Nursing Assessment Quiz: Subjective vs Objective Insights

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Questions and Answers

What is the primary purpose of the HPI section in a patient's medical history?

To document the patient's family history

To record the patient's personal and social history

To provide a detailed description of the primary problem using symptom analysis (correct)

To list the patient's past medical history

Which type of information is obtained through observation, physical examination, and laboratory and diagnostic testing?

Focused assessment information

Objective information (correct)

Comprehensive assessment information

Subjective information

What is the purpose of the 'denies' statement in the Review of Systems section?

To confirm the presence of a symptom

To rule out the presence of a symptom (correct)

To record the patient's family history

To document the patient's medical history

What is the last question that should be asked in any patient interview?

Is there anything else you want to tell me? Signup and view all the answers

What is the purpose of the CC section in a patient's medical history?

To identify the reason the patient is seeking assistance Signup and view all the answers

What is the difference between a comprehensive assessment and a focused assessment?

A comprehensive assessment includes all relevant data, while a focused assessment is limited to data relevant to the patient's complaint Signup and view all the answers

What is the primary goal of primary prevention?

Preventing or arresting disease process by promoting healthier lifestyle or immunizations Signup and view all the answers

Which type of prevention is exemplified by blood pressure screenings?

Secondary prevention Signup and view all the answers

What is the primary focus of a problem-focused exam?

A limited exam of the affected body area Signup and view all the answers

Which level of medical decision making is characterized by a low complexity?

Straightforward Signup and view all the answers

What is the primary goal of counseling and coordination of care?

Composing more than 50% of encounter time Signup and view all the answers

Which level of evaluation and management involves a comprehensive review of the patient's medical history?

Comprehensive Signup and view all the answers

What is the primary goal of tertiary prevention?

Substantial reduction in subsequent morbidity and mortality in an present illness Signup and view all the answers

Which type of exam is characterized by a general multi-system exam or complete exam of a single organ system?

Comprehensive Signup and view all the answers

What is the primary goal of a comprehensive level of evaluation and management?

Conducting a general multi-system exam Signup and view all the answers

Which level of medical decision making is characterized by a high complexity?

High complexity Signup and view all the answers

What is the primary importance of confidentiality when discussing sensitive topics with patients?

To ensure trust and build rapport Signup and view all the answers

What is the purpose of assessing a patient's personal beliefs about health?

To identify potential barriers to care Signup and view all the answers

What is the function of the MMSE Mini Mental State Exam?

To screen for dementia and delirium Signup and view all the answers

What is the purpose of using the 2-question depression screening tool?

To screen for depression and guide further assessment Signup and view all the answers

What is the significance of assessing a patient's functional capacity using the Duke Activity Index?

To determine a patient's peak oxygen uptake Signup and view all the answers

What is the primary component of the HPI?

Complete and clear description of the patient's visit Signup and view all the answers

What is the significance of asking 'Have you ever had this before?' in the HPI?

To assess the patient's prior medical history Signup and view all the answers

What is the significance of optimal weight and nutrition in health promotion and counseling?

To reduce the risk of cardiovascular disease Signup and view all the answers

What is the purpose of the PHQ-9 in assessing depression?

To evaluate the severity of depression symptoms Signup and view all the answers

What is the significance of cultural competence in healthcare?

To enhance patient-provider communication Signup and view all the answers

Study Notes

Understanding Subjective and Objective Information

Subjective information includes the client's point of view, feelings, perceptions, and concerns obtained through interviews
Chief complaint: the reason the patient is seeking assistance, written in quotes
HPI (History of Present Illness): a detailed description of the primary problem using symptom analysis
PQRST: Past medical history, including immunizations, allergies, and responses

Components of a Full and Focused Exam

Comprehensive Assessment:
- Identifying data and source of the history
- Reliability
- CC (Chief Complaint)
- HPI (History of Present Illness)
- PQRST
- Past medical history, including immunizations, allergies, and responses
- Family history
- Personal and social history
- Review of systems (head to toe subjective data)
Focused Assessment:
- Identifying data
- CC
- HPI
- Data from PMH, FH, SH that pertains to the complaint
- ROS (Review of Systems) that pertains to the complaint

