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NURS 5220: Module 1 NEWEST 2025
ACTUAL EXAM 160 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED
ANSWERS)|ALREADY GRADED A+
SOAP note - Answers - ✅✅SOAP note is both a process and a documentation format The Partnership with the Patient - Answers - ✅✅Getting to know your client: Culture Physical characteristics Influence on health and illness Beliefs and behaviors Family relationships Preparing to be an effective health care provider The History and Interviewing process - Answers - ✅✅The history and physical exam begin the diagnostic and treatment process The techniques you will learn are orderly but not rigid To prevent misinterpretations and misperceptions, you must make every effort to view the patient's perspective. GOALS - Answers - ✅✅Discover information leading to diagnosis and management Provide information about diagnosis Negotiate and share health care management Counsel about disease prevention Autonomy - Answers - ✅✅Patient's self-determination
Beneficence - Answers - ✅✅Do good for the patient Nonmaleficence - Answers - ✅✅Do no harm to the patient Utilitarianism - Answers - ✅✅Appropriate use of resources for the greater good Fairness and Justice - Answers - ✅✅Equitable treatment of all Deontological imperatives - Answers - ✅✅Care delivered according to traditions and in cultural contexts Factors that Enhance Communication - Answers - ✅✅Establishing a positive patient relationship depends on communication built on: Courtesy Comfort Connection Confirmation Confidentiality Be Professional: Attire & Response Enhancing Patient Responses - Answers - ✅✅Establish rapport and trust- Seek connection Open‐Ended Question-Allows patient discretion about the extent of an answer Direct Question-Seeks specific information Leading Question
- May limit the information provided to what the patient thinks you want to know If the patient does not understand what you are asking, remember to: - Answers - ✅✅Facilitate: Encourage your patient to say more Reflect: Repeat what you have heard. Clarify: Ask "What do you mean?"
- Make eye contact
- Do not overtire patient
- Do not be judgmental
- Be flexible Avoid medical jargon
- Take notes sparingly
- Avoid leading questions
- Start with general concerns, then move to specific descriptions.
- Clarify responses with where, when, what, how, and why questions.
- Verify and summarize what you have heard Building the History - Answers - ✅✅• Identify what the patient defines as problems.
- Establish patient's reliability.
- Consider intentional or unintentional suppression or underreporting of information.
- Evaluate patient's words and behaviors.
- Adapt to the modifications that age, pregnancy, and physical and emotional handicaps mandate Approaching Sensitive Issues - Answers - ✅✅• Ensure privacy.
- Be direct and firm.
- Do not apologize for broaching the issue.
- Do not preach.
- Use language that is understandable.
- Do not push too hard. Sensitive Issues - Answers - ✅✅• Alcohol and drug use
- Domestic violence
- Spirituality
- Sexuality CAGE Questionnaire - Answers - ✅✅- Cutting down
- Annoyance by criticism
- Guilty feeling
- Eye‐openers TACE Questionnaire - Answers - ✅✅T-How many drinks does it Take to make you feel high?
A-Have people Annoyed you by criticizing your drinking? C-Have you felt you ought to Cut down on your drinking? E-Have you ever had an Eye‐opener drink first thing in the morning to steady your nerves or get rid of a hangover? The CRAFFT questions are a means of screening adolescents for substance‐related problems - Answers - ✅✅C-Have you ever ridden in a Car driven by someone (You?) who is high on alcohol or drugs? R-Do you use alcohol or take drugs to Relax, feel better about yourself, or fit in? A-Do you ever use alcohol or take drugs while you are Alone? - F-Do you ever Forget things you did while using drugs or alcohol? F-Have a Family member or Friend told you to cut down on drinking or drug use? T-Have you ever gotten into Trouble from using alcohol or taking drugs? Screening vs. Assessment - Answers - ✅✅There is a difference between a screening and an assessment interview. The goal of screening is to find out if a problem exists - This is particularly true of CAGE, CRAFFT, and TACE questionnaires. They are effective, but they are only the start, and assessment goes on from there Intimate Partner Violence - Answers - ✅✅Both men and women suffer from intimate partner violence (IPV). More women experience IPV They come from every ethnic and socioeconomic group
sexuality - Answers - ✅✅The sexual orientation of a patient must be known if appropriate continuity of care is to be offered Trust can be better achieved if questions are "gender neutral."
- Tell me about your living situation.
- Are you sexually active? In what way? Subjective Data - Answers - ✅✅Subjective = States/ Says Subjective = Symptoms The purpose of the subjective interview is to identify PATTERNS Outline of the History - Answers - ✅✅Chief complaint (CC) or the reason for seeking care History of present illness or problem (HPI) Past medical history (PMH) Family history (FH) Personal and social history (PH/ SH) Review of systems (ROS) CC: Chief complaint/concern - Answers - ✅✅Reason for seeking Care Always in the patients' words—this sets the focus of the visit. (may need to teach staff!) Should only be a couple of sentences. "I am here for a physical exam." "I need my cholesterol checked." "My wife says I forget everything." Ways to elicit CC:
- What do you want to work on today?
