Chapter 4 Health History
During the health history inquiry about alcohol intake, which of the following is a CAGE question?
"Have you ever felt annoyed by criticism about drinking?" Explanation: "Have you ever felt annoyed by criticism about drinking?" is one of the four questions that make up the CAGE questionnaire.
A client reports feeling depressed for several months since being fired from a long-term job. Which question should the nurse include when assessing this client?
"Have you thought of hurting yourself?" Explanation: If the client seems depressed, ask about thoughts of suicide: "Have you ever thought about hurting yourself or ending your life?" The severity of the depression needs to be assessed since it could be lethal. Asking about a job search or finances are not appropriate questions when a client is depressed.
Which observation would cause the nurse to suspect an abusive situation? Select all that apply.
- A child is persistent in trying to please a parent. - A caregiver of a cognitively intact older adult dominates the interview. - A preschooler rubs her perineum and complains of it hurting. Explanation: Observations suggestive of possible abuse include a caregiver of a cognitively intact older adult dominating the interview, a child being persistent in trying to please a parent, and a preschooler rubbing her perineum and complaining of it hurting. Observations not suggestive of abuse include a parent allowing an adolescent to speak privately with the nurse and an explanation that is appropriate for an injury.
During the comprehensive health assessment, the nurse asks several questions relating to the client's family history of illnesses, such as diabetes and cancer. Why does the nurse do this? Select all that apply.
- To help identify those diseases for which the client may be at risk - To provide counseling and health teaching in high-risk areas - To identify genetic family trends for which the client is at risk Explanation: The nurse asks the client about the health of close family members (i.e., parents, grandparents, siblings) to help identify those diseases for which the client may be at risk and to provide counseling and health teaching. Information concerning client and family history may be elicited to identify genetic family trends. The primary reasons are not to identify a negative family history or help the client feel at ease and not worry about being sick.
A nursing instructor is teaching students about the importance of assessing for medication allergies. A complete assessment of allergies would include which of the following components? Check all that apply.
- Verifying allergies with the client - Comparing allergies to the legal record - Noting the type of response - Documenting both medications and reactions for future reference Explanation: When assessing for allergies, it is important to verify with the client the allergy and check it on the legal record. Also, it is imperative to ask what type of reaction the medication caused, because often a client confuses an adverse reaction with an allergic reaction. Having the client bring the medication from home is necessary only if confusion exists over all the medications the client is presently taking.
A client has been transferred from the Emergency Department to a medical floor. Upon receiving the client, the floor nurse performs a health history, which will include the following (check all that apply):
- history of past illnesses - history of past surgeries - support systems - use of vitamins and herbs Explanation: A complete health history is needed to render safe and effective care to the client. It contains many components, and each one helps the nurse give holistic care. Some of the components include the physical, emotional, religious, and psychosocial aspects of the client.
A pregnant woman comes to the physician's office for her first prenatal visit. The nurse knows the importance of performing a comprehensive health history in this case and understands the following must be included (check all that apply):
- information about current pregnancy - previous pregnancies - obstetrical and gynecological history - family history Explanation: It is important on the first prenatal visit to perform a comprehensive health history, which includes information about the present pregnancy, previous pregnancies, obstetrical and gynecological history, the family, and psychosocial profile. Food preferences are part of a nutritional assessment and not necessary at this time.
While discussing family history with a client who is healthy except for a current UTI requiring IV antibiotics, the client tells the nurse that he has three sisters and two brothers. Two of his sisters have died and one brother is in a nursing home after a stroke. The nurse would include the sibling group in a genogram in what manner?
3 circles and 3 squares with lines through 2 circles
A nurse is interviewing a client complaining of abdominal pain for the last 2 weeks. Why is a history of the present illness vital to treating this client?
A complete description of the present illness is essential to an accurate diagnosis Explanation: The nurse collects information about the present illness by beginning with open-ended questions and have the client explain symptoms. A complete description of the present illness is essential to an accurate diagnosis. Nurses do not diagnose the problem for which the client is seeking medical help; even if knowing where the pain is, it is necessary for a nurse to take a complete health history. It is important to know not only where the pain started but also the quality and intensity of the pain as well as what aggravates or alleviates the pain.
