The Complete Health History
Which questions regarding sexuality should the nurse initially ask a patient whose sexual identity is unknown as part of the patient interview? Select all that apply. "Are you sexually active?" "Are you satisfied with your sexual life?" "Do you have a boyfriend or girlfriend?" "Do you have any worries about your sexual life? It is fine if you do." "How frequently do you have sexual intercourse?"
"Are you sexually active?" Initial questions regarding sexuality should be gender neutral. "Are you satisfied with your sexual life?" Indirect, open-ended questions are appropriate to ask a patient initially as part of a patient interview regarding sexuality. "Do you have a boyfriend or girlfriend?" Initial questions regarding sexuality should be gender neutral until the sexual orientation of the patient is known. Incorrect "Do you have any worries about your sexual life? It is fine if you do." A question about whether the patient has any sexual problems should be part of the patient interview. Although leading, reassuring a patient that it is fine to discuss problems can comfort a patient and does not suggest what the patient's feelings should be. "How frequently do you have sexual intercourse?" More direct questions, such as a question regarding how frequently a patient has sexual intercourse, should come later in the interview, only after trust has been built between the nurse and the patient. Incorrect
Which questions should be asked during the patient history to address spirituality? Select all that apply. "Do you belong to a formal spiritual or religious community?" "Tell me about your living situation." "Have you felt you ought to cut down on your drinking?" "In the last year how often did your partner hurt you physically?" "Do your beliefs help you cope with stress?"
"Do you belong to a formal spiritual or religious community?" (correct) A question about belonging to a religious community can assess patient spirituality. "Tell me about your living situation." A question about a patient's living situation does not address the patient's spirituality. "Have you felt you ought to cut down on your drinking?" A question about how the patient feels about his or her drinking is a social history question designed to detect alcoholism and does not address patient spirituality. "In the last year how often did your partner hurt you physically?" A question about how often the partner has hurt the patient addresses domestic violence and not spirituality. "Do your beliefs help you cope with stress?" (correct) A question about how the patient's beliefs might help cope with stress addresses patient spirituality.
What questions should the nurse include as part of a thorough assessment for a patient suspected of having alcoholism? "Have friends or family ever annoyed you by criticizing your drinking?" "Have you ever had a drink of alcohol?" "Do your parents drink alcohol?" "Are you taking any over-the-counter medication?"
"Have friends or family ever annoyed you by criticizing your drinking?" (correct) A question regarding annoyance at criticism of a patient's drinking is an assessment question on the CAGE screen to determine alcohol use and risk for withdrawal. "Have you ever had a drink of alcohol?" A question about if the patient has ever tried alcohol is not part of a question to identify alcoholism. "Do your parents drink alcohol?" A question about the drinking habits of a patient's parents is not a question to identify alcoholism. "Are you taking any over-the-counter medication?" A question about the medication use of the patient is not a question asked to identify alcoholism.
To identify potential domestic violence, which questions should be asked as part of the patient history? Select all that apply. "Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?" "Do you feel safe in your current relationship?" "Is there a partner from a previous relationship who is making you feel unsafe?" "Tell me about your living situation." "What is your spiritual heritage?
"Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?" (correct) A question about if the patient has been hurt by someone is important to identify domestic violence. "Do you feel safe in your current relationship?"(correct) A question about how safe the patient feels in his or her current relationship is important to identify domestic violence. "Is there a partner from a previous relationship who is making you feel unsafe?" (correct) A question about if the patient has a previous partner who is making him or her feel unsafe is important to identify domestic violence. "Tell me about your living situation." A question about a patient's living situation does not elicit information about possible domestic violence. "What is your spiritual heritage?" A question about a patient's spiritual heritage is not important in identifying domestic violence.
Which question should be asked during the patient history interview as part of the TACE model to screen for alcoholism? Select all that apply. "Have you felt you had to cut down on your drinking?" "Have you ever had an eye-opener drink to get rid of a hangover?" "How many alcoholic drinks do you consume in one sitting?" "How many drinks does it take to make you feel high?" "At what age did you have your first drink?"
"Have you felt you had to cut down on your drinking?" A question about whether the patient has felt the need to cut down (TACE) on his or her drinking should be part of the patient history to screen for alcoholism. Correct "Have you ever had an eye-opener drink to get rid of a hangover?" Asking if the patient has ever had an eye-opener drink (TACE) first thing in the morning to steady his or her nerves or get rid of a hangover should be part of the patient history to screen for alcoholism. Correct "How many alcoholic drinks do you consume in one sitting?" Although a question about how many alcoholic drinks the patient consumes in one sitting may give the nurse information about alcoholism, it is not part of the TACE model to screen for alcoholism. "How many drinks does it take to make you feel high?" Asking how many drinks it takes (TACE) to make the patient feel high should be part of the patient history to screen for alcoholism. Correct "At what age did you have your first drink?" A question about when the patient had his or her first drink is not part of the TACE model to screen for alcoholism.
