Comprehensive Health Assessment Exam 1
UPDATED ACTUAL Questions and CORRECT
Answers
Components of a health assessment - CORRECT ANSWER - Healthy history
Physical examination
Reviewing data from the health record
Document the findings
Comprehensive health history - CORRECT ANSWER - Biographic data
Reason for seeking health care
History of present illness
Present health status
Past health history
Family history
Personal and psychosocial history
Review of systems
Subjective data - CORRECT ANSWER - Symptoms, perceived by the patient, reported by the patient
Objective data - CORRECT ANSWER - signs, observed, felt, heard, measured
Comprehensive Assessment - CORRECT ANSWER - detailed history at onset of care in primary care setting
Problem-based/focused assessment - CORRECT ANSWER - history and exam are limited to specific problem
episodic/follow-up assessment - CORRECT ANSWER - follow up for previously identified problem
Shift assessment - CORRECT ANSWER - assessment completed at each shift change
Screening assessment - CORRECT ANSWER - short exam focused on disease detection
Reason for seeking health care - CORRECT ANSWER - Also called "chief complaint" or "presenting problem",
recorded in quotes
O in OLDCARTS - CORRECT ANSWER - Onset - when did the symptoms begin
L in OLDCARTS - CORRECT ANSWER - Location - where are the symptoms
D in OLDCARTS - CORRECT ANSWER - Duration - how long do the symptoms last
C in OLDCARTS - CORRECT ANSWER - Characteristics - Describe the symptoms
A in OLDCARTS - CORRECT ANSWER - Aggravating factors - what makes the symptoms worse
R in OLDCARTS - CORRECT ANSWER - Related Symptoms - symptoms that may be related
T in OLDCARTS - CORRECT ANSWER - Treatments - Describe self treatment before seeking care
S in OLDCARTS - CORRECT ANSWER - Severity - describe severity of symptoms
Present health status - CORRECT ANSWER - Health conditions, medications, allergies
Past health history - CORRECT ANSWER - Childhood illness, surgeries, hospitalizations, accidents/injuries,
immunizations, last examinations, obstetric history
, Family history - CORRECT ANSWER - Patients blood relative (parents, siblings, aunts, uncles, grandparents),
spouse, family history of conditions
Phases of interview - CORRECT ANSWER - Introduction, discussion, summary
Active listening - CORRECT ANSWER - listening with a purpose, focus on patient's response
Facilitation - CORRECT ANSWER - Use phrases to encourage patient to continue, "Go on", "Uh-huh"
Clarification - CORRECT ANSWER - used to obtain more information about conflicting, vague statements
Restatement - CORRECT ANSWER - Repeat patient to confirm interpretation
Reflection - CORRECT ANSWER - Ask patient questions to clarify phrase or sentence, encourages elaboration
Confrontation - CORRECT ANSWER - Used when inconsistencies are noted between reports and observations
Interpretation - CORRECT ANSWER - Opportunity to share conclusions drawn from data patient has given,
allows patient to confirm, deny or revise information
Summary - CORRECT ANSWER - Condenses data from interview to help clarify a sequence of events
Communication skills that can diminish data collection - CORRECT ANSWER - Using medical terminology
Expressing value judgements
Interrupting the patient
Being authoritarian or paternalistic
Using "why" question
Standard precautions - CORRECT ANSWER - Measures to reduce the risk of transmitting infection from bodily
fluids and non-intact skin. These measures are used on all clients - the potential for infection transmission always exists
Principles of assessment - CORRECT ANSWER - Patient preparation
Cephalocaudal
Periphery inward
Less personal to more personal
Gradually move into client's territory
Proceed by systems/regions
Pain producing/intimate/invasive last
Inspection - CORRECT ANSWER - Visual exam including body movement, posture and smell
Palpation - CORRECT ANSWER - Requires touch to determine- texture, size, shape, consistency, pulsations,
location
Percussion - CORRECT ANSWER - Evaluate size, borders and consistency of internal organs
Auscultation - CORRECT ANSWER - Listening to sounds within the body
Diaphragm - CORRECT ANSWER - Flat surface with rubber/plastic ring on the edge, used for high-pitched
sounds: breath, bowel and normal heart sounds
Bell - CORRECT ANSWER - Concave in shape, used to hear soft, low-pitched sounds: extra heart or vascular
sounds (bruit)
Blood pressure false high - CORRECT ANSWER - Patient's legs crossed, arm below level of heart (prop arm up
with pillow to keep at level of heart), cuff is too loose or uneven, reinflating of cuff without complete deflation, failure to
wait 1-2 minutes before repeating measurement
