Health Assessment Final Exam STUDY GUIDE REVIEW LATEST
UPDATE 2022
:
Health History:
• What is included in a health history
Medical history, medications, surgeries, family history, biographical data. You want to collect
subjective data.
1 Biographic data: name, address, phone number, age and birth date.
2. Reason for seeking care: why are they coming in. Symptoms and signs.
3. Present health or history of present illness. Short statement of general health.
4. Past history: childhood illness. Surgeries, accidents and immunizations.
5. Medication reconciliation: List of medications
6. Family history: any family members with illness or disease
7. Review of systems: examine each body system
8. Functional assessment or activities of daily living (ADLs)
• Define Subjective and objective
Subjective: what the person says about himself or herself during history taking
Objective: what you as the health professional observe by inspecting, percussing, palpating, and
auscultating during the physical examination
• Give an Example of an open-ended question.
• The open-ended question asks for narrative information.
“Tell me how I can help you.”, “What brings you to the hospital?”, “You mentioned
shortness of breath. Tell me more about that.”, “How have you been feeling since your
last appointment?”
Health Assessment Final Exam STUDY GUIDE REVIEW LATEST
UPDATE 2022
,Health Assessment Final Exam STUDY GUIDE REVIEW LATEST
UPDATE 2022
The open-ended question is unbiased; it leaves the person free to answer in any way.
Cant be answered with yes or no
• Give an example of a closed ended question
Closed or direct questions ask for specific information. They elicit a short, one- or two-
word answer, a “yes” or “no,” or a forced choice. Whereas the open-ended question
allows the client to have free rein, the direct question limits his or her answer
Are your headaches on one side or both?
Direct questions are also useful when you need specific facts such as past medical
history or during the review of systems. You need direct questions to speed up
the interview. Ask only one direct question at a time. Avoid double-barreled
questions
• What is redirecting, silence, restating
Redirection: getting off subject
Silence: listening
Restating: asking back
• What should be included in a social history?
Alcohol abusive, pay your bills
• When do you screen for intimate partner violence?
Every screening or when you think there is violence.
Intimate partner violence, dating violence, child abuse, and elder abuse are important health
problems that health care professionals must recognize and assess. The Joint Commission has
set standards that all health care settings have policies and procedures to assess, document,
and make referrals for family violence, including child abuse, intimate partner abuse, and elder
abuse. Intimate Partner Violence include Physical violence , sexual violence, threats of physical
or sexual violence and Psychological/emotional abuse and/or coercive tactics .
Health Assessment Final Exam STUDY GUIDE REVIEW LATEST
UPDATE 2022
, Health Assessment Final Exam STUDY GUIDE REVIEW LATEST
UPDATE 2022
Communication
• Barriers to communication (3)
1. Language
2. Blaming
3. Body language
• What questions do you need to ask each time you enter the room?
1. Name
2. Birthday
• Pain Assessment for different Ages and scales
• How do you do a pain
assessment In pain, after medication
• Non-Pharmacological and pharmacological pain management (2)
1.
2.
• What questions do you ask regarding pain?
P: Provocative or palliative. What brings it on? What makes it better or worse.
Q: Quality or Quantity. How does it look , feel sound. How intense/serve is it?
R: Region or radiation. Where is it? Does it spread anywhere?
S: Severity Scale. How bad is
it. T: Timing. Onset.
Health Assessment Final Exam STUDY GUIDE REVIEW LATEST
UPDATE 2022
UPDATE 2022
:
Health History:
• What is included in a health history
Medical history, medications, surgeries, family history, biographical data. You want to collect
subjective data.
1 Biographic data: name, address, phone number, age and birth date.
2. Reason for seeking care: why are they coming in. Symptoms and signs.
3. Present health or history of present illness. Short statement of general health.
4. Past history: childhood illness. Surgeries, accidents and immunizations.
5. Medication reconciliation: List of medications
6. Family history: any family members with illness or disease
7. Review of systems: examine each body system
8. Functional assessment or activities of daily living (ADLs)
• Define Subjective and objective
Subjective: what the person says about himself or herself during history taking
Objective: what you as the health professional observe by inspecting, percussing, palpating, and
auscultating during the physical examination
• Give an Example of an open-ended question.
• The open-ended question asks for narrative information.
“Tell me how I can help you.”, “What brings you to the hospital?”, “You mentioned
shortness of breath. Tell me more about that.”, “How have you been feeling since your
last appointment?”
Health Assessment Final Exam STUDY GUIDE REVIEW LATEST
UPDATE 2022
,Health Assessment Final Exam STUDY GUIDE REVIEW LATEST
UPDATE 2022
The open-ended question is unbiased; it leaves the person free to answer in any way.
Cant be answered with yes or no
• Give an example of a closed ended question
Closed or direct questions ask for specific information. They elicit a short, one- or two-
word answer, a “yes” or “no,” or a forced choice. Whereas the open-ended question
allows the client to have free rein, the direct question limits his or her answer
Are your headaches on one side or both?
Direct questions are also useful when you need specific facts such as past medical
history or during the review of systems. You need direct questions to speed up
the interview. Ask only one direct question at a time. Avoid double-barreled
questions
• What is redirecting, silence, restating
Redirection: getting off subject
Silence: listening
Restating: asking back
• What should be included in a social history?
Alcohol abusive, pay your bills
• When do you screen for intimate partner violence?
Every screening or when you think there is violence.
Intimate partner violence, dating violence, child abuse, and elder abuse are important health
problems that health care professionals must recognize and assess. The Joint Commission has
set standards that all health care settings have policies and procedures to assess, document,
and make referrals for family violence, including child abuse, intimate partner abuse, and elder
abuse. Intimate Partner Violence include Physical violence , sexual violence, threats of physical
or sexual violence and Psychological/emotional abuse and/or coercive tactics .
Health Assessment Final Exam STUDY GUIDE REVIEW LATEST
UPDATE 2022
, Health Assessment Final Exam STUDY GUIDE REVIEW LATEST
UPDATE 2022
Communication
• Barriers to communication (3)
1. Language
2. Blaming
3. Body language
• What questions do you need to ask each time you enter the room?
1. Name
2. Birthday
• Pain Assessment for different Ages and scales
• How do you do a pain
assessment In pain, after medication
• Non-Pharmacological and pharmacological pain management (2)
1.
2.
• What questions do you ask regarding pain?
P: Provocative or palliative. What brings it on? What makes it better or worse.
Q: Quality or Quantity. How does it look , feel sound. How intense/serve is it?
R: Region or radiation. Where is it? Does it spread anywhere?
S: Severity Scale. How bad is
it. T: Timing. Onset.
Health Assessment Final Exam STUDY GUIDE REVIEW LATEST
UPDATE 2022
