NR 509 Midterm Study Guide

General Study Tips and Recommendations

• Focus and Repetition: Topics and content on guides are intended to focus student attention when reading/studying. Some topics may be repeated in multiple chapters to reinforce learning.
• Depth of Understanding: Multiple test items are derived from the same topic areas to encourage deeper comprehension. Students must have a broad understanding of the content and not simply memorize passages in textbooks or articles.
• Key Information: Information in red letters in the chapters, as well as tables and appendices at the end of the chapters, may include test items.
• Cognitive Levels: Exam questions represent various levels of cognitive learning. Students are expected to analyze, synthesize, and evaluate patient scenarios to answer questions effectively.
• Reading Strategy: Read all of the answers BEFORE reading the stem of the question. This helps focus on the key content and avoids distractions by extraneous information.
• Techniques of Examination and Recording Findings: Be familiar with these sections for all body system chapters in the textbook.

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Chapter 1: Approach to the Clinical Encounter

• The Interviewing Process
  • Stages of the Interview
    • Initiating the Encounter: Set the stage, adjust the environment, review the clinical record, set your agenda, greet the patient, establish rapport, identify patient title/pronouns.
    • Gathering Information: Chief complaint, establish agenda, invite patient’s story, gather information about the patient’s perspective (FIFE: Feelings, Ideas, Effect on function, Experience), identify and respond to emotional cues, explore biomedical perspective, gather background information.
    • Performing the Physical Examination
    • Explaining and Planning: Assess and respond to the patient’s need for information, establish shared understanding, verify patient understanding, negotiate the plan of action with shared decision-making.
    • Closing the Encounter: Allow time for final questions, follow-up plans, self-reflection.
• Interviewing Techniques
  • Gather information about the patient’s understanding of illness (FIFE).
  • Respond to emotional cues (Name, Understand, Respect, Support, Explore).
  • Gather information by exploring the biomedical perspective.
  • Gather important background information and context (Medical, family, and personal/social history).
• Setting the Stage for the Examination
  • Set the stage, adjust the environment, review the clinical record, set your agenda, greet the patient, establish rapport, identify patient name and gender pronoun.

Chapter 2: Interviewing, Communication, and Interpersonal Skills

• Fundamentals of Skilled Interviewing
• Verbal and Nonverbal Communication
• Challenging Patient Situations and Behaviors

Chapter 3: Health History

• Focused and Comprehensive Health Histories
• Determining the Scope of the Patient Assessment
• The Seven Attributes of a Patient’s Principal Symptoms
  • Location, quality, quantity and severity, timing, onset, duration, frequency, setting, aggravating and relieving factors, associated manifestations.
• Subjective vs. Objective Data
  • Subjective: What the patient tells you (medical history).
  • Objective: What is observed (labs).
• Modifying the Clinical Interview for Various Clinical Settings

Chapter 4: Physical Examination

• Determining the Scope of the Physical Examination
• Techniques of Examination (Note: Be familiar with specific techniques in body system chapters)
• Head-to-Toe Physical Assessment
• Examining the Patient from the Right Side: Advantages include more reliable estimates of jugular venous pressure, more comfortable palpation of the apical impulse, more frequently palpable right kidney, and examining tables accommodating right-handed approach.
• Elevating the Head of the Examining Table: Adjust to see jugular venous pulsations. For cardiovascular examination, ask the patient to roll partly onto the left side to listen at the apex for S3 or mitral stenosis. For aortic regurgitation, the patient should sit, lean forward, and exhale.

Chapter 5: Clinical Reasoning, Assessment, and Plan

• The Clinical Reasoning Process
• The Problem List: List the most active and serious problems first, record their date of onset. Separate lists for active and inactive problems or one list in order of priority.
• The Differential Diagnosis (DDx) List
• The Summary Statement
• Assessment (Medical Diagnoses)
• Planning (Treatment and Interventions)

Chapter 6: Integumentary Assessment

• Normal vs. Abnormal Findings and Interpretation
• Common Skin Conditions
  • Melanoma, Primary and Secondary Skin Lesion Nomenclature, Psoriasis, Tinea, Pityriasis Rosea, Lyme Disease, Acne, Systemic Lupus Erythematosus, Herpes Zoster, Cellulitis.

Chapter 7: Evaluating Clinical Evidence

• Using Elements of the Physical Examination as Diagnostic Tests
• Evaluating Diagnostic Tests
• Critically Appraising Clinical Evidence
• Communicating Clinical Evidence to Patients
  • Five As (ask, advise, assess, assist, and arrange).
  • FRAMES (feedback about personal risk, responsibility of patient, advice to change, empathetic style, promote self-efficacy).