- What is bothering you the most today? Note all significant complaints Seek answer to the question "What underlying problems or symptoms brought you here?" Determine the duration of the current illness by asking "How long has this problem been present?" Or "When did these symptoms begin?" Note age, gender, marital status, occupation, and previous hospital admissions HPI: History of Present Illness/ Problem - Answers - ✅✅About 80% of your diagnosis will come from the historical information you collect Establish the problem or the CC HPI = Symptom Analysis Helps differentiate between possible causes Helps in ruling in or ruling out possible causes HPI: Explore the following - Answers - ✅✅Chronology of events Health state before present problem First symptoms Exposure to infection or toxic agents Typical attack Illness impact on lifestyle Stability of problem Immediate reason for visit Review of involved systems Medications list Complementary or alternative therapies Chronology review Problem list HPI should include the following: - Answers - ✅✅Onset Setting Location Quality
- Allergies (drugs, environment, food)
- Past transfusions
- Recent screening tests
- Emotional status
- General health
- Childhood illnesses
- Major adult illnesses
- Immunizations
- Surgery
- Serious injuries and resulting disability
- Functional ability limitations Current Health Data - Answers - ✅✅• Medications‐prescription, OTC, herbal, vitamins, supplements. Reason for taking.
- Allergies‐foods, meds, environmental. Include type of reaction to each one. Example: codeine/nausea.
- Date, results of last physical.
- Screening tests, results. Includes mmg, pap, c‐scope, PSA, lipids, etc. • Immunizations - Name and date (or age) - ‐please don't say UTD! LMP - Answers - ✅✅LNMP BCM/MOC‐document type and typical use. "I use condoms for birth control" "Every time." "Well, every time I have one." Please ask your male and female patients about condom/protection use. Past Medical History - Answers - ✅✅• Childhood illnesses‐ask about pertussis, varicella, measles, mumps, rubella, polio.
- Adult illnesses‐the common ones‐cancers, CAD, HTN, thyroid, diabetes. Plus, always ask about h/o STI.
- Traumas, injuries, disabilities.
- Hospitalizations and blood/blood product transfusion. Common in premature infants, often forgotten by parents.
- Surgeries‐ Circumcision/ C‐ Sections/ BTL/ Vasectomy are commonly forgotten Past Medical History Obstetric/ Gynecologic - Answers - ✅✅Menarche
Menopause History of contraceptive or hormone use. Infections, procedures, devices, etc. OB history abbreviations GPTPAL GPTPAL - Answers - ✅✅Gravida‐how many pregnancies? Term‐how many full-term pregnancies? Preterm‐how many pre‐term pregnancies? Abortions‐spontaneous or induced Living children Complications Sexual history - Answers - ✅✅You will make your client uncomfortable if you are not comfortable with the questions Privacy‐ Confidentiality You may need to explain the reason for asking personal questions Give permission not to answer questions they don't want to Audiotape advice! Current sexual relationship/s BCM/ MOC Number of (lifetime)current and previous partners Sexual debut (onset of coitus) Specifics - Gender preference (Do you prefer sex with males, females, both or neither?) - Oral, Anal, Vaginal Psychiatric History - Answers - ✅✅Dates Diagnoses Treatments, including herbal Results
- Religious/spiritual beliefs
- Cultural background and health beliefs
- Financial situation (a biggie right now!)
- Safety in home
- Housing
- Housemates
- Pets
- Weapons
- Smoke detectors
- Remember to extend this to neighborhoods— like ability to get groceries, safety to exercise
- Working conditions
- Exposures to toxins
- Job satisfaction
- Protective devices
- Any safety concerns
- Long hours
- Alcohol
- Drugs
- Caffeine
- Tobacco products, also secondhand smoke
- Seatbelts
- Helmets
- Sunblock
- Multiple questionnaires also are available to help screen for health risks Personal and Social History ADLs - Answers - ✅✅This is done to get an idea of your patient's typical day. This is most useful with:
- Elderly
- Psychiatric patients
- Differently abled patients
- Children/adolescents Personal and Social History Environmental - Answers - ✅✅• Travel
- Camping
- Also, some housing conditions
Ex: house built before 1978 is at risk for: lead ROS: Review of systems - Answers - ✅✅Purpose is to take an inventory of the body systems looking for s/s that the pt. May not recognize as important Example: pregnant patient with swollen feet ROS explores - Answers - ✅✅• General constitutional symptoms
- Skin, hair, and nails
- Head and neck
- Lymph nodes
- Chest and lungs
- Breasts • Heart and blood vessels
- Peripheral vascular
- Hematologic
- Gastrointestinal
- Diet Endocrine - Female - Male • Genitourinary
- Musculoskeletal
- Neurological
- Psychiatric
- Concluding questions Comprehensive ROS - Answers - ✅✅• Involves questions about each of the 17 body systems
- Many times, this is done by checklist, not by provider
- Key questions for each system.