Which documentation would the nurse include under the "medication reconciliation" section when assessing the patient's current medications? Select all that apply. Allergies Indications Side effects Interactions Names and dosing schedule
"Medication reconciliation" is a section in the health history form that compares the current prescribed drug list of a patient with the patient's previous list. This helps in minimizing errors and promoting safety. The reason for taking the medication is noted, and the patient would also verbalize their perception of why the medication is taken. Side effects of previously administered drugs would be included in the reconciliation report because this information may help in providing immediate interventions if the condition worsens with time. Interactions may either increase or decrease the desired pharmacologic action, so these details would also be documented and reported. Comparison of drug names and the dosing schedule are recorded in the medication reconciliation section to discover medication administration errors. Drug allergies are included in the history section rather than the medication reconciliation section.
A patient tells the nurse, "I've had a terrible headache since Monday morning." Under which section of the health history will the nurse record this information? Past health history Functional assessment Reason for seeking care Medication reconciliation
"Reason for seeking care" is a section of the patient's health history. The nurse asks the reason for consulting the primary health care provider and documents the patient's response under this section. The past health history will include the patient's past illnesses and therapies. The "functional assessment" section will contain data about the patient's daily activities. "Medication reconciliation" is a section that contains a list of current medications and those the patient has used in the past.
Which question would the nurse ask the patient who reports an allergy to a new medication? "Are you sure that you are really allergic to that medication?" "Can you describe what happened when you took the medication?" "Did you take the right dose of the medication?" "Are you worried about taking this medication now?"
A drug allergy is an immune response caused by exposure to a particular medication. The nurse needs to confirm whether the patient has experienced an allergic reaction or simply an adverse effect of that medication. Therefore the nurse asks the patient to state the reaction to the medication to determine whether it is nonimmunologic or life threatening. It is inappropriate to ask the patient about the allergy as the patient may not be able to differentiate between an allergic and a nonallergic reaction. An allergic reaction is not dependent on the medication dose. It is irrelevant at this time to ask whether the patient is worried about taking the medication. Instead, the nurse would encourage the patient to take the medication if the patient does not have an allergy. If the patient has a true allergic reaction, the primary health care provider will change the medication. p. 48
Which action by the nurse is the best way to obtain a patient's family history? Asking the patient's family Visiting the patient's house to collect data Collecting data from previous hospital visits Sending a questionnaire to the patient's house
A patient's family history includes details about the patient's family members. The best way to obtain the data is to send a detailed questionnaire to the patient when the patient makes an appointment. This practice provides ample time for the patient to gather the data, contacting other family members as needed. The nurse would obtain the family history information from the patient rather than going directly to the patient's family, because this practice may violate the patient's privacy. Not all patients live with extended families, so it may not be beneficial or appropriate for the nurse to do a home visit to collect the data. The nurse cannot rely solely on information from previous hospital visits because this information may be incomplete p. 48
While obtaining a health history from a patient, which information should the nurse obtain? Select all that apply. Operations Family health Immunizations Hospitalizations Current symptoms
A patient's past health history should include past operations, immunizations, hospitalizations, and chronic illnesses. Family health history and current symptoms are other categories of the health history but not part of the past health history. p. 47
The nurse teaches the nursing student about recording immunizations. Which statement by the nursing student indicates effective learning? "I will collect immunization information only for pediatric patients." "I will avoid recommending vaccines against the patient's preference." "I will record only those immunizations that are related to the chief complaint." "I will record dates of tetanus and flu shots when working with an adult patient."
Adult patients would receive an influenza vaccine annually and a tetanus-diphtheria-pertussis vaccine once, with a booster every 10 years. Therefore the nurse would record the dates of these vaccines to evaluate whether the vaccination is up-to-date. It is important to collect vaccination information for both pediatric and adult patients, because there are different vaccine recommendations for different age groups. The nurse would urge all patients to obtain recommended vaccinations, because these are preventive measures against various diseases. The nurse would record all immunizations that the patient has received, not just those related to the chief complaint, to gauge the need for further vaccination.
A patient presents to the urgent care center reporting onset of lower back pain. Which question should the nurse ask to obtain information about aggravating factors? "Which activities make the lower back pain worse?" "How long have you experienced these symptoms?" "When did you first experience the lower back pain?" "Have these symptoms affected your ability to work?"
Aggravating factors are what make the symptoms worse. Therefore the nurse should ask which activities make the pain worse. Length of time the patient has experienced the symptoms would be duration. When the patient first experienced the symptoms would be the onset or timing. The patient's perception of the symptoms is how their ability to work is affected.
