NUR 2204 Midterm Exam 1 with
complete verified solutions already
graded A+
Health History - answer interview before physical exam
-*rapport*
-document and elicit signs, symptoms, course of development
-holistic
Health History Tips - answer systematic; confidential; safety in the room,
enough lighting, comfortable, shake hands, dress appropriately, formal titles
only, no slang or jargon, active listening, explain
Documentation - answer LEGAL DOCUMENT
-record data in an orderly manner
-legible ink, no empty space (draw a line)
-never document someone else's data
Error in Documentation - answer cross out with one line, initial and date
"error", no white out, no pencil, no scribbles, no re-writes
Complete Health History - answer demographics, chief complain, history of
present illness, PMH/PSH, FH, psychosocial history, ROS
Demographic Data - answer name, address, age, religion, gender, language
spoken
-DOB
-education level
,-marital status
-occupation
-provider of the information
Chief Complaint - answer major health concern; reason for seeking care
-written in a few words or a quote from the patient
-ex: "throbbing headache for 3 days"
History of the Present Illness - answer story of the problem; why they are
coming in today
-symptoms, allergies, medications
-be specific (no "normal", always bilateral)
-COLDSPA
COLDSPA - answer C- character/description of symptoms
O- onset (when did it begin)
L- location (where does it hurt, radiate?)
D- duration
S- severity (0-10)
P- pattern (after meals, in the morning, after exercise)
A- associated factors (other symptoms)
Past Health History (Medical and Surgical History) - answer any chronic
illness, childhood illness, medications, hospitalizations (date/ year and
reason), surgeries (date/ year and reason)
Family History - answer genogram: patient, parents, grandparents 3
generations
,Psychosocial History - answer typical day
-occupation, diet, exercise, sleep, education, social activities, *alcohol,
caffeine, tobacco, marijuana*, illicit drug use
Review of Symptoms - answer any other symptoms NOT RELATED to what
you came for; covers all body symptoms
-ex: constipation, hearing loss, head ache
Physical Exam Process/Steps - answer systematic from head to toe
-general survey
-skin/hair/nails
-head and neck
-chest (heart, lungs, breasts)
-abdomen
-extremities (peripheral vascular, musculoskeletal)
-neurological (cranial nerves, deep tendon reflexes, sensation, motor,
cerebellum)
Complete Health History vs. Interval vs. Problem Focused - answer complete:
every category; interval: every few months check specific problem
(diabetes); problem focused: only about the problem TODAY (cold, flu, sore
throat)
Physical Exam Tips - answer explain what you're doing, provide privacy,
assure confidentiality, ask permission before touching and get an affirmative
response, wash hands
Vital Signs in the Clinical Setting - answer ask patient to relax if abnormal
-TPRBP
Description of Patient - answer general survey (age, gender, ethnicity)
, -alert and oriented x3
-posture, gait, dress, hygiene, grooming
-tremor, tics, spasms
-body language
-can they speak English?
-reliable historian
Patient as a Reliable Historian - answer verbal and nonverbal behavior
-observe hygiene, dress, well-groomed, memory, explain their health status
Elicit Information from a Child - answer do a demonstration on a stuffed
animal or doll
-ear exam last
Cachectic - answer looks ill, lack of muscle mass and skin elasticity
Physical Exam Techniques - answer Inspection
Palpation
Percussion
Auscultation
Inspection - answer no touch, looking only
-carefully observe and describe in detail what you see
-ex: abdomen is pink, distended, obese, umbilicus midline, no visible scars,
pink striae present bilaterally
Palpation - answer touch
-soft, hard, smooth, pulsating, tender?
-tender area last
complete verified solutions already
graded A+
Health History - answer interview before physical exam
-*rapport*
-document and elicit signs, symptoms, course of development
-holistic
Health History Tips - answer systematic; confidential; safety in the room,
enough lighting, comfortable, shake hands, dress appropriately, formal titles
only, no slang or jargon, active listening, explain
Documentation - answer LEGAL DOCUMENT
-record data in an orderly manner
-legible ink, no empty space (draw a line)
-never document someone else's data
Error in Documentation - answer cross out with one line, initial and date
"error", no white out, no pencil, no scribbles, no re-writes
Complete Health History - answer demographics, chief complain, history of
present illness, PMH/PSH, FH, psychosocial history, ROS
Demographic Data - answer name, address, age, religion, gender, language
spoken
-DOB
-education level
,-marital status
-occupation
-provider of the information
Chief Complaint - answer major health concern; reason for seeking care
-written in a few words or a quote from the patient
-ex: "throbbing headache for 3 days"
History of the Present Illness - answer story of the problem; why they are
coming in today
-symptoms, allergies, medications
-be specific (no "normal", always bilateral)
-COLDSPA
COLDSPA - answer C- character/description of symptoms
O- onset (when did it begin)
L- location (where does it hurt, radiate?)
D- duration
S- severity (0-10)
P- pattern (after meals, in the morning, after exercise)
A- associated factors (other symptoms)
Past Health History (Medical and Surgical History) - answer any chronic
illness, childhood illness, medications, hospitalizations (date/ year and
reason), surgeries (date/ year and reason)
Family History - answer genogram: patient, parents, grandparents 3
generations
,Psychosocial History - answer typical day
-occupation, diet, exercise, sleep, education, social activities, *alcohol,
caffeine, tobacco, marijuana*, illicit drug use
Review of Symptoms - answer any other symptoms NOT RELATED to what
you came for; covers all body symptoms
-ex: constipation, hearing loss, head ache
Physical Exam Process/Steps - answer systematic from head to toe
-general survey
-skin/hair/nails
-head and neck
-chest (heart, lungs, breasts)
-abdomen
-extremities (peripheral vascular, musculoskeletal)
-neurological (cranial nerves, deep tendon reflexes, sensation, motor,
cerebellum)
Complete Health History vs. Interval vs. Problem Focused - answer complete:
every category; interval: every few months check specific problem
(diabetes); problem focused: only about the problem TODAY (cold, flu, sore
throat)
Physical Exam Tips - answer explain what you're doing, provide privacy,
assure confidentiality, ask permission before touching and get an affirmative
response, wash hands
Vital Signs in the Clinical Setting - answer ask patient to relax if abnormal
-TPRBP
Description of Patient - answer general survey (age, gender, ethnicity)
, -alert and oriented x3
-posture, gait, dress, hygiene, grooming
-tremor, tics, spasms
-body language
-can they speak English?
-reliable historian
Patient as a Reliable Historian - answer verbal and nonverbal behavior
-observe hygiene, dress, well-groomed, memory, explain their health status
Elicit Information from a Child - answer do a demonstration on a stuffed
animal or doll
-ear exam last
Cachectic - answer looks ill, lack of muscle mass and skin elasticity
Physical Exam Techniques - answer Inspection
Palpation
Percussion
Auscultation
Inspection - answer no touch, looking only
-carefully observe and describe in detail what you see
-ex: abdomen is pink, distended, obese, umbilicus midline, no visible scars,
pink striae present bilaterally
Palpation - answer touch
-soft, hard, smooth, pulsating, tender?
-tender area last
