati
ona
ndHe
alt
hAs
ses
sme
ntCANADI
AN3
rdEd
iti
onJ
arv
isTe
st
Stuvia.com - The Marketplace to Buy and Sell your Study Material
Ba
nk
Pa
tie
nth
asb
eenp
reg
nan
tsi
xti
mes
ANS:
B
Obst
etr
ichis
toryi
ncl
udesthenu mberofp
regnanci
es(gr
avi
d i
ty
),numberofdeli
veri
esin
whi
chthefetusre
achedte
rm( ter
m) ,
numberofpre
ter
mp re
g nanci
es(pr
eter
m) ,
n u
mb erof
i
ncomplet
ep r
egnanci
es(abort
ions)
,andnumberofch
il
drenli
ving(l
iv
ing)
.Thisisrecor
ded:
Gr
av_____Term____
_Pret
er m_ _
___Ab___
__Livi
ng___
__.Foranyinc
omp l
ete
p
reg
nanc
ies
,thedu
rati
oni
sre
corde
dandwh e
the
rth
epr
egn
anc
yre
sul
te
dina
s
pont
ane
ous(S)o
ra ni
ndu
ced(I
)abor
ti
on.
DI
F:Cogni
ti
veLe
vel
:Appl
yi
ng(
Appli
cat
ion)
MSC:Cl
i
entNee
ds:Saf
eandEf
fec
ti
veCa r
eEnv
ir
onme
nt:
Man
age
men
tofCa
re
Ap
ati
enttel
lst h
en ur
sethatheisal
ler
gictope
n i
ci
ll
in.Whatwoul
dbethe
nurse
’sbes tres
ponsetothi
sinf
ormati
on?
“Areyouallergi
ctoanyotherdr
ugs?”
“Howo f
tenh aveyourecei
vedpeni
cil
li
n?”
“I’
l
lwrit
ey ourall
ergyonyourchar
tsoyouwo n’
tre
c e
iveanyp
enic
il
li
n.”
“Descr
ibewh athappenstoyouwhenyoutakepeni
cil
li
n.”
ANS:
D
Not
eb otht
heall
erge
n(med
icati
on,food,orcont
actage
n t
,suc
hasfabri
cor
env
ir
on ment
alagen
t)an
dthereact
ion(rash,i
tc
hing,
run
n ynos
e,wat
eryeye
s,or
di
ff
icu
ltybre
athi
ng)
.Wit
had r
ug,t
hiss y
mp tomshouldnotbeasi
deeff
ectbuta
t
rueal
lergi
crea
cti
on.
DI
F:Cogni
ti
veLe
vel
:Unde
rst
andi
ng(Compre
hensi
on)
MSC:Cl
i
entNee
ds:Saf
eandEff
ect
iv
eCa r
eEnvi
ron
ment:
Man
age
men
tofCa
re
.T
9 hen
urs
eist
aki
ngaf
ami
l
yhi
st
ory
.Imp
ort
antd
ise
ase
sorp
rob
lemsa
bou
t
whi
chthepati
ents
hou
ldb
esp
eci
fi
cal
l
yas
kedi
ncl
ude
:
a.Emphysema
b.Headtr
auma
c.Menta
lil
lne
ss
d.Fr
actur
edbones
ANS:
C
Quest
ionsaskedshou
lds p
ecif
ica
ll
yenquir
eaboutf
amilyhist
oryofhear
t
di
sease,hi
ghbloodpr
e s
sure,
str
oke,di
abetes
,obes
ity
,blooddisor
ders
,breas
t
andovar
iancancer
s,col
onc a
ncer,s
ickl
ecell
anemia,
arthri
ti
s,al
le
rgi
es,al
cohol
ordru
ga ddi
ct
ion,mental
il
lne
ss,sui
cid
e,sei
zuredi
sorde
r,kidne
yd i
sease
,and
t
u b
ercul
osi
s.