Which is the first question asked by the nurse when communicating with the patient who is a victim of domestic violence? "Do you feel safe?" "Are you afraid of your partner?" "Have you been hit or slapped by your partner?" "Have you been emotionally abused by your partner?"
Asking whether the patient feels safe is an open-ended question that allows the patient to share thoughts freely. Asking this general question may help patients feel more comfortable in sharing any concerns regarding domestic violence, because it is a less-obtrusive question. Asking whether the patient is afraid of his or her partner is a more direct, closed question and may limit the patient's answers. Asking whether the patient was hit by a partner may make the patient feel uncomfortable, and the patient may not communicate further. Many people may not recognize emotional abuse as easily as they recognize physical abuse, so asking if the patient has been emotionally abused may not be as effective as asking a more general question to get the patient to open up. p. 54
Which information should the nurse obtain when performing a medication reconciliation? Select all that apply. Allergies Immunizations Over-the-counter medications Herbal supplements Current prescriptions
Medication reconciliation compares medication lists from the last visit or admission. This would include over-the-counter medications, herbal supplements, and current prescriptions. Allergies and immunizations fall under past medical history. p. 48
When assessing a patient's general independent functional abilities, which findings would the nurse record? Select all that apply. Use of a mobility aid Immediate postoperative activity tolerance Ability to use a cell phone Ability to perform exercise Ability to cope with stress
Functional assessment measures a patient's ability to do his or her routine activities. While assessing functional abilities, the nurse would find out whether the patient uses any mobility aids for walking; this finding helps assess the patient's physical health. The nurse also checks whether the patient is able to use a cell phone; this helps in assessing the patient's functional ability. The nurse would also record the pattern of exercises the patient practices to assess functional abilities. Usual methods for coping and stress are part of a functional assessment. Post-op activity is not part of a general independent functional assessment, because the patient in the immediate postoperative period is not in his/her usual state of health.
Under which section would the nurse record information about hearing aid use? Present health Review of systems Biographic data Functional assessment
Health-promotion devices such as hearing aids and mobility aids are recorded under the review of systems section. The hearing aid is recorded as a health-promotion tip under the review of ears section. Present health includes the current health status of the patient. Biographic data include general information regarding the patient such as occupation, ethnicity, and health practices. Functional assessment deals with the patient's daily living activities.
The nurse understands that gently resting a hand on a patient's arm to orient and reassure the patient is sometimes necessary when the patient exhibits which disability? Hearing impairment Visual impairment Mild cognitive impairment Serious illness
Hearing impairment Hearing-impaired patients typically do not require a hand to orient them. Visual impairment (correct) Orienting a visually impaired patient to his or her surroundings can facilitate the interview process. Mild cognitive impairment Most patients with mild cognitive impairment are able to speak for themselves without much adjustment to the interview technique. Serious illness The interview of patients with serious illnesses may need to be altered to meet their specific needs but does not necessarily require orienting them to their surroundings.
What types of patient disabilities require the nurse to make changes to the interview process? Select all that apply. Hearing impairment Fractured leg Visual impairment Severe cognitive impairment
Hearing impairment The nurse must take special care to face the patient, speak slowly, and articulate words clearly while interviewing a patient with hearing impairment. Fractured leg A patient with a fractured leg does not require special interview considerations. (Incorrect) Visual impairment Orienting a visually impaired patient to his or her surroundings can facilitate the interview process. Severe cognitive impairment Patients with severe cognitive impairment may not be able to adequately communicate. In this case, a patient history may need to be obtained from the patient's family members or caregiver.
The nurse must take special care to face the patient, speak slowly, and articulate words clearly while interviewing a patient with which disability or condition? Hearing impairment Visual impairment Memory loss Anxiety
Hearing impairment (correct) These actions should be employed when interviewing a hearing-impaired patient who can read lips. Visual impairment Key measures to take when interviewing a visually impaired patient are to use a normal tone of voice, speak at a moderate speed, and enunciate words clearly. Memory loss The interview of a patient with memory loss may require additional explanations, but does not necessitate changing one's speech. Anxiety When interviewing an anxious patient, the nurse must take care to ensure privacy but should not have to alter the manner in which the interview is administered.
