Chapter 4 The Health History

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? "How are you managing financially?" "Have you considered a job placement agency?" "Have you thought of hurting yourself?" "Are you looking for a new job?"

"Have you thought of hurting yourself?"

The nurse is conducting a history of the present illness. Which statement represents a possible response by the client? Select all that apply. "I walk 2 miles every day." "My pain is a 7 all the time." "Climbing stairs makes my pain worse." "I want to be able to sleep on my left side." "I am able to dress myself."

"I want to be able to sleep on my left side.", "My pain is a 7 all the time.", "Climbing stairs makes my pain worse."

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

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

The nurse recognizes that an example of subjective data would include: Scratching A pain rating of 7 100 cc of emesis 2-inch scar right lower abdomen

A pain rating of 7

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

After assessing for cigarette use

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? Duration Location Characteristic Onset

Characteristic

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? Simple square Simple circle Square with a cross Circle with a cross

Circle with a cross 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 Low bone density Liver disease Injuries

Coronary artery disease

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? follow-up emergency comprehensive focused

Focused

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? Use a written checklist to make sure you cover all necessary areas Use a focused approach, asking only about symptoms of the present illness Follow the cues of the client during the interview Use a head-to-toe approach to make sure you do not miss anything

Follow the cues of the client during the interview 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.

In the closing phase of the interview process, the nurse analyzes the data collected for what priority reason? Establish a baseline from which to start interviewing the family Communicate information to other staff members Identifying the primary problems or patterns of concern Communicate information to the physician

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? Neurologic Cardiovascular Psychiatric Fluid and electrolytes

Neurologic

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

Nutrition health pattern

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

Primary 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.

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

Quote the client's words.

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. Confront the client. Call social services. Call the police.

Report the findings to a supervisor.

A client comes to the ED complaining of chest pain. This would be considered objective secondary data subjective secondary data objective primary data subjective primary data

Subjective primary data

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 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 elicit negative family history

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 The nurse asks the client about the health of close family members (ie, 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 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? duration of the pain aggravating factors of the pain previous medical and surgical problems intensity of the pain

previous medical and surgical problems