Subjective data - Answers Patient-Reported
Objective data - Answers Observed by the provider via physical examination
Database - Answers Formed by subjective data, objective data, medical records, and lab studies
The Nursing Process - Answers A dynamic, six-phase process including Assessment, Diagnosis,
Outcome Identification, Planning, Implementation, and Evaluation
Clinical Proficiency: Novice - Answers Uses rules to guide performance
Clinical Proficiency: Proficient - Answers Views situations as a whole and recognizes patterns
Clinical Proficiency: Expert - Answers Has an intuitive grasp and targets the accurate solution
immediately
First-level problems - Answers Immediate, life-threatening issues (e.g., airway, breathing)
Second-level problems - Answers Urgent interventions needed to prevent deterioration (e.g., acute
pain, mental status change)
Third-level problems - Answers Important but addressable later (e.g., lack of knowledge)
Database Types: Complete - Answers Full health history and physical
Database Types: Focused - Answers For limited, short-term problems
Database Types: Follow-up - Answers Regular evaluation of identified problems
Database Types: Emergency - Answers Rapid collection of crucial data during lifesaving measures
Internal Factors in Communication - Answers Examiners must possess liking others, empathy, the
ability to listen, and self-awareness
Interview Phases - Answers Introduction, Working phase (data gathering), Closing (summarization
and final questions)
Questioning Techniques - Answers Use open-ended questions for narrative information and
closed/direct questions for specific facts
Ten Traps of Interviewing - Answers Avoid False Reassurance, Unwanted Advice, Authority,
Avoidance Language, Distancing, Professional Jargon, Biased Questions, Talking Too Much,
Interrupting, 'Why' Questions
Professional Communication: SBAR - Answers Standardized reporting between professionals:
Situation, Background, Assessment, Recommendation
Culture - Answers Learned from birth, shared by a group, adapted to environment, and dynamic
(ever-changing)
Linguistic Competence - Answers Providers must offer trained medical interpreters; do not use family
or friends
Spirituality vs. Religion - Answers Religion is an organized belief system; spirituality focuses on a
connection to something larger than oneself
FICA Tool - Answers Used to assess spiritual history: Faith, Importance/influence, Community, and
Address/action
ABCT Components - Answers Appearance, Behavior, Cognition, Thought Processes
Screening Tools: Mini-Mental State Exam (MMSE) - Answers Scored assessment of cognitive functions
(not mood/thoughts)
Screening Tools: Mini-Cog - Answers Quick screen for cognitive impairment in healthy older adults
Screening Tools: Glasgow Coma Scale - Answers Quantitative tool for testing consciousness in aging
people
General Survey Areas - Answers Physical Appearance, Body Structure, Mobility, Behavior
Weight/Height Measurement - Answers Measured without shoes; BMI indicates healthy weight for
height, waist circumference is an independent risk factor for disease
Temperature Measurement - Answers Oral route is most convenient; rectal route is the most
accurate reflection of core temperature
Pulse Rate - Answers Normal adult resting rate is 50 to 95 beats per minute; Bradycardia is <50 bpm;
tachycardia is >95 bpm
Respirations - Answers Counted while appearing to take the pulse; normal ratio of pulse rate to
respiratory rate is 4 to 1
Blood Pressure (BP) Systolic - Answers Max pressure during contraction
Blood Pressure (BP) Diastolic - Answers Recoil pressure between contractions
Cuff Size for BP Measurement - Answers Rubber bladder width must be 40% of the arm
circumference, and length must be 80%