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HEALTH ASSESSMENT MIDTERM 1-5
questions and answers with solutions 2025
Building A Complete Health History (Week 1) Chapters 1 & 26
• Communication techniques used to obtain a patient’s
health history Chapter 1 - Open ended questions: gives the
patient discretion about the extent of the answer
- Direct question: seeks specific information
- Leading question: most risky, may limit information
- Courtesy, comfort, connection, confirmation
- CAGE questionnaire screening: designed to help diagnose
alcoholism
- CRAFT screening: ETOH and substance abuse in adolescents
(Car, Relax, Forgot, Friends, Trouble)
- TACE screening: drinks does it take to feel high, people
Annoyed you about your drinking, Cut back drinking, Eye
opener drink in the AM
- Partner violence screen (PVS): hit kicked or punched, feel
unsafe…
- Domestic Violence (HITS): Hurt you physical, Insult you,
Threaten you, Scream at you?- Spirituality (FICA): Faith,
Importance, Community, Address
- Types of histories: Complete, inventory (touches up on
major points), Problem (focused, acute life-threatening
problem), Interim (designed to chronicle events that have
occurred since last meeting)
• Recording and documenting patient information Chapter 26
- Write out abbreviations Copy and paste or carry forward
(CPCF)
- International Classification of Disease (ICD): diagnostic
coding system that classifies diseases and injuries and u
used to track mortality and morbidity
- Geriatric screening tool: Katz Index consists of six items
(bathing, dressing, toileting, transferring, continence and
feeding
- Geriatric screening tool: Lawton Instrumental ADL-scale
consists of eight items in women (ability to use the
telephone, shopping, cooking, housekeeping, doing laundry,
taking own medication, making transports, and ability to
handle finances)
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Functional impairment was defined as dependency on at
least one domain of ADL (score <6) or IADL (a score <8 from
women or <5 for men). Functional decline was defined as
deterioration on at least one domain of ADL or IADL compared
to baseline (decline ≥1 point).
- Sullivan Book:
CPTP is a listening of descriptive terms and identifying
code for reporting medical services and procedures
SOAP note documentation
- S: subjective (what patient tells you)
- O: objective (observations)
- A: assessment (interpretation and conclusions)
- P: plan (diagnostic testing, rationale for decisions)
• Subjective vs objective information when documenting
- S: pain (use pain score)
- O: relate findings to the process of inspection,
palpation, auscultation, percussion. “no
masses on palpation” “tympanic membranes are pearly gray”
- O: Use anatomic landmarks to add precision
- O: Findings that vary by degrees are customarily graded or
recorded in an incremental scale format (pulse amplitude,
heart murmur intensity, muscle strength, DTR
- Illustrations useful in describing the origin of pain and
where it radiates and the size, shape and location of a
lesion
- HX of present illness: OLDCARTS: onset, location,
duration, character, aggravating factors, relieving factors,
temporal factors, severity of symptoms
• Ethical decision making and beneficence
- Beneficence: doing good
Diversity and Health Assessment – Bullets 6, 7, 8
Cultural Awareness and Diversity
Achieving cultural competence is a learning process that
requires self-awareness, reflective practice, and knowledge
of core cultural issues
A culturally competent health care provider adapts to the
unique needs of patients of backgrounds and cultures that
differ from his or her own
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Culture, in its broadest sense, reflects the whole of human
behavior, including ideas and attitudes; ways of relating to
one another; manners of speaking; and the material products
of physical effort, ingenuity, and imagination.
The stereotype, a fixed image of any group that denies the
potential of originality or individuality within the group
Multiple studies have shown that health care providers
activate these implicit stereotypes, or non-conscious bias,
when communicating with and providing care to minority
patients Members of racial and ethnic groups are not uniform.
Each group is highly heterogeneous and includes a diverse mix
of immigrants, refugees, and multigenerational Americans who
have vastly different histories, languages, spiritual
practices, demographic patterns, and cultures
Culturally competent care requires that health care
providers be sensitive to patients' heritage, sexual
orientation, socioeconomic situation, ethnicity, and
cultural background When cultural differences exist, be
certain that you grasp exactly what the patient means and
know exactly what the patient thinks you mean in words and
actions The definition of “ill” or “sick” is based on the
individual's belief system and is determined in large part
by his or her enculturation.
Socioeconomic, spiritual, and lifestyle factors affecting
diverse populations Age, gender, race, ethnic group and,
with these variables, cultural attitudes, regional
differences, and socioeconomic status influence the way
patients seek medical care and the way clinicians provide
care
A patient who knows the English language, however well,
cannot be assumed to know the culture.
Poverty and inadequate education disproportionately affect
various cultural groups (e.g., ethnic minorities and women);
socioeconomic disparities negatively affect the health and
medical care of individuals belonging to these groups
Age, gender, race, ethnic group and, with these variables,
cultural attitudes, regional differences, and socioeconomic
status influence the way patients seek medical care and the
way clinicians provide care.
Black and Latino children in the United States also
experience health disparities, including lower overall health
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status and lower receipt of routine medical care and dental
care compared to white children
Functional Assessments
Functional Assessment for All Patients
Quite simply, functional assessment is an attempt to
understand a patient's ability to achieve the basic
activities of daily living. This assessment should be made
for all older adults and for any person limited by disease or
disability, acute or chronic. A well-taken history and a
meticulous physical examination can bring out subtle
influences, such as tobacco and alcohol use, sedentary
habits, poor food selection, overuse of medications
(prescribed and nonprescribed), and less than obvious
emotional distress. Even some physical limitations may not be
readily apparent (e.g., limitations of cognitive ability or
of the senses). Keep in mind that patients tend to overstate
their abilities and, quite often, to obscure reality.
When performing a functional assessment consider a variety of
disabilities: physical, cognitive, psychologic, social, and
sexual. An individual's social and spiritual support system
must be as clearly understood as the physical disabilities.
There are a variety of physical disabilities, including:
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o Difficulty walking standard distances: ½ mile, 2 to 3
blocks, 1/3 block, o Toileting
o Moving from bed to chair, chair to standing