DI
F:Cogni
ti
veLe
vel
:Reme
mberi
ng(Knowl
edge)
MSC:Cl
i
entNee
ds:Saf
eandE
ffe
cti
veCareEn
vir
onme
nt:
Man
age
men
tofCa
re
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Th
er e
viewofsyst
emss ecti
onprov
idesthen
ursewit
h:
Phys
ical
findi
ngsrel
atedtoeachsyst
em
I
nfor
ma t
ionrega
rdi
ngh eal
thpr
omot i
onpr
acti
ces
Anopportu
nit
ytoteachthepat
ientmedi
cal
terms
I
nfor
ma t
ionnecess
aryforthenur
setodi
agnosethep
ati
ent
’sme
dic
alp
rob
lem
ANS:
B
Down
loa
dedb
yma
rlonma
rlonJ
uni
or(
ben
kig
och
i@g
mai
l
.com)
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Ph
ysi
cal
Exa
min
ati
ona
ndHe
alt
hAs
ses
sme
ntCANADI
AN3
rdEd
iti
onJ
arv
isTe
st
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Ba
nk
Thepur
posesofth
erev i
ewofsyst
emsareto:(1)e
v a
luat
ethepastandcur
ren
t
he
a l
ths
tat
esofeachb odysy
stem,(2
)doubl
e -
checkfact
sincasean
ys i
gni
fi
cant
da
tawereomitt
edinthepre
sentil
l
nesssec
tion,an
d( 3)eva
lua
teheal
th
pr
omoti
onpract
ices.
DI
F:Cogni
ti
veLe
vel
:Reme
mberi
ng(Knowl
edge)
MSC:Cl
i
entNee
ds:Saf
eandE
ffe
cti
veCareEn
vir
onme
nt:
Man
age
men
tofCa
re
Wh
ichofth e
ses tat
ementsrepresent
ss u
bje
cti
vedatathen
urs
eob
tai
nedf
rom
thep a
tientregar
dingthep at
ien
t’sski
n?
Skinap pearsdry
.
Nol esi
onsa reobvi
ous .
Patientdeniesanycolourchange
.
Lesionisn ote
donth elate
ralas
pe c
tofther
igh
ta r
m.
ANS:
C
Theh
ist
oryshou
ldbel
i
mite
dtopat
ie
ntst
ate
me n
tsors
ubj
ect
iv
eda
ta—f
act
ors
th
att
hepers
ons ay
swer
eorwer
enotpr
esent
.
DI
F:Cogni
ti
veLe
vel
:Unde
rst
andi
ng(Compre
hensi
on)
MSC:Cl
i
entNee
ds:Saf
eandEff
ect
iv
eCa r
eEnvi
ron
ment:
Man
age
men
tofCa
re
Th
en ur
seisobtai
ningthehist
oryf
roma3 0-
yea
r-ol
dma lepat
ie
ntandi
sc once
rne
d
abo
uthealthpr
omotionacti
vit
ie
s.Whic
hoft hes
equ es
ti
onswoul
db e
app
ropri
atetousetoa s
sesshealt
hpr
omotionacti
vit
ie
sforth
ispa
tie
n t
?
“
Doy o
up erfor
mt e
sticul
arsel
f-
exami
nati
on s?
”
“
Havey o
ue vernot
icedanyp ai
ninyo
urtesti
cles?
”
“
Havey o
uh adanyp ro
blemswithpas
singurine
?”
N R IG B.
CM
“
Doy
ouh
avea
nyh
ist
oryo
fU sexuallySN transmittedT O diseases?”
ANS:
A
Heal
thpromoti
onacti
vi
ti
esforamanwoul
dincl
udeth
ep er
for
manceof
t
esti
cul
arself
-ex
aminat
ion
s.Theot
herqu
esti
onsareask
ingabou
tposs
ibl
e
di
seaseoril
l
nessis
sues.
DI
F:Cogni
ti
veLe
vel
:Unde
rst
andi
ng(Compre
hensi
on)
MSC:Cl
i
entNee
ds:Saf
eandEff
ect
iv
eCa r
eEnvi
ron
ment:
Man
age
men
tofCa
re
Wh
ichofthesere
s ponsesmightthenurseexpe
ctd u
rin
gaf u
ncti
onalas
sessmentof
ap at
ie
n twhoselegisinac ast
?
“Ibrok
emyr ightleginac aracci
dent2we e
ksa go.
”
“Thepainisdec r
easi
ng,butIs t
il
lneedtotakeaceta
minophen.
”
“Icheckthecolourofmyt oeseveryeve
ningjustl
ikeIwastau
ght.
”
“I’
ma bl
et ot
ransfermy s
elffr
omt hewheelchai
rtothebedwit
houthe
lp.”