The nurse recognizes that an example of subjective data would include:
A pain rating of 7 Explanation: Subjective data include signs and symptoms the client reports. Objective data are data cues the nurse can observe, while subjective data may not be observable to the nurse. A pain rating of 7 is an example of subjective data. The client must report the number that represents the intensity of his or her pain. A scar, scratching, and emesis are all data cues the nurse can observe.
The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use?
After assessing for cigarette use Explanation: Questions about alcohol and other drugs follow naturally after questions about cigarettes. Questions about alcohol intake occurs before the review of systems. Alcohol intake is a risk factor that is assessed after vaccinations. Alcohol use is assessed before completing the family history.
While completing a history of present illness the nurse asks the client about risk factors. In which way should the nurse use this information?
Analyze as a contributing factor to the current problem Explanation: Risk factors or other pertinent information related to the symptom is frequently relevant, such as risk factors for health problem or a current medication that may have side effects similar to the complaint. Risk factors are not used to determine health teaching, identify a genetic cause, or determine if a family history of the problem exists.
Alexandra, 28 years old, presents to the clinic. She has abdominal pain that she describes as a dull ache, located in the right upper quadrant, and that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago; it lasts for 2 to 3 hours at a time, comes and goes, and seems to be worse a few hours after eating. The client has noticed that the pain starts after eating greasy foods, so she has cut down on this as much as she can. Initially the pain occurred once a week, but now it happens every other day. Nothing makes it better. From this description, which of the attributes of a symptom has been omitted?
Associated symptoms and signs Explanation: The interviewer has not recorded whether nausea, vomiting, fever, chills, weight loss, and so on have accompanied the pain. Associated manifestations are additional symptoms that may accompany the initial chief complaint and that help the examiner to start refining his or her differential diagnosis.
A client reports pain as being 7 on a scale from 1 to 10. In which area of the symptom should the nurse document this information?
Characteristic Explanation: The seven attributes of a symptom should be assessed. The mnemonic OLD CART is used to ensure are all areas are included. Pain is documented under characteristic of the symptom. Onset identifies when the symptom began. Location is the body area including any radiation. Duration is the length of time the symptom lasts.
A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative?
Circle with a cross Explanation: The standard format for representing a deceased female relative in a genogram is using a circle with a cross. A simple circle indicates a living female relative. A simple square indicates a living male relative. A square with a cross indicates a deceased male relative.
While gathering data for the family history portion of the health history, what would you ask about?
Coronary artery disease (CAD) Explanation: Review each of the following conditions and record whether they are present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, as well as symptoms reported by the client.
When collecting data on the history of the present illness, it is appropriate to include what?
Current medications Explanation: Present Illness • Amplifies the Chief Complaint; describes how each symptom developed • Includes client's thoughts and feelings about the illness • Pulls in relevant portions of the Review of Systems, called "pertinent positives and negatives" • May include medications, allergies, and habits of smoking and alcohol, which are frequently pertinent to the present illness
The nurse documents that a client completed a 4-year college program and speaks English. How will this information be used?
Determine health literacy Explanation: Knowledge of the client's education level and primary language will help assess the client's health literacy level which is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Education level and primary language are not used to validate the client's age, understand the choice of occupation, or to analyze the client's lifestyle patterns.
An adult client is brought to the ED after falling 12 feet from a ladder. The client has an obvious deformity to his left lower leg. What kind of assessment is the nurse going to perform?
Emergency Explanation: An emergency assessment occurs when the client's condition is unstable. A focused assessment covers one subject, usually the current illness. A comprehensive assessment covers every system in the body, including a past history and a family history. A head-to-toe assessment is a complete physical assessment of the body.
A client arrives at the Emergency Department reporting shortness of breath. She is cyanotic with bilateral wheezing. The client begins to gasp for air and cannot speak. The nurse begins to gather information so that interventions can resolve the immediate breathing problem. Her assessment and interventions are concurrent. The nurse is performing what type of health history?
