NR 616 Study Guide for Quiz 1

This quiz will be all short answers

1. Be able to provide 5 interviewing and history taking pointers

▪ Position yourself at the same level as the patient
▪ Recognize biases that may affect your ability to be impartial
▪ Observe the patient for any sensory deficits
▪ Prioritize information needs
▪ Know and respect cultural norms and values of patients
▪ Assure patient that information provided is confidential
▪ Use open-ended questions; allow time for answers

2. Be able to explain the difference between comprehensive and focused health history
▪ Comprehensive health history and physical examination
▪ Patient presents for an annual physical examination or is a new patient
▪ Focused, or episodic, health history and physical examination, Patient is presenting to
the healthcare provider for a specific problem

3. Know the 8 components to the Comprehensive Health History

Patient identifiers

▪ Patient identifiers
▪ Reliability
▪ Chief complaint (CC)
▪ History of present illness (HPI)
▪ Past medical history (PMI)
▪ Family history (FH)
▪ Social history (SH)
▪ Review of systems (ROS)

4. What is subjective data

◦ Chief complaint
◦ History of present illness
◦ Past medical history
◦ Medications
◦ Allergies
◦ Last menstrual period for women
◦ Family and social history
 ◦ Nutritional assessment
◦ Review of systems

5. Explain in detail PQRST

▪ P: precipitating factors (What provokes the symptom?)
▪ Q: quality (Describe the character and location of symptoms.)
▪ R: radiation (Does the symptom radiate to other areas of the body?)
▪ S: severity (Ask the patient to quantify the symptom(s) on a scale of 0–10.)
▪ T: timing (Inquire about the onset, duration, frequency, etc.)

6. What is objective data (in detail)

7. Know the ROS and their subcomponents
a. General/constitutional
b. Skin
c. Eyes
d. Ears
e. Nose
f. Mouth/throat
g. Cardiovascular
h. Respiratory
i. Gastrointestinal
j. Genitourinary
k. Breast
l. Musculoskeletal
m. Neurologic
n. Mental/psychiatric
o. Lymphatic
p. Hematologic
q. Endocrine

8. How would you interact with your patient during physical exam (3 ways)
9. What are the assessment techniques, describe?

10.In detail, describe Assessment and Plan in the SOAP note

This coming right from your slides and text (esp. question #1)