Questions and Answers
What is the primary purpose of the interview in health assessment?
What are the two main components of a complete health database?
What type of database is used in emergency situations?
What is an important aspect of the interview in health assessment?
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What is a characteristic of a successful interview?
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What is the purpose of health assessment?
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What is an example of a type of data collected during the physical examination?
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What is communication based on?
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What is an important factor to consider when conducting a health assessment?
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What is an important aspect of nonverbal communication?
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In receiving messages, what do receivers use to interpret the meaning of the message?
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What is an internal factor that can affect an interview?
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What is the purpose of the introduction phase of an interview?
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What type of question is used to collect narrative information in an interview?
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What is necessary for effective communication to occur?
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What is an example of a nonverbal cue in communication?
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What should an interviewer avoid during the closing phase of an interview?
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Which of the following is an example of nonverbal communication?
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What is the purpose of collecting health history in a patient's care?
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What should an interviewer avoid asking during an interview?
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What is an example of a trap of interviewing?
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What is the importance of silence in an interview?
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What is an example of inappropriate nonverbal communication by a nurse?
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What is the main goal of an interviewer?
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What does a health history describe?
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What is the purpose of a health history?
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What is included in biographical data?
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What is the purpose of the chief complaint?
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What does the history of present illness include?
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What is included in the details of the history of present illness?
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What is the purpose of understanding the patient's perception in the history of present illness?
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What is the purpose of the review of systems?
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What is the purpose of the Review of Systems (ROS)?
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What is included in the obstetric history?
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What is the purpose of constructing a genogram?
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What is included in the past health history?
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What is assessed in the functional assessment?
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What is the order of examination in the Review of Systems?
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What is recorded in the Review of Systems?
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Why is the Review of Systems used?
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Study Notes
Health Assessment
- Health assessment is the collection of data about an individual's health state to reveal health problems, including subjective data (what the person says about themselves) and objective data (what the healthcare professional observes during the physical examination).
Types of Databases
- There are four types of databases:
- Complete (Total Health) Database: includes complete health history and full physical examination
- Focused or Problem-Centered Database: collects "mini" data related to the system with a problem
- Follow-Up Database: evaluates the status of an individual's health
- Emergency Database: rapid collection of data in emergency situations
The Interview
- The interview is a structured interaction between the healthcare provider and the patient, and is the first point of contact with a client and the most important part of data collection.
- Characteristics of a successful interview include:
- Ending with a complete and accurate health history
- Discussing health promotion and disease prevention
- Initiating teaching
- Establishing a trust and therapeutic relationship with the patient
- Communication is exchanging information so each person clearly understands the other, and is based on behavior, conscious and unconscious, verbal and nonverbal.
Communication
- Communication involves sending and receiving messages, and is affected by internal factors (e.g. liking others, empathy, self-awareness) and external factors (e.g. privacy, interruptions, physical environment).
- The interview has three phases: introduction, working, and closing, and involves verbal responses to gather more data, such as facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, and summary.
Traps of Interviewing
- Traps of interviewing include providing false assurance or reassurance, giving unwanted advice, using authority, using avoidance language, engaging in distancing, using professional jargon, using leading or biased questions, talking too much, and interrupting.
Nonverbal Communication
- Nonverbal communication involves physical appearance, posture, gestures, facial expression, eye contact, voice, and touch.
- Examples of inappropriate communication include standing instead of sitting at the patient's eye level and talking to the patient's mother rather than directly to the patient.
Health History
- The purpose of health history is to collect subjective data (patient's story) and provide a complete picture of a person's past and present health.
- Components of health history include biographical data, reason for seeking care, history of present illness, past health history, family history, review of systems, functional assessment, and perception of health.
- Biographical data includes name, age, gender, birth place, marital status, race, religion, occupation, and address.
- Reason for seeking care includes a brief spontaneous statement in the person's own words that describes the reason for seeking care, and is framed by the patient's own words.
- History of present illness includes details (PQRSTU) of the reason for seeking care from the time the symptom first started until now.
Review of Systems (ROS)
- Review of Systems (ROS) evaluates the past and present health state of each body system, and includes the head, chest, abdomen, musculoskeletal, and neurological systems.
- The order of examination is from head to toe, and excludes symptoms covered in the present health history.
Functional Assessment
- Functional Assessment measures a person's self-care ability, including self-esteem, self-concept, education, income, and religious practices, as well as activity/exercise, including activity of daily living (ADLs) such as bathing, dressing, toileting, eating, and walking.
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Description
Introduction to health assessment, including the importance of collecting data to identify health problems and the types of data collected during a health history.