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F
unc
tiona
lassessmentmeasu
resape
rson
’sse
lf-
car
eabi
li
tyint
heare
asof
g
ene
ralphys
ical
he a
lthora
bsenc
eofi
ll
nes
s.Theoth
ers
tat
e ment
sconce
rn
h
eal
thori
ll
nessis
s ue
s .
DI
F:Cogni
ti
veLe
vel
:Appl
yi
ng(
Appli
cat
ion)
MSC:Cl
i
entNee
ds:Saf
eandEf
fec
ti
veCa r
eEnv
ir
onme
nt:
Man
age
men
tofCa
re
I
nre
spons
etoaques
ti
onabouts
tre
ss,a39-
yea
r-ol
dwomante
ll
sthenu
rset
hath
erhusbanda
nd
he
rmoth
erb
othdie
dinth
epastye
ar.
Wh i
chrespon
seb
ythenu
rsei
smostappr
opr
iat
e?
Down
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onJ
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Ba
nk
“
Thi
shasbeenad i
ff
icul
tye a
rforyou.”
“
Ido
n ’
tkno
wh owanyonec oul
dh a
ndletha
tmuchs t
res
si n1year
!”
“
Whatdidy
oud ot
oc opewiththelos
sofbothy
ou rhus
b anda
ndy ou
rmo th
er?
”
“
Thati
salotofst
ress;
n o
wl et’
sgoo ntot
henextsect
ionofyou
rh i
stor
y.”
ANS:
C
Quest
ionsaboutcopi
nga n
ds t
ressma nag
e menti
ncludeques
ti
onsreg
ardi
ngth
e
ki
ndsofstre
ss e
sino n
e’sli
fe,
e s
p e
c i
al
lyinth
ep astyear
,anychan
gesin
l
if
estyl
eo ranycurr
entstr
ess,methodstr
iedtore
li
e v
es t
res
s,andwhet
hert
hese
meth
odsh avebeenhelpf
ul.
DI
F:Cogni
ti
veLe
vel
:Appl
yi
ng(
Appli
cat
ion)
MSC:Cl
i
entNee
ds:Saf
eandEf
fec
ti
veCa r
eEnv
ir
onme
nt:
Man
age
men
tofCa
re
I
nre
sponsetoaq uest
ionregar
dingtheuseofalcohol
,ap at
ientasksthenursewhy
thenurseneedstoknow.Wh ati
sthereasonforneedi
n gthi
sinformati
on?
Thisi
nformatio
nisn ec
e s
sarytod et
ermi
net hepati
ent’
sre l
iabi
li
ty.
Alcoh
ol cani
nter
actwithal
lme dic
ati
onsandc anma kesomed iseasesworse
.
Thenursen e
edstob eabl
etot e
a c
hthepa t
ie
n tab
outthed angersofalc
oholuse
.
Thisi
nformati
onisnotnecessaryunl
essad r
inki
ngp r
ob l
emi sobviou
s.
ANS:
B
Al
cohola d
versel
yinte
ractswit
hallmedi
cat
ionsandisaf a
ctorinma nysoci
al
pr
ob l
ems,s u
cha sc hil
da buseorsexua
la bus
e ,aut
omobil
ea cci
dents
,a nd
as
sa ul
ts
;a l
coholalsoc ont
ri
but
estoma nyil
lnesse
sa nddiseaseprocess
es.
The
r e
foreassessi
ngfors i
gnsofhaz
ard
ousa l
coholusei
simp or
tant
.Theother
opt
ionsarenotcorr
ect.
DI
F:Cog
nit
iv
eLe
vel
:Un
der
sta
ndi
ng(
Comp
reh
ens
ion
)
MSC:
Cli
entNe
eds
:Sa
fea
ndEf
fec
ti
veNRI
Car
eGEnvi
ron
men
t:B.
CMManagementofCar
e
USNT O
Th
emotherofa1 6-month-
o l
dtoddl
ertel
l
st h
en ur
sethath
erdaugh
terh
asa
n
e
arac
he.Wha twou l
db eanappropr
iat
eresponse
?
“
Maybesheisj ustte
ething.
”
“
Iwil
lchec
kh e rearforaneari
n f
ect
ion.”
“
Areyousures heisreal
lyhavi
ngp a
in?”
