EXAMINATION AND HISTORY TAKING REVISION
HANDBOOK 2026 CLINICAL EXAMINATION
TECHNIQUES AND DOCUMENTATION
◉ when learning about physical assessment, students often want to
proceed directly to the examination; however,. Answer: the
collection of subjective information during history taking assists to
focus your examination accordingly
◉ the physical examination is a process to obtain ____________________
from the patient. Answer: objective data
◉ the ____________________ in the health history is obtained prior to the
examination and will assist the nurse to navigate through a complex
examination. Answer: subjective data
◉ a finding in one system may not be an ____________ finding. Answer:
isolated
for example, the patient who presents with a chief complaint of
blurred vision may be having vision changes because of age, an
injury, a retina or macular affliction, or changes due to
hyperglycemia
,◉ what is the purpose of the physical examination?. Answer: to
determine changes in a patient's health status and how to respond
to a problem as well as promote healthy lifestyles and well-being
◉ how to prepare for the physical examination?. Answer: -reflect on
your approach to the patient
-adjust the lighting and the environment
-check that the equipment is available and in working order
-make the patient comfortable
-choose the sequence of examination
◉ as you enter the room to conduct a physical examination, identify.
Answer: yourself as a nursing student
appear calm and organized, even when you feel inexperienced
it is common to forget part of the examination, especially at first
if that occurs, simply examine that area out of sequence
it is not unusual to go back to the patient and ask to check one or
two items that might have been overlooked
◉ beginners will need to spend more time than experienced nurses
on select portions of the examination, such as. Answer: the
fundoscopic examination or cardiac auscultation
, ◉ to avoid alarming the patient, warn the patient ahead of time by
saying, for example,. Answer: "i would like to spend extra time
listening to your heart and the heart sounds, but this doesn't mean i
hear anything wrong"
◉ many patients view the physical examination with some anxiety.
they feel. Answer: vulnerable, physically exposed, apprehensive
about possible pain, and uneasy about what the nurse may find
at the same time, they appreciate your concern about their health
and respond to your attention
◉ the skillful nurse is thorough without _____________, systematic but
______________, and ___________ yet not afraid to cause discomfort should
it be required. Answer: -wasting time
-flexible
-gentle
◉ when doing a physical examination the skillful nurse. Answer:
examines each region of the body and at the same time is aware of
the whole patient, notes the wince or worried glance, and shares
information that calms, explains, and reassures
◉ as a beginner, avoid _________________ your findings. Answer:
interpreting