NUR 2092 Final Exam Study Guide

What is included in a health history?

Biographic data [Name, address, DOB, occupation, gender, martital status,

primary language, ethnicity]

Reason for seeking care: Subjective from pt

Present health status

Medications, Immunizations, What improves it, What makes it worse,

Past medical history

Surgical history, OB /GYN Nutritional Hx

Family history

First generation

Personal and psychosocial history

Support, living environment, Substances, Safety

Review of body systems: PQRSTU

Define subjective and objective.

Subjective: What pt says about themself

Objective: what is observed during assessment

Give an example of an open ended question.

Tell me about , how are you doing today

Now a closed question

Do you have pain?

What is redirecting, silence, restating?

Communication that client has time to think; silence can be uncomfortable;

provides you w/ chance to observe client and note nonverbal cues

What should be included in social history?

where do they live, are they safe, do they have clean water, head, air

conditioning, do you work, do you feel safe, smoke, alcohol, recreational

drugs, safety devices, do you exercise, safety equipment, sun screen

Why is this information necessary?

 1 / 2

When do you screen for intimate partner violence?

Always

Barriers to communication: Name 3

-Lack of interest or attention/lack of respect

-Physical barriers: a curtain, a door, a computer, a monitor, pain, room temperature

-The patient’s inability to hear you, hearing deficit, or language barrier

-Language/ use of jargon, or speaking above someone’s educational level

-Safety: fear

-Psychological barriers: embarrassment, disbelief,shock, anger, fear, grief, fatigue, hostility

• What questions do you need to ask each time you enter a

patient’s room? (2 of them)

-Name and DOB

• Pain assessment: what scale do you use?

0-10

• How often do you do a pain assessment?

Every Assessment

• Non pharmacological and pharmacological pain management.

Describe 2 methods.

Deep or patterned breathing

Relaxation techniques

Warm or cool compresses

Compression/elevation

Quiet dark room

Position change

Pillows/clean linens

Bathing

Music

distraction

• What questions do you ask regarding pain?

What kind of pain? When did it start? Where? Worse

or better?

• PQRST

Proactive/Palliation:Quality:Region:Severity:Timing

Powered by qwivy(www.qwivy.org)

 2 / 2