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NSG 6020 Exam 1 - Advanced Health Assessment Fall 2023 AGMSN Questions With Complete Solutions Identify essential components of the health history correct answer: a. Identifying data and source of the history b. Chief complaint - use "quotes" from patient c. Present illness - chronological order!
- Medications, allergies, tobacco use, alcohol and drug use
- 7 attributes (OLD CARTS) d. Past illness
- Medical, surgical, Obstetric/gynecological, psychiatric
- Health maintenance e. Family history f. Personal and social history g. Review of systems - Go through each one! Discuss scope of nursing assessment correct answer: Can be either:
- Comprehensive Assessment
- Focused Assessment What are the indications for and what is included in a Comprehensive Assessment? correct answer: a. Comprehensive assessment - a complete assessment.
- Includes all elements of the health history and a complete physical assessment.
- This is useful for new patients.
- Gives a good baseline for future assessments.
- Opportunity for health promotion.
- Gives you a lot of information about the patient and also gives you time to build a relationship. What are the indications for and what is included in a Focused Assessment? correct answer: b. Focused assessment - is focused on the concern or the problem the patient presents with
- Restricted to a specific body system or two
- May be useful for an ongoing relationship once you established a baseline if there are no new concerns. Components of the Health History: Identifying Data and Source of the History; Reliability correct answer: a. Identifying data and source of the history: age, gender, occupation, marital status. Who is giving the information? How reliable is it?
- Name/Age/Gender
- Occupation
- Marital status
- Source of data (family member, parent) Gives you indication of reliability of the data Child vs. parent confused adult vs. the adult child or family member Components of the Health History: Chief Complaint(s) correct answer: b. Chief complaint: Symptoms that cause the patient to seek care
- One or more symptoms causing them to seek care.
- Use quotes from patient
- Just a phrase Components of the Health History: Present Illness correct answer: c. Present illness: More details about the chief
Screenings Components of the Health History: Family History correct answer: e. Family history: Genogram with health, illnesses, death, etc. Document the absence or presence of illnesses. Specifically ask about diabetes, cancers, HTN, CAD, heart disease, mental illness (especially things that are familial)
- Genogram
- Causes of death
- Ages of death
- Illnesses and health
- Presence or absence of diseases - ask about key ones: Diabetes HTN CAD Genetics Components of the Health History: Personal and Social History correct answer: f. Personal and social history: educational level, family origin, current household, personal interests, lifestyle— alcohol, drugs?
- Educational level
- Family of origin, cultural influences
- Who is in the household
- Personal interests
- Lifestyle
- Sexual history-partners, frequency
- Habits—drugs and alcohol
- Nutrition, sleep, exercise
- Religious preference
- Military
Components of the Health History: Review of Systems correct answer: g. Review of systems: go through each body system and document the presence and/or absence to each major body system. People forget things...so you will have to ask about each one and then examples of important illnesses or symptoms in each system.
- Series of questions from head to toe: General (may include psychiatric) Skin HEENT (may include neurological) Neck Breasts Respiratory Cardiovascular Gastrointestinal Peripheral Vascular Urinary Genital Musculoskeletal Psychiatric Neurologic Hematologic Endocrine
- Prepare the patient for the questions
- Start general and then focus questions if there is a concern
- Helps uncover problems the patient has overlooked
- Be organized.
Recognize ethical considerations in patient-examiner relationships correct answer: a. Cultural humility - self- awareness, respectful communication, collaborative relationships b. Sexuality - clinician and patient relationships c. Ethics and professionalism
- Confidentiality
- Non-maleficence or "first, do no harm"
- Autonomy—patient's right to determine their care
- Beneficence—provider needs to do good for the patient. d. Issues
- Seduction
- Anxiety
- Excessive flattery
- Financial concerns The "silent" patient correct answer: • Some issues may be painful to discuss
- Tearful, unable to speak
- Be attentive
- Look for nonverbal cues
- Are your questions too quick or offensive? "Altered" capacity correct answer: • Delirium, dementia or other health conditions
- What is the decision making capacity?
- Durable power of attorney or health care proxy?