Which are the goals of obtaining a patient's health history? Select all that apply. Documenting the findings of the physical assessment Establishing rapport between the nurse and the patient Assessing and diagnosing the patient's health needs and problems Providing a picture of the patient as a whole Understanding the patient's medical knowledge
Knowing the patient's health history helps establish a rapport between the patient and the nurse because it helps the nurse understand the patient better. The patient's health history will help the nurse diagnose health problems and how the patient responds to those problems. This will help diagnose the patient's health needs. The health history helps the nurse understand the patient's strengths, coping skills, and response to the environment. This helps provide a complete picture of the patient. The health history helps collect subjective data. However, it will not help to document the findings of the physical assessment, which are objective data. The nurse does not aim to understand the patient's medical knowledge by obtaining the patient's health history. Instead, the nurse tries to understand the patient's health concerns. p. 45
During the patient interview, the nurse should ask about the ability to perform daily living activities (toileting, dressing, and personal hygiene) to caregivers of patients with which disability? Mild cognitive impairment Hearing deficit Inability to speak Severe cognitive impairment
Mild cognitive impairment Patients with mild cognitive impairment typically can perform daily living activities. Hearing deficit Hearing does not have a direct impact on grooming and hygiene practices. Inability to speak Inability to speak does not have a direct impact on grooming and hygiene practices. Severe cognitive impairment A patient with severe impairment may have difficulty with tasks of hygiene and grooming. Correct
When interviewing an older adult patient, the nurse understands that history-taking must include questions assessing which age-related issues? Select all that apply. Multiple concurrent health problems Chronic symptoms Complete drug assessment Assessment of functional capacity Family history
Multiple concurrent health problems Questions assessing multiple overlapping health problems are part of a comprehensive health history for older patients. Correct Chronic symptoms Questions about chronic symptoms are part of a comprehensive health history for older patients. Correct Complete drug assessment A complete drug assessment is part of a comprehensive health history for all ages and is not age-specific. Assessment of functional capacity Assessment of functional capacity is necessary as part of a comprehensive health history for older patients. Correct Family history Family history should be obtained for all patients and is not specific to an age-related issue.
While documenting a complete health history, under which section would the nurse record a patient's activities of daily living? Family history Review of systems Functional assessment Reason for seeking care
My Family Health Portrait and the Utah Health Family Tree are official electronic tools to collect family history. Patients can log in to these tools and enter details about all their family members. Nurses can then use these tools to obtain the history and plan effective interventions. The personal health and electronic health record tools include an individual's health care data, but not information regarding the patient's family. Activities of daily living records are used to assess a person's self-care abilities but are not used to record family history. p. 48
Which patient disability affects the way the patient hears high-pitched sounds and requires the nurse to speak in a lower, more distinct voice? Otitis media Presbycusis Tinnitus Swimmer's ear
Otitis media Otitis media is inflammation of the inner ear that may cause hearing loss, but it does not affect the way the patient hears high-pitched sounds specifically. Correct Presbycusis Presbycusis is a hearing disorder that affects the way a person hears high-pitched sounds. Tinnitus Tinnitus describes a ringing in the ears, which does not affect the way the patient hears high-pitched sounds. Swimmer's ear Swimmer's ear is an infection of the outer ear canal that does not affect the way the patient hears high-pitched sounds specifically.
Under which section would the nurse record the following statement from a patient: "I had a car accident about 20 years ago when I was a child"? Past health history Reason for seeking care History of present illness Functional assessment
Past health history includes the patient's past illnesses such as childhood illnesses, accidents, hospitalizations, and operations. Because the patient is describing a past accident, it would be documented under the past health history section. The patient is not mentioning any signs and symptoms; therefore this would not be included in the reason for seeking care section. The patient is not mentioning present health status; therefore this would not be included in the history of present illness. The patient does not mention daily activities; therefore this would not be included under the "functional assessment" section.
Which age-related issues may hinder history-taking in older adult patients? Select all that apply. Sensory loss Use of hearing aids Cognitive impairment Memory loss Visual impairment
Sensory loss Loss of sensory perception may occur in older individuals and can affect the patient interview. Use of hearing aids (incorrect) Use of hearing aids will typically improve patient hearing and may enhance the interview process. Cognitive impairment Cognitive impairment affects the patient's ability to understand and answer the nurse's questions during the interview. Memory loss Short-term memory loss may affect the patient's ability to answer questions during the interview. Visual impairment The patient who is unable to see well may have difficulty completing the patient interview.
When asked by the nurse about current medication use, the patient replies, "I take a little white pill, a yellow tablet, and a red-and-white capsule for my heart." Which response by the nurse is best? "Tell me about your family medical history now." "I don't think it is safe to take so many heart medications." "Are you experiencing any side effects of the medications?" "Let us discuss the purpose of taking each medication."