Chapter 8: General Survey, Vital Signs, and Pain

• General Survey
• Vital Signs
• Classifying Normal and Abnormal Blood Pressures
• Acute and Chronic Pain
• Exploring Weight Loss (Including Anorexia Nervosa and Bulimia Nervosa)

Chapter 9: Cognition, Behavior, and Mental Status

• Techniques of Examination
• Speech Patterns (Including Aphasia)
• Assessing Abstract Thinking
• Mental Status Examination
• Screening for Depression
• Screening for Substance Abuse
• Hallucinations and Illusions

Chapter 10: Skin, Hair, and Nails

• Techniques of Examination
• Anatomy
• Skin Lesion Morphology
• Melanoma Risk Factors
• Health Promotion and Skin Cancer Screening
• Herpes Zoster

Chapter 11: Head and Neck

• Techniques of Examination
• Anatomy
• Lymph Node Assessment
• Thyroid Assessment
• Screening for Thyroid Cancer

Chapter 12: Eyes

• Techniques of Examination
• Anatomy
• Visual Acuity Assessment (Snellen)
• Visual Fields Assessment
• Extraocular Muscle Assessment (And Associated Cranial Nerves)
• Ophthalmoscopic (Funduscopic) Examination and Common Findings
• Nystagmus
• Glaucoma
• Macular Degeneration

Chapter 13: Ears and Nose

• Techniques of Examination
• Anatomy
• Screening for Hearing Loss
• Nasal Cavity and Mucosa
• Sinus Assessment
• Vertigo
• Tinnitus
• Rhinorrhea
• Otitis Externa and Otitis Media

Chapter 14: Throat and Oral Cavity

• Techniques of Examination
• Anatomy
• Oral Cavity Assessment
• Pharynx
• Carcinoma
• Grading Tonsils (Note: Not in the textbook; see corresponding course lesson)

Chapter 15: Thorax and Lungs

• Techniques of Examination (Including Percussion)
• Anatomy
• Respiratory Distress
• Lung Sounds
• Asthma
• Pneumonia
• Chronic Obstructive Pulmonary Disease (COPD)
• Atelectasis

Chapter 16: Cardiovascular System

• Techniques of Examination
• Anatomy
• Screening for Cardiovascular (CV) Risk Factors
• Cardiovascular Disease
• Lipid Screening
• Heart Rhythms and Sounds
• Jugular Venous Pressure (JVP)
• Carotid Arteries
• Murmurs
• Congestive Heart Failure (CHF)
• Heart Valve Pathology

Chapter 17: Peripheral Vascular System

• Techniques of Examination
• Anatomy
• Lymph Nodes
• Peripheral Edema
• Peripheral Pulses
• Chronic Venous Insufficiency
• Claudications
• Aneurysms
• Acute Arterial Occlusion
• Deep Vein Thrombosis (DVT)

By following these detailed guidelines and recommendations, students can enhance their understanding and performance in the NR 509 Midterm Exam. For comprehensive support and study materials, visit nursingschooltutors.com for tailored tutoring services.

Week 4: Preparing for the Midterm

Chapter 1: Approach to the Clinical Encounter

• Basic and Advanced Interviewing Techniques
  • Basic
    • Gather a sensitive and nuanced history.
    • Perform a thorough and accurate exam.
    • Improve patient rapport.
    • Focus your assessment.
    • Set guideposts that direct clinical decision-making.
    • Avoid interpreting findings prematurely.
    • Warn patients that the assessment may take longer without implying negative findings.
  • Advanced
    • With time and practice, integrate:
      • Empathetic listening.
      • Ability to interview patients of all ages, genders, races, and ethnicities.
      • Improved techniques to examine different body systems.
      • Differentiate the level of sickness.
      • Improved clinical reasoning leading to diagnosis and plan.
      • Identify symptoms and abnormal findings, linking underlying pathology.
      • Establish and test explanatory hypotheses.
• Components of the Health History
  • Identifying Data
    • Age, gender, marital status, occupation.
    • Source of history (patient, family, friend, referral, clinical record).
    • Establish the source of referral if necessary.
  • Reliability
    • Patient memory, trust, mood.
  • Chief Complaint
    • One or more symptoms or concerns causing the patient to seek care.
    • Keep this in the patient’s own words (e.g., “my stomach feels awful”).
  • Present Illness
    • Amplifies the chief complaint.
    • Complete, clear, and chronological description of the problems prompting the patient’s visit, including onset, setting, manifestation, and treatment to date.
    • Includes patient thoughts and feelings about the illness.
    • Pertinent positives and negatives.
    • May include medications, allergies, tobacco, alcohol, etc.
    • Seven attributes of a symptom:
      • Location
      • Quality
      • Quantity or severity
      • Timing (onset, duration, frequency)
      • Setting
      • Factors that aggravate or relieve
      • Associated manifestations
    • Consider placing past medical history in this area to support the potential problem.
    • How symptoms affect ADLs.
    • Medications taken to help or that may exacerbate the issue.
  • Past Medical History
    • List illnesses (childhood and adult) with dates.
    • Surgeries.
    • OB/GYN.
    • Health maintenance.
    • Psychological history.
    • Immunizations, screenings, lifestyle issues, and home safety.
  • Family History
    • Include parents, siblings, and grandparents.
    • Outline current age or age at death, medical history/illnesses, and cause of death.
  • Personal and Social History
    • Education, family origin, current household, interests and lifestyle.
    • Relationship status, stress, job, important life experiences, financial status, religion, retirement plan, leisure activities, friends/support.
  • Review of Symptoms
    • Document presence or absence of common symptoms related to each of the major body systems.
    • Start with general, skin, HEENT, neck, breasts, respiratory, cardiovascular, GI, peripheral vascular, urinary, genitals, musculoskeletal, psychological, neurological, hematologic, and endocrine systems.

