GUIDE IN REPORTING NORMAL PHYSICAL EXAMINATION
COMPLETE PHYSICAL EXAMINATION
Awake and alert; properly groomed; friendly and cooperative; short & slender; fairly
nourished; speaks in a slow, moderate tone of voice; oriented to time, p
Providing Indwelling Catheter Care
1. The nurse is reviewing catheter care with a newly hired nursing assistive personnel
(NAP). Which statement made by the NAP indicates that further instruction is needed?
1. Urinary catheter care is a clean procedure; s
The following list is a direct excerpt from: Jarvis, Carolyn. Physical Examination and Health
Assessment, 6th Edition. Saunders, 2012. VitalBook file.
General Overall Health State
Present weight (gain or loss, over what period of time, by diet or other fa
Undergraduate Test Drive
Before You Begin
o Open Google Chrome. Close all other programs, tabs, and windows.
o Login to the Digital Clinical Experience (DCE) at ShadowHealth.com.
Learn to effectively comm
DCE Health History With Clinical Reasoning Rubric
DO NOT WAIT UNTIL THE LAST MINUTE TO DO THIS ASSIGNMENT - IT IS TIME
Demonstrate the ability to establish the parameters for a health interview
Begin and enhance use of effective te
1. For which of the following patients would a comprehensive health history be
A new patient with the chief complaint of I sprained my ankle
An established patient with the chief complaint of I have an upper respiratory
1. A patient presents for evaluation of a sharp, aching chest pain which increases with
breathing. Which anatomic area would you localize the symptom to?
Chest pain may be due to
1. You are running late after your quarterly quality improvement meeting at the hospital
and have just gotten paged from the nurses' station because a family member of one of
your patients wants to talk with you about that patient's care. You have clinic
TEST 3 STUDY MAP
Mental Health 6 questions
When and why 4-word recall test would be used
Highly sensitive and valid memory test
Requires more effort than recall of personal or historic events and avoids danger of unverifiable recall
Pick four words with
Test 2 Review
Skin 8 questions Chapter 12 (Chapter 30)
Specific antibiotics and diabetic agents that require sun protection
Tetracycline, sulfonamides, thiazide diuretics, oral hypoglycemic agents can increase sunlight sensitivity and
give burn response.
Test Map 4
Abdomen 8 questions
Focus on normal, even with aging and children
o Infants and children: newborn has an umbilical cord containing an artery and a vein which shows prominently on the abdomen.
o Liver takes up proportionately more space in the a
Review Exam 1
Nutrition- 4 questions
Optimal nutritional status: achieved when sufficient nutrients are consumed to support day-to-day body
needs and any increased metabolic demands caused by growth, pregnancy or illness
Undernutrition: occurs when nutrit
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Health History Results | Turned In Health Assess
Skin, hair, nails and General and Mental Exams
General/Mental: + anxiousness resulting from school, 6 hours per night,
-memory loss, recent life changes/ stresses, changes in coping patterns, personality changes,
behavior changes, mood
1. A.How many liters of Oxygen does this deliver? 15L
B. What is it set at? 4L
C. At how many liters/minute would it be best to humidify oxygen via Nasal Cannula? Greater
than or equal to 4L (pg 902)
2. Can you tell me an advantage of an oxymizer? Allows
Collecting Midstream Urine
What do you do if your client is menstruating? Record this on the laboratory requisition
form and collect the specimen.
What factors are necessary to determine whether a patient can be instructed to
Test 2 Review: 75 Questions
Mental status assessment definitions, objective data, what
makes up the assessment and how to test each area
Chapter 8, 9
Definitions discussed in notes, what each assessment technique
Skin hair and nails with peripheral vascular system
P: radial 64,regular, +2; R: 18, regular, unlabored; BP: 118/68 L arm, sitting, T 98.6,
O2 98%. Hair brown, fine, thin, wavy with even distribution. Head is normocephalic.
Skin is olive with pink underto