Some patients do not know the names of their prescribed medications, and it may not be clear from their descriptions if all the drugs are meant to treat one condition or multiple conditions. Therefore the nurse needs to discuss with the patient the purpose of taking each medication. The nurse can also ask the patient to bring all medications in for identification. The nurse has not understood the purpose of the medications yet. Therefore the nurse would not change the subject to the family medical history. The patient may be taking each medicine for a different ailment, so it is inappropriate to assume that the patient is taking all medications for the heart. The nurse can ask about the side effects after asking about the purposes of the medications. p. 48
Which question would the nurse ask when assessing the mental status of a patient? "Do you have mood swings?" "Do you forget things often?" "Do you have regular sleeping cycles?" "Do you experience any tics or tremors?"
The nurse would ask the patient about mood changes while assessing the patient's mental status. Memory-related questions are asked to evaluate the patient's cognitive status. Regular sleeping cycles can be assessed to determine sleep disorders resulting from stress; sleep/rest is a functional assessment. The patient who has tics or tremors may have problems with motor function. pg 52
Which documentation would the nurse include in the history of present illness section of the record? Select all that apply. Severity of pain Location of problem Immunizations Hospitalizations Onset, duration, and frequency of symptoms
The history of present illness section includes the problems the patient is experiencing at that particular moment. The severity, location, onset, duration, and frequency are the components that the nurse would include in the history of present illness section. The nurse would specify the exact location of the problem. The nurse would also include the onset, duration, and frequency of the symptoms. Immunizations and hospitalizations are included in the patient's past history.
Why would the nurse analyze the patient's symptoms? Separates actual from imaginary symptoms Puts the patient at ease about the symptoms Focuses on the patient's chief health concern Determines whether the patient is reporting accurately
The nurse analyzes the patient's symptoms to focus on the chief health concern. This will help the nurse formulate an accurate nursing diagnosis and plan appropriate interventions. The patient may have multiple concerns and ailments that are not the primary reason for seeking care. However, this does not mean that the patient has imaginary symptoms. The purpose of analyzing the symptoms is not to put the patient at ease, but it is to give the health care team a better understanding of the patient's medical status. The nurse does not analyze the patient's symptoms to determine the accuracy of the patient's report. p. 45
Which questions would the nurse include in a patient's screening for health promotion practices? Select all that apply. Use of contraceptives Use of sunscreen Use of prescription medications Use of seatbelts Use of antacids
The nurse asks the patient about the use of contraceptives to understand the patient's sexual health care practices. Asking about the use of sunscreen will help the nurse understand whether the patient takes precautions against sunburn and tanning. The nurse will ask about the use of seatbelts to understand whether the patient takes precautions against environmental hazards. The use of antacids is also part of health promotion. The use of prescription medications is not a health promotion intervention. It indicates that the patient has sought treatment for a health concern. pp. 50-52
Why would the nurse include data related to employment in the patient's assessment? Select all that apply. Changes in occupation may indicate some health problems. Occupations may help understand exposure to environmental hazards. Changes in occupation may indicate the level of the patient's disability. Occupation determines the ability to access support services. Occupation is a reliable way to determine the patient's education.
The nurse assesses the patient's employment details to understand whether any health problems are work related. The patient may have changed jobs because of health problems. The patient may also be exposed to environmental hazards such as chemicals, asbestos, or inhalants. The patient may also need to change jobs because of functional disabilities such as sensory problems or cognitive disabilities. A patient's occupation does not determine whether the patient can access any support services. The nurse determines the patient's need for support services according to the patient's health status. There may be a discrepancy in the educational level and the patient's occupation. Therefore it is difficult to determine the patient's education from the occupational details. pp. 45, 54
Which would the nurse include in the review of a patient's gastrointestinal (GI) system? Select all that apply. Ascites Appetite Constipation Use of antacids Family history of cancer
The nurse includes the present health state and health promotion activities in the review of body systems. Ascites and constipation are GI conditions that the nurse will include in the review of the GI system. The use of antacids is a treatment for an abnormal GI condition. A change in the appetite will affect the GI system, so the nurse needs to assess the patient's appetite. The review of systems includes the past and present physical health status. Therefore a history of cancer is not included in the review of systems. p. 51
Under which section of the health history would the nurse record pain severity? Present health Biographic data Review of systems Reason for seeking care
The nurse is quantifying a symptom in the patient, so this information is recorded in the present health or history. Biographic data includes information related to the patient's occupation, ethnicity, and health practices. The review of systems does not include information regarding symptoms of the present illness. Reason for seeking care includes only the patient's spontaneous statements but not analysis of the symptoms. p. 46
Which would the nurse document as the reason for seeking care for a patient who is in the office for suture removal? Suture removal was scheduled. Left leg potentially is infected. There are black, nonabsorbable sutures in the left leg. "I'm afraid of having the sutures removed.