“
Descr
ibewha tsheisd o
ingtoindi
catesheishavi
ngpai
n.”
ANS:D
Wit
hav e
ryy
oun
gch
il
d,t
hep
are
nti
sas
ked
,“Ho
wdoy
ouk
nowt
hec
hil
disi
npa
in?
”A
y
oun
gch
il
dpu
ll
in
gath
isorh
ere
arss
hou
lda
ler
tpa
ren
tst
oth
ech
ild
’se
arp
ain
.
St
ate
men
ts
a
boutt
eet
hin
gandqu
es t
ioni
ngwhe
the
rthech
il
disrea
ll
yhavi
ngpai
ndon ot
e
xpl
oret
hesymp
toms,whic
hs h
oul
dbedonebef
oreaphy
sic
alex
amina
tion.
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ysi
cal
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a lthAs s
to ess
Buy me
and nt
Sell CAN
your AD
Study IAN3
Material r
dEd
iti
onJ
arv
isTe
st
Ba
nk
Chap
ter05:TheComp
leteHeal
thHi
sto
ry
Ja
rvi
s:Physic
alEx
amina
tion&Heal
thAss
ess
men
t,3r
dCa
nad
iane
dit
ion
MUL
TIPL
ECHOI
CE
Th
en u
rseispre
parin
gtoc onductah eal
thhist
ory.Whichofthesest
ateme
ntsbe
st
des
cri
besthepurposeofah ealt
hh i
stor
y?
Toprov
ideanop por
tuni
tyfori
n t
eract
ionbetweenthep at
ien
ta n
dthenur
se
Toprovi
deaformf orobtai
ningthepa t
ien
t’sbi
o gr
aphicinf
ormati
on
Todocumentthenormal a
nda bnormalfi
nding
sofap hys
icalas
sessment
Toprovi
dead a
tabaseo fsubj
ectiv
ein f
ormati
ona boutthepati
ent
’s
pastandcurr
enth e
alth
ANS:
D
Thepur
poseoftheh
e a
lthhist
oryi
stocol
le
ctsub
ject
iv
edata
—whatthe
pe
rsonsay
sab ou
thimselforher
sel
f.Th
eothe
ropti
onsar
enotc
orre
ct.
DI
F:Cogni
ti
veLe
vel
:Unde
rst
andi
ng(Compre
hensi
on)
MSC:Cl
i
entNee
ds:Saf
eandEff
ect
iv
eCa r
eEnvi
ron
ment:
Man
age
men
tofCa
re
.Wh
2 ent
hen
urs
eise
val
uat
ingt
her
eli
abi
li
tyofap
ati
ent
’sr
esp
ons
es,
whi
chof
t
hes
estat
eme nt
swou l
dbec or
rec
t?Thepati
ent
:
.Ha
a sahist
o r
yofdrugabuseandth
eref
oreisnotr
eli
abl
e.
.P
b rov
ide
dc onsi
ste
ntinf
ormati
onandther
efor
eisrel
iab
le.
.S
c mil
edthr
ou gh
outint
erv
iewandther
efor
eisassumedrel
ia
ble
.
.Wo
d u
ldn
ota
nswe
rqu
est
ion
scon
cer
nin
gst
res
san
dth
ere
for
eisn
otr
eli
abl
e.
ANS:
B
Areli
abl
epe
rsona
lwaysgi
vesth
esameanswer
s,e
venwhenques
ti
onsar
e
r
e p
hrase
dorar
erepe
atedl
ateri
nth
ein
ter
vi
e w.
Theot
hers
tate
me nt
sar
enot
cor
rect
.
DI
F:Cogni
ti
veLe
vel
:Appl
yi
ng(
Appli
cat
ion)
MSC:Cl
i
entNee
ds:Saf
eandEf
fec
ti
veCa r
eEnv
ir
onme
nt:
Man
age
men
tofCa
re
A5
9-y
ear
-ol
dpa
tie
ntt
ell
sth
enu
rset
hath
eha
sul
cer
ati
vec
oli
ti
s.Heh
asb
eenh
avi
ng“
bla
ck
s
too
ls”f
ort
hep
ast24h
our
s.Ho
wwou
ldt
hen
urs
ebe
std
ocu
men
thi
sre
asonf
ors
eek
ingc
are
?
