Assessment Exam Questions
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SOAPIER - ANSWER ✓ S - subjective
O - objective
A - assessment
P - plain
I - intervention
E - evaluation
R - revision
SBAR - ANSWER ✓ S - situation
B - background
A - assessment
R - recommendation
EHR(electronic health record) - ANSWER ✓ a digital collection of personal
health information that can be shared by all health care providers involved in an
individual's care and includes data from the history, physical examination,
laboratory and diagnostic tests, and surgical procedures and progress notes entered
by all health professionals.
physical examination - ANSWER ✓ collection of objective data sometimes
referred to as signs
, factors that may affect the data that is revealed from the patient - ANSWER ✓ -
physical setting
- nurse's behavior
- types of questions asked
- how the questions are asked
-personality/behavior of the patients
-how the patient is feeling during the time of the interview
- nature of the info being discussed
present health status - ANSWER ✓ -focuses on the patient's conditions (acute and
chronic), medications the patient is currently taking, and allergies the patient has
experienced.
examples
-health conditions: diabetes, hypertension, heart disease, sickle cell anemia, cancer,
seizures
-medications: reason for taking medication, how long the patient has been taking
the medication, dose and frequency, any adverse effects
-allergies: ask patient about allergies to foods, medication, environmental factors,
and contact substances
past health history - ANSWER ✓ -past and present conditions may have some
effect of the patient's current health needs and problems
examples
-childhood illnesses: measles, mumps, rubella, chicken pox, pertussis, strep throat
-surgeries: types, dates, outcomes
-hospitalizations: illnesses, dates, outcomes
-accidents or injuries: type, dates, outcomes
history of present illness - ANSWER ✓ -patients seek health care for a specific
problem, the nurse documents the present illness or problem
-what is going on with the patient right now
(back pain)
-symptom analysis to gather more data
-need more info to treat the client
-use OLD CARTS
, ***new problem
SMART - ANSWER ✓ S - specific
M - measurable
A - attainable
R - reasonable
T - timely
NIRR - ANSWER ✓ N - noticing (recognizing abnormal findings)
I - interpreting (organize findings)
R - responding (what action to take)
R - reflection (what can be expected)
clinical decision making is based on ... - ANSWER ✓ -evidence based practice
-patient preference
-clinician experience
-physical exam and assessment
ABCs - ANSWER ✓ A - airway
B - breathing
C - circulation
-Maslow's physiological
health assessment - ANSWER ✓ -systematic method of collecting and analyzing
data
-used to create a patient centered plan of care
-utilize ANA standards of practice, which incorporates the nursing process
major components of a health assessment - ANSWER ✓ -history
-physical examination
-documentation of data
health history - ANSWER ✓ -subjective data
-current state of health
-medications
-any previous illness/surgery