The nurse records the patient's purpose, symptoms, and signs as the reason for seeking care. In this case, suture removal is the purpose of seeking care. The nurse is diagnosing the possibility of an infection. However, the reason for seeking care is not a diagnostic statement. A statement that there are black, nonabsorbable sutures in the left leg is the objective information that the nurse can observe. However, it does not explain the patient's reason for seeking care. The patient's fear about suture removal would constitute subjective data, and is not the real reason for seeking care. p. 46
The patient presents with headaches that have lasted for 3 days without relief and has a history of hypertension and atherosclerosis. Which should the nurse document in the medical record as the reason for seeking care? Atherosclerosis Hypertensive crisis Onset of migraines Intractable headaches
The nurse should not make assumptions about the reason the patient is seeking care. The reason for seeking care is not a diagnostic statement. Therefore the nurse should document the patient has intractable headaches, not atherosclerosis, hypertensive crisis, nor onset of migraines. p. 46
The patient's social relationships, management of finances, and self-concept would be recorded in which section of the record? Review of systems Functional health patterns Nurse's notes Diagram a family tree
The nurse uses functional health patterns to organize data that relate to the patient's self-care ability. The review of systems includes a patient's past and present physical health status. The nurse may want to note the details of patient teaching that helped the patient perform better. The nurse can include this in the nurse's notes. The nurse will use a family tree to understand family relationships while assessing a child.
Which questions would the nurse ask a patient who is an immigrant to the United States when collecting biographic data? Select all that apply. "What is your occupation?" "What is your marital status?" "What is your country of origin?" "What are your working hours?" "What ritualistic procedures have you undergone?"
The nurse would collect additional information from immigrants because their lifestyles and cultures may differ from those of other patients. First, the nurse would collect information about the patient's native country. Ritualistic procedures such as blood collection and administration may differ from one health care facility to another, so the nurse would add this additional data in the biographic section of the health history. Questions about the patient's occupation, marital status, and working hours are commonly asked during the collection of biographic data, regardless of a patient's immigration status.
Under which section of the record would the nurse record vaccination dates? Past health Present health Review of systems Medication reconciliation
The past health section includes the patient's past illness and treatment, and this is where the nurse records information about a prior vaccination. Present health includes the current health status of the patient. Review of systems includes present and past health status and health-promotion aids. Medication reconciliation compares the current and previous lists of prescribed drugs to minimize errors and promote patient safety. p. 48
Which are the components of a patient's past health history? Select all that apply. Symptoms Transfusions Family history Immunizations Hospitalizations
The past history helps the nurse understand the residual effects of disease and treatment on the patient's current health status. Transfusions, immunizations, and hospitalizations are all a part of the patient's past history because they happened in the past and may show residual effects on the patient's present health status. The symptoms that the patient is experiencing will constitute the current health status. The family history section will contain all the information related to the patient's family members; this section does not give any information about the patient's past health status.
Under which section of the health history will the nurse document the following patient statement: "I haven't felt well lately. I just had to come in for a checkup"? Past health history Present health status Reason for seeking care Physical assessment
The patient is not sure about the cause of the illness. Therefore the nurse will record these spontaneous statements as the reason for seeking care. The past health history will include the patient's past illnesses and therapies. The present health status will include the main concerns that the patient is experiencing at present. The physical assessment section will contain the patient's objective data that the nurse obtains after assessing the patient. p. 46
Under which section in the review of body systems would the nurse document a history of back pain? Endocrine system Neurologic system Musculoskeletal system Peripheral vascular system
The review of body systems records the past and present health status of each body system. In the musculoskeletal system, the problems associated with the muscles and the skeleton, such as muscle pain, cramps, gait problems, and back pain, are included. In the endocrine system, the symptoms and history of endocrine disorders such as diabetes and thyroid gland disorders are recorded. In the neurologic system, motor functions, cognitive functions, sensory functions, and mental status are included. In the peripheral vascular system, the symptoms associated with the obstruction of blood flow in the arteries and veins are included. P.52
Which is a component of the review of systems? Symptom analysis Immunizations Health promotion Prenatal status
The review of systems includes a patient's past and present physical health status. The patient's health promotion is a component of the review of systems, because it helps to understand the patient's current health-promotion practices. The nurse will perform a symptom analysis after the assessment and review of systems. Immunizations and prenatal status constitute the past health history of the patient. p. 50
During the review of systems, which would the nurse assess? Select all that apply. Sociologic system History of skin disease Physical assessment findings Appetite and food intolerances Usual daily activities
The review of systems refers to the act of evaluating each body system, which would include the skin (e.g., a history of skin disease) and gastrointestinal system (e.g., appetite and food intolerances). The nurse evaluates the patient's sociologic system to understand the patient's interpersonal relationships, family support, and role in the family. The review of systems is not used to record the physical assessment findings; it is used to understand the patient's body systems. Usual daily activities are part of the functional assessment not the review of systems.