J
.M.i
sa5 9-
year
-ol
dma nse
eki
ngtr
eatmentf
orul
cer
ati
vecoli
ti
s.
J
.M.camein
tothecli
ni
ccompl
aini
ngofhavi
ngbl
ackst
oolsfort
hepast2
4hou
rs.
J
.M.i
sa5 9-
year
-ol
dma nwhost
ate
sthath
eh asu
lcer
ati
vecoli
ti
sand
want
sitche
cked.
J
.M.i
sa5 9-
year
-ol
dma nwhost
ate
sthathehasbee
nh av
ing“bla
ck
st
ools
”fort
hep as
t24hour
s.
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Ther
eas
onf
ors
ee kin gc a rei sab r i
e fs p o nta ne ou ss ta te me n tint h ep
ers
on’
sownwo
rdst
hat
d
escr
ibesth
ereas
onfort
hevis
it
. I
tsta
tesone(p
oss
ibl
ytwo)s
ign
sorsymptomsandt
hei
r
d
ura
tion.Thes
ymptomdesc
ript
ionisencl
osedi
nquot
ati
onmarkst
oin
d i
catet
he
p
ers
on ’
s
e
xac
twor
ds.
DI
F:Cogni
ti
veLe
vel
:Appl
yi
ng(
Appli
cat
ion)
MSC:Cl
i
entNee
ds:Saf
eandEf
fec
ti
veCa r
eEnv
ir
onme
nt:
Man
age
men
tofCa
re
Down
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yma
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ysi
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ati
ona
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alt
hAs
ses
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ntCANADI
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rdEd
iti
onJ
arv
isTe
st
Stuvia.com - The Marketplace to Buy and Sell your Study Material
Ba
nk
Ap
ati
entte
ll
sthen ur
sethatsheh ashada bdomina
lpai
nfort
hep
astwe
ek.
Wha
t
wouldbethenu r
se’sbestresponse
?
“Canyoupointtowh e
reithurts?”
“We’l
ltal
kmo reaboutthatla
terintheint
e r
vie
w.”
“Whathaveyouh adtoeatinth epast24h o
urs?”
“Haveyoueverhada nysurgeriesonyourabdomen?”
ANS:
A
Afi
nalsu
mma r
yofanysympt
omtheper
sonhassh
oul
dincl
ude
,al
ongwi
ths
evenoth
er
cr
it
ica
lchar
act
eri
sti
cs,
“Loc
ati
on:Bes
peci
fi
c.”Thep
ers
onisask
edtop
oin
ttothel
oca
tio
n.
DI
F:Cogni
ti
veLe
vel
:Appl
yi
ng(
Appli
cat
ion)
MSC:Cl
i
entNee
ds:Saf
eandEf
fec
ti
veCa r
eEnv
ir
onme
nt:
Man
age
men
tofCa
re
A2
9-yea
r-o
ldwo mantel
lsthen ur
sethatshehas“excr
uci
ati
ngpai
n ”i
nher
back.Whichwo u
ldbethen urse
’sappr
op r
iat
erespons
etothewoma n
’s
stat
eme nt
?
“Howd oesyourfami
lyreacttoyourpai
n?”
“Thepainmu stbete
rri
ble.Youp r
obabl
yp i
nchedanerve
.”
“I’
vehadb ac
kp ai
nmy se
lf,anditcanbeexcruci
ati
ng.
”
“Howwo uldyousaythepa i
naffect
syourabil
it
ytodoyourdai
lyact
ivi
ti
es?
”
ANS:
D
Thesymptomofpaini
sdif
fi
cul
ttoquant
if
ybecaus
eofindi
vi
duali
nte
rpr
etat
ion.
Wit
hp ai
n,adj
ecti
vessh
ouldbeavoid
ed,andth
ep at
ie
ntshoul
dbea sk
edh ow
th
ep aina f
fec
tsh i
so rherdail
ya ct
iv
it
ie
s.Theot he
rresponse
sa ren ot
appr
opri
ate.
DI
F:Cog
nit
iv
eLe
vel
:Ap
ply
ing NU(Application)RSI
NGTB.
