Case Study, Chapter 28: Pulling it All Together: Integrated Head-To-Toe Assessment

A 21-year-old male college student attends the health care facility to have a history and

physical conducted for work. The client will be working as a camp counselor for the

summer. The client’s last physical was a few years ago when he was a freshman in college.

The client hands over the camp forms that the nurse needs to complete. The forms ask for a

complete physical to be conducted, along with certain blood tests and a chest x-ray. The

nurse proceeds with the interview. The client gives a negative history for medical conditions

or surgical procedures. He is not on any medication and does not smoke or drink alcohol.

Upon interviewing the client, the nurse notes that the client is very shy and does not easily

reveal information. The nurse has been working at the health care facility for only a few

months and is not sure how to proceed with the physical exam. The nurse goes out of the

room to enlist the help of the senior nurse at the facility.

(Learning Objectives: 1, 3)

Questions:

a. In order for an interview and a health assessment to be accurately completed, what

key elements should be in place?

b. The novice nurse knows that a complete health assessment takes approximately 2
hours; however, the senior nurse completed the exam in 1 hour. How is this
possible?