- Allow them to be fully involved to the limit of his/her ability. "Talkative" patient correct answer: • Let talk for 5-10 minutes and listen closely
- Focus on what seems to be most important to the patient
- Learn how to set limits when needed
- Interrupt only if necessary "Crying" patient correct answer: • "I can see that you are not feeling well, it is alright to cry"
- Silence or pausing
- Gentle probing and respond empathetically
- Be supportive
- Give them a tissue Permission to cry "Confused" Patient correct answer: • Multiple symptoms
- Neurological disorder?
- Mental illness?
- Dementia?
- Intoxication?
- Mental status exam
- Family member help? "Angry" patient correct answer: • Face it
- It may be displacement on to the HCP because of frustration, illness, or pain
- Be calm
- Avoid confrontation
- No one is happy to be sick.... Describe the components of the clinical reasoning process correct answer: a. Clinical Reasoning -
- This is what makes you a nurse - nursing is intellectual
If obese, is fat distributed evenly or concentrated over trunk, upper torso, around the hips? Any rapid change in weight? (fluid retention?)
- Calculating the body mass index (BMI) Normal BMI is 19-25. Obesity increases risk for HTN, DM, heart disease, stroke, sleep apnea, depression
- Apply concepts of the general survey to patient situations: General Appearance correct answer: b. General appearance:
- Apparent state of health Acute or chronically ill, frail Age appropriate?
- Level of consciousness Awake, alert, responsive or lethargic, obtunded, comatose
- Signs of distress Cardiac or respiratory; pain; anxiety/depression
- Skin Lesions, turgor, color Sun exposure
- Dress, grooming, and personal hygiene Appropriate to weather and temperature Clean, properly buttoned/zipped
- Facial expression Eye contact, appropriate changes in facial expression Mood
- Odors of body and breath
- Posture, gait, and motor activity Blood Pressure (normal and abnormal) correct answer: • Normal < 120/
- Pre- HTN 120-139/ 80-
- HTN > 140/ Stage I 140-159/ 90- Stage II >160/ > Heart Rate (normal and abnormal) correct answer: • Normal 60- 100 Bradycardia < 60 Tachycardia > Respiratory Rate (normal and abnormal) correct answer: • Normal rate: 12-20 breaths/minute Tachypnea > Bradypnea < 12 Temperature (normal and abnormal) correct answer: • Average oral temperature:37°C or 98.6°F
- Fever: 100.4°F or 38°C
- Diurnal variation: 35.8°C - 37.3°C (96.4°F - 99.1°F) Pain (normal and ways to assess) correct answer: • Normal - No pain: 0 out of 10
- Ways to assess: Numeric Rating Scale - Rate pain from 0 - 10 Wong-Baker FACES Scale - used by children or patients with language barriers or cognitive impairment FLACC Pain Scale - for newborns or babies Level of consciousness (LOC) correct answer: how aware the person is of his environment
thought processes correct answer: the logic, coherence, and relevance of a patient's thoughts as they lead to thoughts and goals; HOW people think insight correct answer: awareness that thought, symptoms, or behaviors are normal or abnormal; e.g. distinguishing that a daydream or hallucination is not real judgment correct answer: process of comparing and evaluating different possible courses of action affect correct answer: the observable mood of a person expressed through facial expression, body movements, and voice mood correct answer: the sustained emotion of the patient
- euthymic: normal
- dysthymic: depressed
- manic: elated language correct answer: the complex symbolic system for expressing written and verbal thoughts, emotion, attention, and memory higher cognitive functions correct answer: level of intelligence assessed by vocabulary, knowledge base, calculations, and abstract thinking Mental Status Examination correct answer: • Consists of the following components: Appearance and behavior
Speech and language Mood Thoughts and perceptions Cognitive function: memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability Assessing Cognitive Functions correct answer: • Assess orientation to person, place, and time
- Assess attention Digital span: give the patient a string of numbers to recite back to you Serial 7s: ask the patient to subtract serial "7s" from 100 Spelling backward: ask the patient to spell W-O-R-L-D backwards
- Assess remote memory by asking about past historical events
- Assess recent memory by asking about something recent (weather, national event, etc.)
- Assess new learning ability by giving the patient three or four words to remember; then ask him to repeat the words after several minutes Assessing Higher Cognitive Functions correct answer: • Through your conversation, you can often assess the patient's higher cognitive functions
- Information and vocabulary
- Calculating ability: ask the patient to perform more difficult calculations such as making change (e.g., if you had a dollar's worth of nickels and someone needed 65 cents how many nickels would you have left?)
- Abstract thinking