COM
MSC:
Cli
entNe
eds
:Sa
fea
ndE
ffe
cti
veCa
reE
nvi
ron
men
t:Ma
nag
eme
ntofCa
re
I
nreco
rdi
n gthechi
ldhoodil
lnesse
sofap atie
ntwh odeni
eshavi
nghada
ny,
whi
ch
not
ebyt henurs
ewou ldbemos taccur
ate?
Pat
ien
td eni
esus u
alchil
dhoodill
nesse
s.
Pat
ientstat
eshewa sa“ve r
yhe a
lth
y”ch i
ld.
Pat
ien
ts t
ateshissi
sterhadme asl
es,buthedidnot.
Pat
ien
td eni
esha v
inghadme asl
es,mump s,r
ub el
l
a,chi
cke
npox,
pertus
sis,a
nds tr
epthroat
.
ANS:
D
Chi
ldh
oodil
lnes
sesincl
udemeasl
es,
mu mps,r
ubel
la
,chi
cken
pox,p
ertus
sis
,an
d
st
repthr
oat
.Avoidre
cordi
ng“usu
alchi
ldh
oodill
ness
es”beca
useanil
lnes
s
co
mmo ninthepers
on’schi
l
dhoodmaybeu n
usualt
oday(
e.g
.,measl
es)
.
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DI
F:Cogni
ti
veLe
vel
:Reme
mberi
ng(Knowl
edge)
MSC:Cl
i
entNee
ds:Saf
eandE
ffe
cti
veCareEn
vir
onme
nt:
Man
age
men
tofCa
re
Af
ema l
ep atie
ntte l
l
st h
en urs
et hatshehashadsixpr
egnan
cies
,wit
hfourli
ve
bir
thsa tter
ma n dt wospontaneousabor
ti
ons.He
rfourc
hil
dre
na r
esti
l
lli
vi
ng.
Howwou l
dt henurserecordthi
sinfor
mati
on?
P-6,B-
4, (
S)Ab-2
Grav6,Te r
m4 ,(S)Ab -
2,Li
vi
ng4
Pati
e n
th ashadfou rli
vi
ngb abi
es
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ysi
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alt
hAs
ses
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ntCANADI
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rdEd
iti
onJ
arv
isTe
st
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Ba
nk
Pa
tie
nth
asb
eenp
reg
nan
tsi
xti
mes
ANS:
B
Obst
etr
ichis
toryi
ncl
udesthenu mberofp
regnanci
es(gr
avi
d i
ty
),numberofdeli
veri
esin
whi
chthefetusre
achedte
rm( ter
m) ,
numberofpre
ter
mp re
g nanci
es(pr
eter
m) ,
n u
mb erof
i
ncomplet
ep r
egnanci
es(abort
ions)
,andnumberofch
il
drenli
ving(l
iv
ing)
.Thisisrecor
ded:
Gr
av_____Term____
_Pret
er m_ _
___Ab___
__Livi
ng___
__.Foranyinc
omp l
ete
p
reg
nanc
ies
,thedu
rati
oni
sre
corde
dandwh e
the
rth
epr
egn
anc
yre
sul
te
dina
s
pont
ane
ous(S)o
ra ni
ndu
ced(I
)abor
ti
on.
DI
F:Cogni
ti
veLe
vel
:Appl
yi
ng(
Appli
cat
ion)
MSC:Cl
i
entNee
ds:Saf
eandEf
fec
ti
veCa r
eEnv
ir
onme
nt:
Man
age
men
tofCa
re
Ap
ati
enttel
lst h
en ur
sethatheisal
ler
gictope
n i
ci
ll
in.Whatwoul
dbethe
nurse
’sbes tres
ponsetothi
sinf
ormati
on?
“Areyouallergi
ctoanyotherdr
ugs?”
“Howo f
tenh aveyourecei
vedpeni
cil
li
n?”
“I’
l
lwrit
ey ourall
ergyonyourchar
tsoyouwo n’
tre
c e
iveanyp
enic
il
li
n.”
“Descr
ibewh athappenstoyouwhenyoutakepeni
cil
li
n.”
ANS:
D
Not
eb otht
heall
erge
n(med
icati
on,food,orcont
actage
n t
,suc
hasfabri
cor
env
ir
on ment
alagen
t)an
dthereact
ion(rash,i
tc
hing,
run
n ynos
e,wat
eryeye
s,or
di
ff
icu
ltybre
athi
ng)
.Wit
had r
ug,t
hiss y
mp tomshouldnotbeasi
deeff
ectbuta
t
rueal
lergi
crea
cti
on.