Which documentation would the nurse include in the health history when reviewing the patient's musculoskeletal system? Select all that apply. Arthritis Paralysis Gait problems Muscle cramps Tingling in the legs
The section called "review of systems" includes the present and past health status of the patient, along with health-promotion aids. While reviewing the musculoskeletal system, the nurse documents whether the patient has arthritis and whether the patient uses mobility aids or has gait problems. Arthritis is a musculoskeletal disorder involving inflammation of the joints. Gait refers to the patient's walking patterns. Gait abnormality may indicate a musculoskeletal or neurologic disorder. Muscle cramps are involuntary muscle contractions; these can indicate minor or serious musculoskeletal disorders and would be documented. Paralysis is loss of muscle function such that the patient lacks sensation and function of the body part. It is a neurologic disorder and is not documented under the musculoskeletal system. Tingling is an abnormal sensation in the patient's body, especially in the hands and feet, which may indicate a neurologic or vascular issue rather than a musculoskeletal problem, so this finding is recorded in a different section.
Under which section of the patient's health history will the nurse record the following comment: "I want to join a recreational sports team and came in for a physical"? Past history Present health Biographic data Reason for seeking care
The statements of the patient who visits the clinic for a regular checkup without any specific illness would be documented under the reason for seeking care section. The past history section includes the patient's history of past illness and treatment. The present health section includes the patient's current health status. Biographic data include the patient's general information such as occupation, ethnicity, and health practices. p. 46
Which documentation in the review of systems section would the nurse include when addressing a patient's peripheral vascular system? Select all that apply. Palpitations Coldness of the hands Inflammation of the veins Diarrhea and constipation Numbness and swelling of the legs
Under the review of systems section, the nurse includes the past and present health status of each body system. The peripheral vascular system includes the arteries and veins of the arms, hands, legs, and feet. Coldness of the hands is caused by poor blood supply to the hands. Inflammation of the veins obstructs the blood flow in the veins. Numbness and swelling of the legs are caused by impaired blood supply to the legs. Palpitation refers to abnormal heartbeats; therefore it is included in the cardiovascular review of systems. Diarrhea and constipation are problems of the gastrointestinal tract and therefore are included in the review of the gastrointestinal system.
Which impairment of an adult patient would necessitate obtaining patient health information from a relative or caregiver? Visual impairment Severe cognitive impairment Mild cognitive impairment Serious illness
Visual impairment Most visually impaired patients can respond to questions appropriately. Severe cognitive impairment (Correct) Patients with severe cognitive impairment may not be able to adequately communicate. In this case, a patient history may need to be obtained from the patient's family members or caregiver. Mild cognitive impairment Most patients with mild cognitive impairment can speak for themselves. Serious illness The interview of patients with a serious illness may need to be altered to meet their specific needs, but does not require obtaining patient health information from a relative or caregiver.
Key Points
When dealing with patients with physical or cognitive impairments, the nurse should adapt interview techniques based on the patient's condition and immediate needs. An interpreter should be obtained for hearing-impaired patients who use sign language. If the patient has some hearing, or can read lips, the nurse should speak slowly and enunciate so that the patient is able to understand. The visually impaired patient should be frequently reoriented to the surroundings. For patients with cognitive impairments, the nurse must be careful to note the patient's ability to understand and respond to questions. Using a family member to help relay information is especially helpful for patients with severe cognitive impairments.
Which information should the nurse obtain when conducting a health history for a patient during an annual exam? Select all that apply. Current insurance Level of education Family medical history Reason for current visit Presence of chronic illnesses
When obtaining a health history, components include biographic data, who is providing the data, reason for seeking care, present health or history of present illness, past health, and family history. Current health insurance and level of education are not part of a health history. pp. 45-49
While caring for a patient with influenza, the nurse asks, "When did the symptoms first appear?" Under which section will the nurse record this information? Biographic data Review of systems History of present illness Medication reconciliation
While collecting a patient's complete health history, the nurse records the location, character, onset, and frequency of the symptoms under the "history of present illness" section. Biographic data include the patient's personal information, such as occupation, ethnicity, and health practices. Review of systems evaluates the health condition of each body system. Medication reconciliation is a comparison of a list of current medications with a list of previous medications.
Which would the nurse document as the reason for seeking care for a patient who says, "I didn't feel right all last week. I want to throw up now, and I have a headache. What is wrong with me?" Flulike symptoms Gastrointestinal (GI) distress Nausea and headache. Not "feeling right" for 1 week. Possible pregnancy. Needs workup.