Emergency Explanation: The nurse is performing an emergency health history, the purpose of which is to collect the most important information and defer obtaining details until the client is stable. The focused health history involves questions that relate to the current situation. The comprehensive health history takes place during an annual physical examination. There is not a primary health history for clients.
During a health history, a client reports drinking bloody Mary's several mornings a week before going to work. In which part of the CAGE questionnaire should the nurse document this information?
Eye-openers Explanation: The client drinking alcohol in the morning would be applicable to the area on eye-openers specifically the question "Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? This information is not applicable to the other areas of the CAGE questionnaire, specifically, annoyance, cutting down, or guilty feelings.
A genogram is developed to visually show what?
Family health patterns Explanation: A common tool used to understand family health patterns is the genogram. This graphic representation allows the nurse to map family structures and compile a large amount of information visually. Genograms make it easier for the nurse to identify the complexity of families and validate patterns pertinent to clients. A genogram is much more than a family tree showing family relationships or nationalities of family members.
A client with hypertension seeks medical attention for a new onset of a nosebleed. Which type of assessment should the nurse complete with this client?
Focused Explanation: A focused or problem-oriented assessment focuses on the client's current problem. The client's symptoms, age, and this history will determine the extent of the physical examination to perform. An emergent or emergency assessment focuses on a specific problem that may be life-threatening. This type of assessment focuses on circulation, airway, and breathing (CAB) when cardiac arrest is suspected. A follow-up history is a form of a focused assessment. The client is returning to have a problem evaluated after treatment. Data is gathered to evaluate if the treatment plan was successful. A comprehensive assessment is completed when admitting a client to a facility.
A clinical instructor is discussing with a clinical group how to take a history of the client's present illness. A student asks how to best guide the interview. What would be the instructor's most appropriate answer?
Follow the cues of the client during the interview Explanation: Regardless of the order of data, the nurse guides the conversation following the cues of the client and uses a mental checklist to ensure that he or she has assessed all categories before the end of history taking. The nurse would not use a written checklist during the interview, and the nurse would not use a head-to-toe approach when eliciting information about the present illness. The nurse also would not focus only on the symptoms of the present illness.
A client with a foot wound returns to the outpatient wound clinic for a weekly appointment and treatment. Which type of assessment should the nurse complete with this client?
Follow-up Explanation: A follow-up history is a form of a focused assessment. The client is returning to have a problem evaluated after treatment. Data is gathered to evaluate if the treatment plan was successful. A focused or problem-oriented assessment focuses on the client's current problem. The client's symptoms, age, and this history will determine the extent of the physical examination to perform. A comprehensive assessment is completed when admitting a client to a facility.
In the closing phase of the interview process, the nurse analyzes the data collected for what priority reason?
Identifying the primary problems or patterns of concern Explanation: The nurse prioritizes, collects, and analyzes subjective and objective data and summarizes and states the two to three most important patterns or problems might be. The nurse's priority is not use the data gathered in the client interview as a baseline for interviewing the family or for communicating to the physician or other staff members.
Which item would be included in a review of the neurological system? Select all that apply.
Memory loss Loss of coordination Numbness Explanation: A review of the neurological system would include memory loss, loss of coordination, and numbness. Syncope and headaches would be included in a review of the head and neck.
During the review of systems, a client reports dizziness, tingling, and mood changes. In which area should the nurse document this information?
Neurologic Explanation: Dizziness, tingling, and mood changes would be documented under neurologic. Nervousness, tension, depression, memory change, and suicide attempts should be documented under psychiatric. This information is not appropriate to document under cardiovascular or fluid and electrolytes.
During a health history, a client lists the most recent immunizations received and the date and reason for surgeries. In which area of the history should the nurse document this information?
Past history Explanation: The past history includes childhood illnesses, previous illnesses and surgeries with dates, and health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety. The family history outlines the age and health or cause of death for family members. The chief complaint identifies the symptoms or concerns that caused the client to see care. The history of present illness describes how each symptom developed and factors that may have contributed to the illness.