DI
F:Cogni
ti
veLe
vel
:Unde
rst
andi
ng(Compre
hensi
on)
MSC:Cl
i
entNee
ds:Saf
eandEff
ect
iv
eCa r
eEnvi
ron
ment:
Man
age
men
tofCa
re
.T
9 hen
urs
eist
aki
ngaf
ami
l
yhi
st
ory
.Imp
ort
antd
ise
ase
sorp
rob
lemsa
bou
t
whi
chthepati
ents
hou
ldb
esp
eci
fi
cal
l
yas
kedi
ncl
ude
:
a.Emphysema
b.Headtr
auma
c.Menta
lil
lne
ss
d.Fr
actur
edbones
ANS:
C
Quest
ionsaskedshou
lds p
ecif
ica
ll
yenquir
eaboutf
amilyhist
oryofhear
t
di
sease,hi
ghbloodpr
e s
sure,
str
oke,di
abetes
,obes
ity
,blooddisor
ders
,breas
t
andovar
iancancer
s,col
onc a
ncer,s
ickl
ecell
anemia,
arthri
ti
s,al
le
rgi
es,al
cohol
ordru
ga ddi
ct
ion,mental
il
lne
ss,sui
cid
e,sei
zuredi
sorde
r,kidne
yd i
sease
,and
t
u b
ercul
osi
s.
DI
F:Cogni
ti
veLe
vel
:Reme
mberi
ng(Knowl
edge)
MSC:Cl
i
entNee
ds:Saf
eandE
ffe
cti
veCareEn
vir
onme
nt:
Man
age
men
tofCa
re
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Th
er e
viewofsyst
emss ecti
onprov
idesthen
ursewit
h:
Phys
ical
findi
ngsrel
atedtoeachsyst
em
I
nfor
ma t
ionrega
rdi
ngh eal
thpr
omot i
onpr
acti
ces
Anopportu
nit
ytoteachthepat
ientmedi
cal
terms
I
nfor
ma t
ionnecess
aryforthenur
setodi
agnosethep
ati
ent
’sme
dic
alp
rob
lem
ANS:
B
Down
loa
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yma
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Ph
ysi
cal
Exa
min
ati
ona
ndHe
alt
hAs
ses
sme
ntCANADI
AN3
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onJ
arv
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Stuvia.com - The Marketplace to Buy and Sell your Study Material
Ba
nk
Thepur
posesofth
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v a
luat
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tawereomitt
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sentil
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nesssec
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lua
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omoti
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DI
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thep a
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Skinap pearsdry
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Nol esi
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Patientdeniesanycolourchange
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Lesionisn ote
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ANS:
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ANS:
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ingabou
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et ot
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F
unc
tiona
lassessmentmeasu
resape
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uni
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, l
OMoARc
PSD|
1162
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Ph
ysi
cal
Exa
min
ati
ona
ndHe
alt
hAs
ses
sme
ntCANADI
AN3
rdEd
iti
onJ
arv
isTe
st
Stuvia.com - The Marketplace to Buy and Sell your Study Material
Ba
nk
“
Thi
shasbeenad i
ff
icul
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Ido
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henextsect
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ANS:
C
Quest
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dingtheuseofalcohol
,ap at
ientasksthenursewhy
thenurseneedstoknow.Wh ati
sthereasonforneedi
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sinformati
on?
Thisi
nformatio
nisn ec
e s
sarytod et
ermi
net hepati
ent’
sre l
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actwithal
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.
Thisi
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emi sobviou
s.
ANS:
B
Al
cohola d
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ractswit
hallmedi
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omobil
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dents
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as
sa ul
ts
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coholalsoc ont
ri
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estoma nyil
lnesse
sa nddiseaseprocess
es.
The
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foreassessi
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gnsofhaz
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coholusei
simp or
tant
.Theother
opt
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ect
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“
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“
Descr
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ingtoindi
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n.”
ANS:D
Wit
hav e
ryy
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gch
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hep
are
nti
sas
ked
,“Ho
wdoy
ouk
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npa
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dpu
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gath
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hou
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tst
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ech
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St
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a
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toms,whic
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oul
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oreaphy
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alex
amina
tion.
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