UPDATED ACTUAL Questions and CORRECT
Answers
Components of a health assessment - CORRECT ANSWER - Healthy history
Physical examination
Reviewing data from the health record
Document the findings
Comprehensive health history - CORRECT ANSWER - Biographic data
Reason for seeking health care
History of present illness
Present health status
Past health history
Family history
Personal and psychosocial history
Review of systems
Subjective data - CORRECT ANSWER - Symptoms, perceived by the patient, reported by the patient
Objective data - CORRECT ANSWER - signs, observed, felt, heard, measured
Comprehensive Assessment - CORRECT ANSWER - detailed history at onset of care in primary care setting
Problem-based/focused assessment - CORRECT ANSWER - history and exam are limited to specific problem
episodic/follow-up assessment - CORRECT ANSWER - follow up for previously identified problem
Shift assessment - CORRECT ANSWER - assessment completed at each shift change
Screening assessment - CORRECT ANSWER - short exam focused on disease detection
Reason for seeking health care - CORRECT ANSWER - Also called "chief complaint" or "presenting problem",
recorded in quotes
O in OLDCARTS - CORRECT ANSWER - Onset - when did the symptoms begin
L in OLDCARTS - CORRECT ANSWER - Location - where are the symptoms
D in OLDCARTS - CORRECT ANSWER - Duration - how long do the symptoms last
C in OLDCARTS - CORRECT ANSWER - Characteristics - Describe the symptoms
A in OLDCARTS - CORRECT ANSWER - Aggravating factors - what makes the symptoms worse
R in OLDCARTS - CORRECT ANSWER - Related Symptoms - symptoms that may be related
T in OLDCARTS - CORRECT ANSWER - Treatments - Describe self treatment before seeking care
S in OLDCARTS - CORRECT ANSWER - Severity - describe severity of symptoms
Present health status - CORRECT ANSWER - Health conditions, medications, allergies
Past health history - CORRECT ANSWER - Childhood illness, surgeries, hospitalizations, accidents/injuries,
immunizations, last examinations, obstetric history
, Family history - CORRECT ANSWER - Patients blood relative (parents, siblings, aunts, uncles, grandparents),
spouse, family history of conditions
Phases of interview - CORRECT ANSWER - Introduction, discussion, summary
Active listening - CORRECT ANSWER - listening with a purpose, focus on patient's response
Facilitation - CORRECT ANSWER - Use phrases to encourage patient to continue, "Go on", "Uh-huh"
Clarification - CORRECT ANSWER - used to obtain more information about conflicting, vague statements
Restatement - CORRECT ANSWER - Repeat patient to confirm interpretation
Reflection - CORRECT ANSWER - Ask patient questions to clarify phrase or sentence, encourages elaboration
Confrontation - CORRECT ANSWER - Used when inconsistencies are noted between reports and observations
Interpretation - CORRECT ANSWER - Opportunity to share conclusions drawn from data patient has given,
allows patient to confirm, deny or revise information
Summary - CORRECT ANSWER - Condenses data from interview to help clarify a sequence of events
Communication skills that can diminish data collection - CORRECT ANSWER - Using medical terminology
Expressing value judgements
Interrupting the patient
Being authoritarian or paternalistic
Using "why" question
Standard precautions - CORRECT ANSWER - Measures to reduce the risk of transmitting infection from bodily
fluids and non-intact skin. These measures are used on all clients - the potential for infection transmission always exists
Principles of assessment - CORRECT ANSWER - Patient preparation
Cephalocaudal
Periphery inward
Less personal to more personal
Gradually move into client's territory
Proceed by systems/regions
Pain producing/intimate/invasive last
Inspection - CORRECT ANSWER - Visual exam including body movement, posture and smell
Palpation - CORRECT ANSWER - Requires touch to determine- texture, size, shape, consistency, pulsations,
location
Percussion - CORRECT ANSWER - Evaluate size, borders and consistency of internal organs
Auscultation - CORRECT ANSWER - Listening to sounds within the body
Diaphragm - CORRECT ANSWER - Flat surface with rubber/plastic ring on the edge, used for high-pitched
sounds: breath, bowel and normal heart sounds
Bell - CORRECT ANSWER - Concave in shape, used to hear soft, low-pitched sounds: extra heart or vascular
sounds (bruit)
Blood pressure false high - CORRECT ANSWER - Patient's legs crossed, arm below level of heart (prop arm up
with pillow to keep at level of heart), cuff is too loose or uneven, reinflating of cuff without complete deflation, failure to
wait 1-2 minutes before repeating measurement