Approaches to Discussing Sensitive Topics

Be aware of self and how personal judgments affect thinking
Confidentiality is of high importance
Patient's autonomy cannot be ignored
Be direct and firm
Do not apologize for questions
Do not preach
Do not push too hard
Be ready to explain why you need to ask
Explore patient's feelings
Offer patient opportunity to ask questions
Use gender-neutral language

Cultural Competence

Assess patient's personal beliefs about health
What religious influences may affect care?
What language is primary?
What are the roles in the family?
Are there special dietary practices that may influence compliance or recovery?
Recognize diversity
Demonstrate respect for the unfamiliar
Identify own cultural beliefs
Don't stereotype
Learn the facts
Develop a plan with culture in mind

Assessment Tools

2-question depression screening:
- In the last month, have you been bothered by little interest or pleasure in doing things?
- Feeling down, depressed, or hopeless?
MMSE (Mini-Mental State Exam):
- Standardized screening tool for mental status
- Max score: 30
- Depressed clients w/o dementia score 24-30
- Score of 20 or less is found with dementia, delirium, schizophrenia, or an affective disorder
MOCA (Montreal Cognitive Assessment):
- Brief (10-minute) screening tool for mild cognitive impairment
- More sensitive for early or mild impairment, a risk factor for dementia
- Normal score: 26-30
- Lower score requires more in-depth assessment
Beck's Depression Scale:
- Assesses severity of depression in adults and adolescents (13 and up) without a diagnosis of a psychiatric illness
- Not a sole diagnostic measure
- Highly reliable
- Score of < 15: mild depression
- Score 15-30: moderate depression
- Score > 30: severe depression
PHQ-9:
- Rates the frequency of symptoms to score severity
- Can be utilized multiple times to show trends
- Question 9 asks about suicide ideation
- Score 5-9: minimal symptoms
- Score 10-14: mild depression
- Score 15-19: major depression, moderately severe
- Score > 20: major depression, severe
Duke Activity Index:
- Self-administered questionnaire that measures a patient's functional capacity
- Can be used to get a rough estimate of a patient's peak oxygen uptake
- Assesses the functional capacity of patients with cardiovascular disease
- Final score ranges between zero and 58.2 points
- The higher the score, the better the functional capacity

HPI Components

Complete, clear, and chronologic description of the problems prompting the patient's visit
Symptom Analysis:
- P: precipitating/palliative/provocative
- Q: Quantity or Quality
- R: Region/Radiation
- S: Severity
- T: Timing
- Most important: HAVE YOU EVER HAD THIS BEFORE?

Health Promotion and Counseling

Optimal weight, nutrition, and diet
BMI > 25: risk for heart disease, HTN, high LDL, low HDL, high triglycerides, hyperglycemia
Blood pressure and dietary sodium
A difference of 5g of salt intake a day is linked to a 23% difference in the rate of stroke and a 17% difference in the rate of total cardiovascular disease
Daily dietary intake of 2300 mg is tolerable
Exercise
Tobacco cessation

Billing Types and Time

Problem-focused: CC, brief HPI
Expanded problem-focused: CC, limited exam of affected body area or organ system and other symptomatic or related organ system
Detailed: CC, extended HPI, problem pertinent ROS and other additional pertinent PMH, SH &/or FH related to problem
Comprehensive: CC, extended HPI, full ROS, complete past, family, and social history

Complexity of Medical Decision Making

Straightforward
Low complexity
Moderate complexity
High complexity

Type/Definition of Each of the 5 Billing Levels

Levels of Evaluation and Management:
- Level 1: straightforward
- Level 2: low complexity
- Level 3: moderate complexity
- Level 4: high complexity
- Level 5: high complexity with multiple conditions

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Description

Learn the difference between subjective and objective information in nursing assessment. Understand how to gather data from the client's point of view and observable signs. Test your knowledge of chief complaint, HPI, and symptom analysis.

Nursing Assessment: Subjective vs Objective Information

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