- Start system with "Are you having any problems with your ‐‐‐‐‐‐‐‐‐‐‐?" Then move to specific questions. types of histories - Answers - ✅✅Complete History‐ New Client on first visit Inventory History‐ Major points Problem or Focused History‐ Problem Episodic or Interval visit
Examination Techniques and Equipment Order of Physical Examination - Answers - ✅✅• Inspection
- Palpation
- Percussion
- Auscultation EXCEPT Abdomen Abdomen order of examination - Answers - ✅✅Inspection Auscultation Percuss Palpation inspection - Answers - ✅✅observation used for data collection using eyes and nose can use extra lighting palpation - Answers - ✅✅Sense of Touch used for data collection Palmer surface of fingers and finger pads are more sensitive to determine position, texture, size, consistency, masses, fluid and crepitus. Ulnar surface of and finger are sensitive to distinguish vibration. Dorsal surface of the hand is best for estimating temperature Light, Deep touch is therapeutic respect boundaries and ask for permission Percussion - Answers - ✅✅Sense of touch to produce vibration and sound waves Sound waves are heard as percussion tones or resonance Percussion hammer and Tuning Fork Depth of underlying tissue determines the percussion tones:
Tympany Hyperresonance Resonance Dullness Flatness Percussion tones - Answers - ✅✅• Tympany‐ gastric bubble
- Hyperresonance‐ lungs with emphysema
- Resonance‐ healthy lungs
- Dullness‐ liver
- Flatness‐ muscle
- Direct (sinus)
- Indirect or mediate (percussion striking own finger)
- Blunt (CVA tenderness)
- Scratch test Auscultation - Answers - ✅✅• Sense of hearing
- Stethoscope on bare skin (no fabric)
- High pitch sounds (diaphragm)
- Low pitch sounds (bell)
- Quiet environment
- Listen to characteristics of the sound
- Intensity - Duration - Pitch - Quality SOAP and Diagnostic Reasoning - Answers - ✅✅• CDM involves taking ALL of the possibilities that fit the chief complaint—this is called differential diagnosis.
- You will discard the ones that don't fit—this is called "ruling out."
- Ruling out is just as important as ruling in
- You will use your physical examination, lab tests and imaging to get further information. Diagnostic Reasoning Clinical Decision Making - Answers - ✅✅• Differential diagnosis is a PROCESS
- Involves taking all the possible explanations for a problem
- Discarding the ones that don't fit
- Keeping the ones that do fit the patterns
- You may develop THE diagnosis—because it is obvious
Pathognomonic: - Answers - ✅✅means a finding that is so characteristic of a disease that is leads you to a diagnosis in diagnostic reasoning asking questions - Answers - ✅✅use your 7 variables of a symptom to narrow list Assign a probability - Answers - ✅✅• Cluster and Trend
- How likely is this?
- Time of year?
- Other family members?
- Previous symptom? Order Diagnostic Tests - Answers - ✅✅• Need to know what the validity of the test is - Specificity - Sensitivity
- Cost
- Don't order a test if you don't know what to do with it! subjective content - Answers - ✅✅Information that comes from opinion, perceptions, or experiences the patient reports Information gathered from the patient telling you something that you did not measure or evaluate building a history - Answers - ✅✅Building" a history rather than "taking" one because you and your patient are involved in a joint effort Context of that relationship in emotional, physical, and ethical terms Verbal and nonverbal behavior that you may adapt to your individual comfort and style Approaches to the structure of a history with adaptations suggested for age, gender, and disability History begins with developing a relationship - Answers - ✅✅The first meeting with the patient sets the tone for a successful partnership You will be open, flexible, and eager to deal with questions and explanations You will explain the boundaries of your practice and the degree of your availability in any situation Trust evolves from honesty and candor
Objectives to developing a patient relationship - Answers - ✅✅Primary objectives: To discover the details about a patient's concern To explore expectations for the encounter To display genuine interest, curiosity, and partnership To prevent misinterpretations and misperceptions, you must make every effort to sense the world of the patient as that patient sees it Patient centered care - Answers - ✅✅Defined by the Institute of Medicine as: "respecting and responding to patients' wants, needs and preferences, so that they can make choices in their care that best fit their individual circumstances" Your own beliefs, attitudes, and values cannot be discarded, but you do have to discipline them Effective communication - Answers - ✅✅Establishing a positive patient relationship depends on communication built on: Courtesy Comfort Connection Confirmation Confidentiality Enhancing patient responses - Answers - ✅✅Open-ended question Allows patient discretion about the extent of an answer Direct question Seeks specific information Leading question May limit the information provided to what the patient thinks you want to know Communication Pearls - Answers - ✅✅If the patient does not understand what you are asking, remember to: Facilitate: Encourage your patient to say more. Reflect: Repeat what you have heard. Clarify: Ask "What do you mean?" Empathize: Show understanding and acceptance. Confront: Address disturbing patient behavior. Interpret: Repeat what you have heard to confirm the patient's meaning. Barriers to communication - Answers - ✅✅Curiosity about you Anxiety
