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NR 509 Mid-Term Exam. Questions And Answers Full Paper

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● Chapter 1 Basic and Advanced Interviewing Techniques Basic maximize patient's comfort, avoid unnecessary changes in position, enhance clinical efficiency, move head to toe, examine the patient ... from their right side Active listening, empathic responses, guided questioning, nonverbal communication, validation, reassurance, partnering, summarization, transitions, empowering the patient Active Listening- closely attending to what the patient is communicating, connecting to the patient’s emotional state and using verbal and nonverbal skills to encourage the patient to expand on his or her feelings and concerns. Empathic Responses-the capacity to identify with the patient and feel the patient’s pain as your own, then respond in a supportive manner. Guided Questioning- show your sustained interest in the patient’s feelings and deepest disclosures and allows the interviewer to facilitate full communication, in the patient’s own words, without interruption. Non-verbal- includes eye contact, facial expression, posture, head position and movement such as shaking or nodding, interpersonal distance, and placement of the arms or legs-crossed, neutral, or open. Validation- helps to affirm the legitimacy of the patient’s emotional experience. Reassurance- an appropriate way to help the patient feel that problems have been fully understood and are being addressed. Partnering- building rapport with patients, express your commitment to an ongoing relationship. Summarization- giving a capsule summary of the patient’s story during the course of the interview to communicate that you have been listening carefully. Transitions- inform your patient when you are changing directions during the interview. Empowering the Patient- empower the patient to ask questions, express their concerns, and probe your recommendations in order to encourage them to adopt your advice, make lifestyle changes, or take medications as prescribed. Advanced: Determine scope of assessment: Focused vs. Comprehensive: pg5 Comprehensive: Used for patients you are seeing for the first time in the office or hospital. Includes all the elements of the health history and complete physical examination. A source fundamental and personalized knowledge about the patient, strengthens the clinician-patient relationship. ● Is appropriate for new patients in the office or hospital ● Provides fundamental and personalized knowledge about the patient ● Strengthens the clinician–patient relationship ● Helps identify or rule out physical causes related to patient concerns ● Provides a baseline for future assessments ● Creates a platform for health promotion through education and counseling ● Develops proficiency in the essential skills of physical examination Flexible Focused or problem-oriented assessment: For patients you know well returning for routine care, or those with specific “urgent care” concerns like sore throat or knee pain. You will adjust the scope of your history and physical examination to the situation at hand, keeping several factors in mind: the magnitude and severity of the patient’s problems; the need for thoroughness; the clinical setting—inpatient or outpatient, primary or subspecialty care; and the time available. ● Is appropriate for established patients, especially during routine or urgent care visits ● Addresses focused concerns or symptoms ● Assesses symptoms restricted to a specific body system ● Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible Tangential lighting: JVD, thyroid gland, and apical impulse of heart. Components of the Health History Jenna/Ashley Initial information Identifying data and source of the history; reliability Identifying data- age, gender, occupation, marital status Source of history- usually patient. Can be: a family member or friend, letter of referral, or clinical record. Reliability- Varies according to the patient’s memory, trust, and mood. Chief Complaint Chief Complaint- Make every attempt to quote the patient’s own words. Present Illness Complete, clear and chronological description of the problem prompting the patient visit Onset, setting in which it occurred, manifestations and any treatments Should include 7 attributes of a symptom: ● Location ● Quality ● Quantity or severity ● Timing, onset, duration, frequency ● Setting in which it occurs ● Aggravating or relieving factors ● Associated manifestations -Differential diagnosis is derived from the “pertinent positives” and “pertinent negatives” when doing Review of Systems that are relevant to the chief complaint. A list of potential causes for the patients problems. -Present illness should reveal patient’s responses to his or her symptoms and what effect this has on their life. -Each symptom needs its own paragraph and a full description. -Medication should be documented, name, dose, route, and frequency. Home remedies, nonprescriptions drugs, vitamins, minerals or herbal supplements, oral contraceptives, or borrowed medications. -Allergies-foods, insects, or environmental, including specific reaction Tobacco use, including the type. If someone has quit, note for how long -Alcohol and drug use should always be investigated and is often pertinent to the Presenting Illness. Past history -Childhood Illness: measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever, and polio. Also include any chronic childhood illness -Adult illnesses: Provide information in each of the 4 areas: ● Medical: diabetes, hypertension, hepatitis, asthma and HIV; hospitalizations; number and gender of sexual partners; and risk taking sexual practices. ● Surgical: dates, indications, and types of operations ● Obstetric/gynecologic: Obstetric history, menstrual history, methods of contraception, and sexual function. ● Psychiatric: Illness and time frame, diagnoses, hospitalizations, and treatments. -Health Maintenance: Find out if they are up to date on immunizations and screening tests. Review Tb tests, pap smears, mammograms, stool tests for occult blood, colonoscopy, cholesterol levels etc.. Family history Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents Documents presence or absence of specific illnesses in family, such as hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, and symptoms reported by patient. Ask about history of breast, ovarian, colon, or prostate cancer Ask about Genetically transmitted diseases Personal or social history Describes educational level, occupation, family of origin, current household, personal interests, and lifestyle Capture the patients personality and interests, sources of support, coping style, strengths, and concerns Includes lifestyle habits that promote health or create risk, such as exercise and diet, safety measures, sexual practices, and use of alcohol, drugs, and tobacco Expanded personal and social history personalizes your relationship with the patient and builds a rapport Review of systems pg 11-13 Documents presence or absence of common symptoms related to each of the major body systems Understanding and using Review of Systems questions may seem challenging at first. These “yes-no” questions should come at the end of the inter- view. Think about asking a series of questions going from “head to toe.” It is helpful to prepare the patient by saying, “The next part of the history may feel like a hundred questions, but it is important to make sure we have not missed anything.” Most Review of Systems questions pertain to symptoms, but on occasion, some clinicians include diseases like pneumonia or tuberculosis. Note that as you elicit the Present Illness, you may also draw on Review of Systems questions related to system(s) relevant to the Chief Complaint to establish “pertinent positives and negatives” that help clarify the diagnosis. For example, after a full description of chest pain, you may ask, “Do you have any history of high blood pressure . . . palpitations . . . shortness of breath . . . swelling in your ankles or feet?” or even move to questions from the Respiratory or Gastrointestinal Review of Systems The Review of Systems questions may uncover problems that the patient has overlooked, particularly in areas unrelated to the Present Illness. Significant health events, such as past surgery, hospitalization for a major prior illness, or a parent’s death, require full exploration. Keep your technique flexible. Remember that major health events discovered during the Review of Systems should be moved to the Present Illness Past History in your write-up. Some experienced clinicians do the Review of Systems during the physical examination, asking about the ears, for example, as they examine them. If the patient has only a few symptoms, this combination can be efficient. If there are multiple symptoms, however, this can disrupt the flow of both the history and examination, and necessary note taking becomes awkward The Review of Systems: Pg. 12-13 ROS Chart Copied from online book General: Usual weight, recent weight change, clothing that fits more tightly or loosely than before; weakness, fatigue, or fever. Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles. Head, Eyes, Ears, Nose, Throat (HEENT): Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased, use or nonuse of hearing aids. Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble. Throat (or mouth and pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness. Neck: “Swollen glands,” goiter, lumps, pain, or stiffness in the neck. Breasts: Lumps, pain, or discomfort, nipple discharge, self-examination practices. Respiratory: Cough, sputum (color, quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (pleuritic pain), last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis. Cardiovascular: “Heart Trouble”; high blood pressure; rheumatic fever; heart murmurs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea breathing (paroxysmal nocturnal dyspnea); swelling in the hands, ankles, or feet (edema); results of past electrocardiograms or other cardiovascular tests. Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea. Bowel move-ments, stool color and size, change in bowel habits, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble; hepatitis. Peripheral vascular: Intermittent leg pain with exertion (claudication); leg cramps; varicose veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness. Urinary: Frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling. Genital Male: Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infections and their treatments. Sexual habits, interest, function, satisfaction, birth control methods, condom use, and problems. Concerns about HIV infection. Female: Age at menarche, regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension. Age at menopause, menopausal symptoms, postmenopausal bleeding. If the patient was born before 1971, exposure to diethylstilbestrol (DES) from maternal use during pregnancy (linked to cervical carcinoma). Vaginal discharge, itching, sores, lumps, sexually transmitted infections and treatments. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy, birth-control methods. Sexual preference, interest, function, satisfaction, any problems, including dyspareunia. Concerns about HIV infection. Musculoskeletal: Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe the location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness. Psychiatric: Nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts. Past counseling, psycho-therapy, or psychiatric admissions. Neurologic: Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, black-outs; weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles”. 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