NUR 600 Midterm Study Guide: SOAP Notes
UPDATED ACTUAL Exam Questions and
CORRECT Answers
What are the parts of a SOAP note? - CORRECT ANSWER -Subjective, Objective,
Assessment, Plan.
What does the 'Subjective' part of a SOAP note include? - CORRECT ANSWER -
Symptoms which are health concerns that the patient tells you.
What is the 'Chief complaint' in a SOAP note? - CORRECT ANSWER -The primary
symptom or concern causing the patient to seek care, typically one or two concerns.
What does HPI stand for and what does it include? - CORRECT ANSWER -HPI stands
for History of Present Illness; it amplifies the chief complaint, describes the chronology of
events, includes the patient's thoughts and feelings about the illness, and incorporates pertinent
positives and negatives from the review of systems.
What are the key attributes of a symptom? - CORRECT ANSWER -The key attributes of a
symptom include Location, Quality, Quantity or severity, Timing (Onset, Duration, Frequency),
Modifying factors, and Associated manifestations.
What is the purpose of documentation in a medical assessment? - CORRECT ANSWER -
Documentation serves to provide an opening statement, characterize the chief complaint,
describe pertinent positives and negatives, and include relevant information from the health
history.
What does the review of systems aim to uncover? - CORRECT ANSWER -The review of
systems aims to uncover problems or symptoms that the patient may have overlooked.
, What are common general symptoms assessed in the review of systems? - CORRECT
ANSWER -Common general symptoms include usual weight, recent weight change,
weakness, fatigue, and fever.
What are the symptoms associated with respiratory issues? - CORRECT ANSWER -
Symptoms include cough, sputum (color and quantity), shortness of breath (dyspnea), wheezing,
and pain with a deep breath (pleuritic pain).
What are the symptoms of cardiovascular issues? - CORRECT ANSWER -Symptoms
include heart trouble, high blood pressure, chest pain or discomfort, palpitations, and shortness
of breath.
What constitutes a single disease process versus multiple disease processes? - CORRECT
ANSWER -A single disease process involves symptoms occurring in a single system,
while multiple disease processes involve problems in different, apparently unrelated systems.
What is the sequence of a patient interview? - CORRECT ANSWER -The sequence
includes initiating the encounter, gathering information, performing a physical examination,
explaining and planning, and closing the encounter.
What are some skilled interview techniques used in patient assessments? - CORRECT
ANSWER -Techniques include active listening, guided questioning, empathetic responses,
summarization, and validation.
What are common and concerning symptoms in a general survey? - CORRECT
ANSWER -Common symptoms include fatigue, weakness, fever, chills, night sweats,
weight change, and pain.
What are the signs and symptoms of diabetic ketoacidosis (DKA)? - CORRECT
ANSWER -Signs include mild nausea, fatigue, weakness, fruity-scented breath, rapid
breathing, and hyperglycemia.
UPDATED ACTUAL Exam Questions and
CORRECT Answers
What are the parts of a SOAP note? - CORRECT ANSWER -Subjective, Objective,
Assessment, Plan.
What does the 'Subjective' part of a SOAP note include? - CORRECT ANSWER -
Symptoms which are health concerns that the patient tells you.
What is the 'Chief complaint' in a SOAP note? - CORRECT ANSWER -The primary
symptom or concern causing the patient to seek care, typically one or two concerns.
What does HPI stand for and what does it include? - CORRECT ANSWER -HPI stands
for History of Present Illness; it amplifies the chief complaint, describes the chronology of
events, includes the patient's thoughts and feelings about the illness, and incorporates pertinent
positives and negatives from the review of systems.
What are the key attributes of a symptom? - CORRECT ANSWER -The key attributes of a
symptom include Location, Quality, Quantity or severity, Timing (Onset, Duration, Frequency),
Modifying factors, and Associated manifestations.
What is the purpose of documentation in a medical assessment? - CORRECT ANSWER -
Documentation serves to provide an opening statement, characterize the chief complaint,
describe pertinent positives and negatives, and include relevant information from the health
history.
What does the review of systems aim to uncover? - CORRECT ANSWER -The review of
systems aims to uncover problems or symptoms that the patient may have overlooked.
, What are common general symptoms assessed in the review of systems? - CORRECT
ANSWER -Common general symptoms include usual weight, recent weight change,
weakness, fatigue, and fever.
What are the symptoms associated with respiratory issues? - CORRECT ANSWER -
Symptoms include cough, sputum (color and quantity), shortness of breath (dyspnea), wheezing,
and pain with a deep breath (pleuritic pain).
What are the symptoms of cardiovascular issues? - CORRECT ANSWER -Symptoms
include heart trouble, high blood pressure, chest pain or discomfort, palpitations, and shortness
of breath.
What constitutes a single disease process versus multiple disease processes? - CORRECT
ANSWER -A single disease process involves symptoms occurring in a single system,
while multiple disease processes involve problems in different, apparently unrelated systems.
What is the sequence of a patient interview? - CORRECT ANSWER -The sequence
includes initiating the encounter, gathering information, performing a physical examination,
explaining and planning, and closing the encounter.
What are some skilled interview techniques used in patient assessments? - CORRECT
ANSWER -Techniques include active listening, guided questioning, empathetic responses,
summarization, and validation.
What are common and concerning symptoms in a general survey? - CORRECT
ANSWER -Common symptoms include fatigue, weakness, fever, chills, night sweats,
weight change, and pain.
What are the signs and symptoms of diabetic ketoacidosis (DKA)? - CORRECT
ANSWER -Signs include mild nausea, fatigue, weakness, fruity-scented breath, rapid
breathing, and hyperglycemia.