Chapter 2: Evaluating Clinical Evidence

• Critical Thinking and Clinical Reasoning
  • Differential Diagnoses
  • Pathological and Physiological Processes
  • Problem List
  • Problem Prioritization

Chapter 3: Interpretation and Analysis of Data

• Logical Examination Sequence
• Associated Symptoms
• Adaptive Questioning
• Challenging Patients

Chapter 4: General Approach to the Physical Examination

• Interview Facilitation
• Vital Signs
• BMI Interpretation
• Review of Systems

Chapter 6: Integumentary Assessment

• Normal vs. Abnormal Findings and Interpretation
• Melanoma
• Primary and Secondary Skin Lesion Nomenclature
• Common Skin Conditions
  • Psoriasis
  • Tinea
  • Pityriasis Rosea
  • Lyme Disease
  • Acne
  • Systemic Lupus Erythematosus
  • Herpes Zoster
  • Cellulitis

General Study Tips and Recommendations

• Focus and Repetition: Topics and content on guides are intended to focus student attention when reading/studying. Some topics may be repeated in multiple chapters to reinforce learning.
• Depth of Understanding: Multiple test items are derived from the same topic areas to encourage deeper comprehension. Students must have a broad understanding of the content and not simply memorize passages in textbooks or articles.
• Key Information: Information in red letters in the chapters, as well as tables and appendices at the end of the chapters, may include test items.
• Cognitive Levels: Exam questions represent various levels of cognitive learning. Students are expected to analyze, synthesize, and evaluate patient scenarios to answer questions effectively.
• Reading Strategy: Read all of the answers BEFORE reading the stem of the question. This helps focus on the key content and avoids distractions by extraneous information.
• Techniques of Examination and Recording Findings: Be familiar with these sections for all body system chapters in the textbook.

Chapter 1: Approach to the Clinical Encounter

The Interviewing Process

1. Stage 1: Initiating the Encounter
   • Set the stage, adjust the environment, review the clinical record, set your agenda.
   • Greet the patient and establish rapport.
   • Identify patient title/pronouns.
2. Stage 2: Gathering Information
   • Initiate information gathering – “chief complaint,” establish the agenda for the encounter (begin with open-ended questions), invite the patient’s story (“tell me more about…”).
   • Gather information about the patient’s perspective of illness (FIFE – Feelings, Ideas, Effect on Function, Experience).
   • Identify and respond to emotional cues (illness accompanied by emotional distress – 30-40% of patients have anxiety and depression in primary care practices).
   • Gather information by exploring the biomedical perspective.
   • Gather background information and context.
3. Stage 3: Performing the Physical Examination
4. Stage 4: Explaining and Planning
   • Assess and respond to the patient’s need for information.
   • Establish a shared understanding.
   • Verify patient understanding.
   • Negotiate the plan of action with shared decision-making.
5. Stage 5: Closing the Encounter
   • Allow time for final questions.
   • Follow-up plans.
   • Take time for self-reflection.

Interviewing Techniques

• Gather Information About Patient’s Understanding of Illness (FIFE)
  • Feelings: What are the patient’s feelings about the illness?
  • Ideas: What are the patient’s ideas about the nature and cause of the problem?
  • Effect on Function: How has the illness affected the patient’s life and function?
  • Experience: What has the patient experienced in terms of symptoms and overall impact?
• Respond to Emotional Cues
  • Name: “That sounds like a scary experience.”
  • Understand or Legitimize: “It’s understandable that you feel that way.”
  • Respect: “You’ve done better than most people would with this.”
  • Support: “I will continue to work with you on this.”
  • Explore: “How else were you feeling about it?”
• Gather Information by Exploring the Biomedical Perspective
  • Use the health history format to gather detailed information.
• Gather Important Background Information and Context
  • Medical, family, and personal/social history.

Setting the Stage for the Examination

• Preparation: Set the stage, adjust the environment, review the clinical record, and set your agenda (balance patient-centered goals and provider goals).
• Establish Rapport: Greet the patient, establish rapport, and identify the patient’s name and gender pronoun.

By following these guidelines and recommendations, students can enhance their understanding and performance in the NR 509 Midterm Exam. For comprehensive support and study materials, visit nursingschooltutors.com for tailored tutoring services.