NURS 5220 400 Advanced Health Assessment Quiz - University of Texas at Arlington
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Free NURS 5220 400 Advanced Health Assessment Quiz - University of Texas at Arlington Questions
The Review of Symptoms/Systems in a SOAP note documents which type of information?
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Objective
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Subjective
Explanation
Explanation:
Correct Answer: (B) Subjective The Review of Symptoms/Systems is based on the patient's self-reported symptoms across various body systems, making it subjective data gathered through patient interview.
Why Other Options are Incorrect:
A. Objective — Objective data comes from measurable findings observed by the provider, such as physical exam results or lab values, not patient-reported symptoms.
The mnemonic OLDCARTS is used in which section of the SOAP note?
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Review of Systems/Symptoms
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History of Present Illness
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Physical Assessment
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Plan of Care
Explanation
Explanation:
Correct Answer: (B) History of Present Illness OLDCARTS (Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing, Severity) is a mnemonic used to systematically explore and document the details of the patient's current symptoms within the History of Present Illness section.
Why Other Options are Incorrect:
A. Review of Systems/Symptoms — This section involves a broader systematic inquiry across body systems, not the detailed characterization of the chief complaint.
C. Physical Assessment — This section involves the provider's physical examination findings, not the mnemonic-guided symptom history.
D. Plan of Care — This section outlines the treatment plan and interventions, not the exploration of symptom characteristics.
Vital Signs is an example of which type of data?
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Objective
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Subjective
Explanation
Explanation:
Correct Answer: (A) Objective Vital signs, such as blood pressure, heart rate, temperature, and respiratory rate, are measurable and observable data collected directly by the provider, making them objective data.
Why Other Options are Incorrect:
B. Subjective — Subjective data refers to information reported by the patient, such as symptoms or feelings, which cannot be directly measured or observed by the provider.
Sally tells you that she is having headaches for the last few days after you finish your physical exam. Where would you place this information on your SOAP note?
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Physical Assessment
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Review of Systems/Symptoms
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Plan
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This information is irrelevant because she told you after the exam
Explanation
Explanation:
Correct Answer: (B) Review of Systems/Symptoms Since the headache is a patient-reported symptom, it belongs in the Review of Systems/Symptoms section regardless of when during the visit it was mentioned, as this section captures subjective patient-reported information.
Why Other Options are Incorrect:
A. Physical Assessment — This section documents the provider's objective examination findings, not patient-reported symptoms.
C. Plan — This section outlines the treatment approach, not where new subjective symptom information is initially documented.
D. This information is irrelevant because she told you after the exam — Timing of disclosure does not make patient-reported symptoms irrelevant; all relevant information should be documented appropriately.
The Chief Complaint is an example of which type of data?
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Subjective
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Objective
Explanation
Explanation:
Correct Answer: (A) Subjective The chief complaint is stated by the patient in their own words, describing their reason for seeking care, which makes it subjective data since it reflects the patient's personal experience rather than measurable findings.
Why Other Options are Incorrect:
B. Objective — Objective data consists of measurable, observable findings gathered by the provider, such as vital signs or physical exam results, not the patient's stated reason for the visit.
A brief statement of the reason the patient is seeking health care is called the:
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Assessment
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Medical history
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Chief Complaint
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Review of Symptoms/Systems
Explanation
Explanation:
Correct Answer: (C) Chief Complaint The chief complaint is a concise statement, often in the patient's own words, describing the primary reason for seeking healthcare during that visit.
Why Other Options are Incorrect:
A. Assessment — This refers to the provider's clinical evaluation and judgment, not the patient's stated reason for the visit.
B. Medical history — This encompasses a broader review of past health conditions, surgeries, and family history, not just the reason for the current visit.
D. Review of Symptoms/Systems — This is a systematic inquiry into symptoms across body systems, not a brief statement of the primary complaint.
Shortness of breath reported when walking one block is an example of which type of information? Shortness of breath when getting on the exam table for the physical assessment is an example of which type of information?
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Subjective, subjective
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Objective, objective
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Subjective, objective
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Objective, subjective
Explanation
Explanation:
Correct Answer: (C) Subjective, objective Shortness of breath reported by the patient about their experience walking one block is subjective (patient-stated), while shortness of breath observed by the provider during the physical exam is objective (directly observed).
Why Other Options are Incorrect:
A. Subjective, subjective — The second instance is directly observed by the provider during the exam, making it objective, not subjective.
B. Objective, objective — The first instance is patient-reported history, making it subjective, not objective.
D. Objective, subjective — This reverses the correct classification; the reported symptom is subjective and the observed finding during exam is objective.
Allergies, Immunizations, and medications go in which section of the SOAP note?
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Assessment
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Objective
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Subjective
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Plan
Explanation
Explanation:
Correct Answer: (C) Subjective Allergies, immunizations, and medications are typically reported by the patient and documented as part of the patient's history within the Subjective section of the SOAP note.
Why Other Options are Incorrect:
A. Assessment — This section contains the provider's clinical judgment and diagnoses, not historical patient-reported information.
B. Objective — This section includes measurable findings from examination or testing, not patient-reported history.
D. Plan — This section outlines the treatment approach, not the documentation of allergies, immunizations, or current medications.
Culture includes which factor?
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Travel
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Entertainment
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Job position
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Family tree
Explanation
Explanation:
Correct Answer: (C) Job position Culture encompasses shared beliefs, values, and social structures, including socioeconomic factors such as occupation or job position, which shape a person's identity and worldview.
Why Other Options are Incorrect:
A. Travel — This is an activity rather than a defining element of a person's cultural background.
B. Entertainment — This is a leisure activity, not a core component of cultural identity.
D. Family tree — This refers to genealogy or lineage tracking rather than the broader concept of culture itself.
Which question would be considered a "leading question"?
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"You don't get headaches often, do you?"
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"What do you think is causing your headaches?"
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"On a scale of 1 to 10, how would you rate the severity of your headaches?"
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"At what time of the day are your headaches the most severe?"
Explanation
Explanation:
Correct Answer: (A) "You don't get headaches often, do you?" A leading question suggests the expected answer within the question itself, guiding the patient toward a particular response rather than allowing an open, unbiased answer.
Why Other Options are Incorrect:
B. "What do you think is causing your headaches?" — This is an open-ended question that invites the patient's own perspective without suggesting an answer.
C. "On a scale of 1 to 10, how would you rate the severity of your headaches?" — This is a neutral, structured question used to quantify symptom severity without bias.
D. "At what time of the day are your headaches the most severe?" — This is a neutral, direct question seeking factual information without leading the patient toward a specific answer.
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