Ch 4 Health History PrepU

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

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

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

The nurse is preparing to obtain a health history on a client who recently migrated from Asia. What is the first action of the nurse?

Determine if an interpreter is needed.

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

A client reports a weight loss and fatigue during the review of systems. In which area should the nurse document this information?

General

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

While discussing health patterns, a client says, "I hate my job." In which category should the nurse document and further assess this information?

Role-relationship

A nurse receives a new order for intravenous fluids (IVF) for a client. The nurse reviews the client's health history prior to administration. For which of the following findings should the nurse clarify this order?

The client has a long history of congestive heart failure and fluid overload.

The nurse would document driving with car seatbelt fastened, bicycling with properly-fitted helmet, and installing a smoke detector in a vacation home in the client's health history under which of the following?

Personal and social 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?"

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?"

A client with a long history of back pain is scheduled for back surgery. The nurse obtains the client's health history. Which of the following statements by the client requires further investigation?

"I take medication to thin my blood."

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

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.

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

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

After an initial interview with a new client, the nurse identifies and prioritizes client concerns. What is the next action of the nurse?

Develop a plan.

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

The nurse is collecting data for a comprehensive health history on a client new to the clinic. Under what component of the health history would the nurse place data on a chronic childhood illness?

Past history

A client is describing a very personal part of her history very quickly and in great detail. How should the nurse react to this?

Push away from the keyboard or put down the pen.

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.

A comprehensive health history includes which components? Select all that apply.

Reason for seeking care History of present illness Past health history

A client has come to the physician's office several times in the last month with a black eye, bruises, and lacerations on the lower extremities. The client always explains having fallen and tripped. The nurse suspects abuse. The next step should be to:

Report the findings to a supervisor.

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

Jason, a 41-year-old electrician, presents to the clinic for evaluation of shortness of breath, which occurs with exertion and improves with rest. The shortness of breath has been occurring for several months. Initially, it happened only a few times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than 12 times a day. The shortness of breath lasts for fewer than 5 minutes at a time. The client has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. Which of the following symptom attributes was not addressed in this description?

Severity

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

The nurse has completed a health history and assessment on a new client and is now documenting the findings. Which of the following would be considered objective data? Select all that apply.

Skin is pale and cool. Client appears disheveled. Client is emotionally labile, crying and laughing at times.

What information aids the nurse in assessing possible biases in the data collected in the health history?

Source of information

The nurse is taking a comprehensive health history on a new client. Why would it be essential for the nurse to obtain a complete description of the present illness?

To establish an accurate diagnosis

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

When assessing the gastrointestinal system, the nurse correctly asks, "Do you have any trouble swallowing?"

True

A client is being admitted to a medical unit with an acute illness. The nurse would plan to gather information using which tool?

comprehensive health history

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

A nurse is performing a client assessment in an urgent care clinic. The most likely tool being used is the

focused assessment

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

A nurse conducts a health history on a new client and documents the following findings: ● Age: 45 ● Sex: male ● Allergies: penicillin (PCN), peanuts ● Medications at home: daily multi-vitamin, MDI inhalers ● PMH: chronic obstructive pulmonary disease, past smoker Based on the client's history, which of the following orders would the nurse question?

penicillin IVPB every 6 hours

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

The nurse is conducting an initial health history with a client. The nurse asks about the client's history of neurological, respiratory, cardiovascular, and musculoskeletal problems. Which part of the subjective health assessment is the nurse performing?

review of the systems

The nurse understands that health promotion is a very important part of nursing care. When performing the health history, there are many different opportunities for the nurse to teach healthy behaviors. One way the nurse can do this is by focusing on which of the following topics:

sexual history and pattern

A nurse is about to obtain a health history on a client of Southeastern Asian descent who recently moved to the United States 6 months ago. Which of the following is the most important consideration the nurse must take into account when obtaining a health history?

the client's cultural norms

When teaching students how to perform an assessment, the nurse informs the students that the reason this information needs to be accurate and complete is:

to develop a plan with interventions that promote health