During the interview process, the nurse obtains what type of data from the client?
Primary Explanation: Nurses collect primary data from clients themselves. Secondary data come from family and medical records. Objective data are data observed. Oral data is a form of data obtained through conversation.
As a nursing student you learn that mastering all the components of the comprehensive history provides what?
Proficiency Explanation: Mastery of all the components of the comprehensive history provides proficiency and the ability to select the elements most pertinent to the client encounter.
When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following?
Quote the client's words. Explanation: When recording the client's chief concern, it is preferable to quote the client's exact words whenever possible.
The nurse is assessing an older adult client a hospice unit. The client cannot speak or communicate, but the client's daughter is there and answers all the questions as best as she can. What type of data source is the daughter?
Secondary Explanation: Charts and family members are considered secondary data sources. Primary data would be directly from the client. Subjective data are based on the signs and symptoms that the client reports; they may not be perceived by observers.
The nurse is admitting a new client to the unit. While reviewing old records of the client, the nurse knows that the data being gathered are what kind of data?
Secondary Explanation: Charts and family members are considered secondary data sources. The client is the source of primary data. Subjective data are data provided to the nurse by the client; objective data are data that the nurse observes.
During the review of systems, a client reports having difficulty with urination and with establishing an erection. Which additional information should the nurse recognize as the highest priority to assess at this time?
Sexual history Explanation: If the chief complaint involves genitourinary symptoms, include questions about sexual health as part of "expanding and clarifying" the client's story. Lifestyle, medication, and substance use can be contributing factors but gathering a sexual history is the priority action at this time.
What information aids the nurse in assessing possible biases in the data collected in the health history?
Source of information Explanation: Designating the source helps the nurse and reader assess the type of information provided and possible biases.
A client comes to the ED complaining of chest pain. This would be considered
Subjective primary data Explanation: The individual client is considered the primary data source. When possible, clients provide subjective information regarding their health behaviors and situations. Subjective information is from the perspective of the client.
During a health history, a client states "I want to know why my feet are swelling" whereas the primary diagnosis is arthritis. What should the nurse do with the client's statement?
Write is as the chief complaint Explanation: The chief complaint may be the same as the admitting diagnosis, but do not assume this is always so. The client may have other concerns or problems which should be documented as the chief complaint. The inconsistency between client statement and admitting diagnosis should not be identified as referral information or documented within the health history. The client's statement may be a goal for care however it is not a health promotion goal.
A client comes to the community clinic seeking help for acute low back pain. Which type of assessment should the nurse complete for this client?
focused Explanation: A focused assessment gathers information about the current health problem. A follow-up assessment evaluates a specific problem after treatment. An emergency assessment focuses on data to quickly resolve the immediate health problem. A comprehensive assessment includes demographic data, a full description of the reason for seeking care, individual health history, family history, functional status, and a history in all physical and psychosocial areas.
A client with acute onset of shoulder pain is answering questions during a health history. The nurse is utilizing a mnemonic specific to the attributes of a symptom. The nurse first asks about the onset of symptoms followed by
location duration characteristic symptoms associated manifestations relieving/exacerbating factors treatment Explanation: This is an example of using the "OLDCARTS" mnemonic to understand a symptom.
A client says that food is not important and meals are not enjoyable. Where should the nurse document this information?
nutrition health pattern Explanation: Information about diet and intake should be documented within the nutrition health pattern. There is no evidence to support that this is the a past or present health problem for the client. It would not be appropriate to document this information within the gastrointestinal review of systems.
A client comes to the emergency department with severe abdominal pain. When performing a complete assessment, the nurse would focus on which of the following areas when covering past health history?
previous medical and surgical problems Explanation: The past health history includes asking about previous medical and surgical problems along with their dates. Aggravating factors, duration, and intensity of the pain are all part of the history of present illness.
A client comes to the ED complaining of chest pain. This would be considered
subjective primary data Explanation: The individual client is considered the primary data source. When possible, clients provide subjective information regarding their health behaviors and situations. Subjective information is from the perspective of the client.
