ch. 4 prep-u: the 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 -follow-up -emergency -comprehensive

focused

During the health history inquiry about alcohol intake, which of the following is a CAGE question? -"How many days per week do you drink?" -"How often do you have a hangover?" -"Have you ever felt annoyed by criticism about drinking?" -"Describe the types of alcohol that you prefer."

"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?" -"Are you looking for a new job?" -"Have you considered a job placement agency?" -"How are you managing financially?"

"Have you thought of hurting yourself?"

During a health history, a client asks why family information is requested. Which response should the nurse make to the client? -"It can help identify any illnesses that you might be at risk for developing." -"It is used to predict your longevity." -"It helps determine your response to prescribed medications." -"It helps determine what health problems you might be experiencing now."

"It can help identify any illnesses that you might be at risk for developing."

Which observation would cause the nurse to suspect an abusive situation? Select all that apply. -A pre-schooler rubs her perineum and complains of it hurting. -A parent allows the adolescent to speak privately with the nurse. -A child is persistent in trying to please a parent. -The explanation of an injury seems appropriate. -A caregiver of a cognitively intact older adult dominates the interview.

-A pre-schooler rubs her perineum and complains of it hurting. -A child is persistent in trying to please a parent. -A caregiver of a cognitively intact older adult dominates the interview.

As a nurse assessing the endocrine and hematologic systems, it is important to ask the client about what? Select all that apply. -Intolerance to cold -Swelling of the lower extremities -Explained weight gain or loss -Changes in body hair -Excessive bruising

-Changes in body hair -Excessive bruising -Intolerance to cold

The nurse is beginning the health history with a client. Which information will the nurse designate as identifying data? (Select all answer choices that apply) -Childhood illnesses -Appearance of reliability -Date of birth -Age -Gender -Occupation

-Date of birth -Age -Gender -Occupation

Your patient has two affirmative answers to the CAGE Questionnaire. What other questions should you ask? (Mark all that apply.) -Do you have seizures while drinking? -Do you experience blackouts when drinking? -What OTC medications do you take? -Do you have any legal problems? -How would you describe your level of nutrition?

-Do you have seizures while drinking? -Do you experience blackouts when drinking? -Do you have any legal problems?

A comprehensive health history includes which components? Select all that apply. -Reason for seeking care -Employment history -Past health history -History of present illness -Income

-Reason for seeking care -Past health history -History of present illness

An adult client presents at the ED complaining of severe pain in the left upper quadrant. The nurse uses a mnemonic to remember the important elements to assess for the presenting symptom. What elements are represented by the mnemonic OLDCARTS? Select all that apply. -Other complaint -Timing -Character -Dynamic -Location

-Timing -Character -Location

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 elicit negative family history -To identify genetic family trends for which the client is at risk -To provide counseling and health teaching in high-risk areas -To help the client feel at ease and not worry about being sick -To help identify those diseases for which the client may be at risk

-To identify genetic family trends for which the client is at risk -To provide counseling and health teaching in high-risk areas -To help identify those diseases for which the client may be at risk

While discussing family history with a patient who is healthy except for a current UTI requiring IV antibiotics, the patient 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 squares -3 circles and 3 squares with two diagonal slashed lines through lines connecting the 2 deceased siblings -3 circles and 3 squares with lines through 2 circles -3 circles and 3 squares with broken lines connecting 2 of the circles

3 circles and 3 squares with lines through 2 circles

The review of systems component of the health history is best described as which of the following? -A large number of questions about major body systems -A focus on symptoms related to each of the different body systems -A focus on diseases of the major body systems -A series of questions that start at the head and finish at the feet

A focus on symptoms related to each of the different body systems

The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use? -During the review of systems -Before assessing for vaccinations -While completing the family history -After assessing for cigarette use

After assessing for cigarette use

A 23-year-old graduate student comes to the clinic for evaluation of a urethral discharge. The provider needs to get a sexual history. Which of the following questions is inappropriate to ask when eliciting this information? -Are you sexually active? -Do you have sex with men, women, or both? -How many sexual partners have you had in the last 6 months? -When was the last time you had intimate physical contact with someone, and did that contact include sexual intercourse?

Are you sexually active?

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 -Onset -Duration -Location

Characteristic

During the admission process, the client states, "I am allergic to sulfa drugs." How would the nurse verify this information? -Ask the physician -Ask family members -Compare against the client's medical records -Ask the client about the response to the allergen

Compare against the client's medical records

While gathering data for the family history portion of the health history, what would you ask about? -Coronary artery disease -Injuries -Low bone density -Liver disease

Coronary artery disease

When collecting data on the history of the present illness, it is appropriate to include what? -Chronic childhood illnesses -Current medications -Treatment recommendations -Reliability of information source

Current medications

A patient arrives at the Emergency Department reporting shortness of breath. She is cyanotic with bilateral wheezing. The patient 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? -Comprehensive -Emergency -Focused -Primary

Emergency

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 -Annoyance -Guilty feelings -Cutting down

Eye-openers

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? -Comprehensive -Follow-up -Focused -Problem-oriented

Follow-up

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 -Establish a baseline from which to start interviewing the family -Communicate information to the physician -Communicate information to other staff members

Identifying the primary problems or patterns of concern

During the review of systems, a client reports dizziness, tingling, and mood changes. In which area should the nurse document this information? -Cardiovascular -Psychiatric -Neurologic -Fluid and electrolytes

Neurologic

During the interview process, the nurse obtains what type of data from the client? -Objective -Oral -Secondary -Primary

Primary

The patient is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the patient, the nurse is obtaining what other type of data from the patient? -Secondary -Objective -Primary -Tertiary

Primary

As a nursing student you learn that mastering all the components of the comprehensive history provides what? -Advocacy -Empathy -Proficiency -Authority

Proficiency

When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following? -Summarize the client's words. -Paraphrase the client's words. -Describe the client's concerns and health goals. -Quote the client's words.

Quote the client's words

A patient 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 patient always explains having fallen and tripped. The nurse suspects abuse. The next step should be to: -Report the findings to a supervisor. -Confront the patient. -Call the police. -Call social services.

Report the findings to a supervisor.

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? -Alcohol and tobacco -Lifestyle -Substance use -Sexual history

Sexual history

The nursing instructor explains that sometimes a nurse uses a mnemonic, such as OLDCARTS, as the nurse completes the assessment. What is the purpose of the mnemonic? -To remember how to document assessment findings -To remember the elements that are important to assess with a symptom -To remember the parts of a focused assessment -To remember the order of the assessment

To remember the elements that are important to assess with a symptom

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

True

A client says that food is not important and meals are not enjoyable. Where should the nurse document this information? -nutrition health pattern -gastrointestinal review of systems -history of present illness -past medical history

nutrition health pattern

A patient 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? -intensity of the pain -previous medical and surgical problems -aggravating factors of the pain -duration of the pain

previous medical and surgical problems

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 -gender -culture -spirituality

sexual history and pattern