While documenting the reason for seeking care, the nurse records the patient's symptoms and the purpose of the visit as the patient informs. In this scenario, "nausea and headache" and "not 'feeling right' for 1 week" are the most appropriate statements to reveal the patient's reason for seeking care. The reason for seeking care is not a diagnostic statement. Flulike symptoms and GI distress are medical terms for symptoms. The nurse would record the symptoms as the patient states them. Stating "possible pregnancy" and "needs workup" shows that the nurse is inferring the patient's condition and suggesting interventions.
Which note is included in the record to document the patient's reason for seeking care? "Is sick." "Has high glucose level." "Requesting a different birth control method." "Is pregnant."
While documenting the reason for seeking care, the nurse records the patient's symptoms and the purpose of the visit as the patient states them. The patient who comes to the clinic asking for a different birth control method has a definite purpose for seeking care. Stating that the patient is sick does not help the nurse understand clearly the patient's reason for seeking care. The reason for seeking care is not a diagnostic statement. Therefore the nurse would not mention the diagnosis of a high glucose level as the reason for seeking care. Instead, the nurse would state the symptoms or signs that indicate a high glucose level in the patient. Stating that the patient is pregnant does not help the nurse understand whether the patient needs care. Any problems related to the pregnancy would be the reason for seeking care.
How would the nurse record a patient's reason for seeking care? Use the North American Nursing Diagnosis Association (NANDA) list. Write the symptoms without quotations. Record the symptoms in the patient's words. List all of the complaints of the patient.
While documenting the reason for seeking care, the nurse records the patient's symptoms and the purpose of the visit in the patient's words. The NANDA list is used to formulate nursing diagnoses. However, the reason for seeking care is not a diagnostic statement. The nurse encloses the patient's statements in quotation marks to indicate that they are the patient's exact words. The nurse does not write down all complaints, because only a few of the problems may be the actual reasons for seeking care. Therefore the nurse focuses on the main concerns by asking the patient what prompted him or her to seek care at present. p. 46
Which action would the nurse take while discussing the patient's reason for seeking care? Ascertain the patient's views on the cause of problem. Ask whether the patient is unable to determine the cause of the problem. Suggest the most common causes of the problem to the patient. Refer the patient to the primary health care provider for discussion.
While documenting the reason for seeking care, the nurse records the patient's symptoms and the purpose of the visit in the patient's words. The nurse can do this by ascertaining the patient's perspective or views on the cause of the problem. If the patient is unable to determine the cause of the problem, the nurse focuses on the main concerns that the patient is experiencing at that time. The nurse does not suggest the common causes of the problem to the patient but asks the patient to state the concerns. The nurse would understand the patient's reason for seeking care and health history before referring the patient to the primary health care provider. p. 46
How would the nurse record the reason for seeking care for the patient who says, "I have difficulty breathing, and so I can't sleep at night"? "Dyspnea and insomnia" "The patient has dyspnea and insomnia." "Difficulty in breathing and sleepless nights" "The patient has difficulty breathing and is sleepless."
While documenting the reason for seeking care, the nurse would use quotation marks and would record the patient's symptoms and the reason for seeking care as said by the patient. Therefore the nurse would report "difficulty in breathing and sleepless nights." The nurse would not use any medical terminology and therefore would not report "dyspnea and insomnia." The nurse would not report the statements in indirect speech by excluding quotation marks. "The patient has dyspnea and insomnia" is incorrect because it is not in the patient's own words; it also includes medical terminology, which is prohibited. "The patient has difficulty breathing and is sleepless" cannot be reported because it is indirect speech, excluding quotation marks.
A patient with a viral upper respiratory infection says, "I've been drinking ginger tea for three days, but I've still got this cold." In which section will the nurse record this information? Review of systems Functional assessment History of present illness Medication reconciliation
While recording a patient's health history, the nurse records the previous medication history under the medical reconciliation section. This section also includes information about the over-the-counter medications and herbal remedies that the patient has used for relief. Drinking a cup of ginger tea is an herbal remedy to get relief from the cold and would be recorded under the medication reconciliation section. Under the review of systems section, the nurse records the health status of each body system. Under the functional assessment section, the nurse records the patient's daily activities. The patient's present health status is included under the history of present illness section.
Which documentation would the nursing instructor strike from the information entered by a nursing student under the past history? Allergies Immunization history Physical findings Statements given by the patient
While recording the past health history of the patient, the nurse would not include physical findings because they are related to the patient's present condition; they would be recorded in a different section of the patient record. Allergies would be included in the past health history because knowledge about them can help prevent further complications in the patient's condition. Immunization history would be included, because it helps in determining the patient's resistance to various infections. Statements given by the patient would be included if they relate to the patient's past health problems. pp. 47-48
Under which section in the health history will the nurse include the patient's name and primary language? Past history Family history Biographic data Functional assessment
While recording the patient's complete health history, the nurse will record the patient's personal details such as occupation, ethnicity, and health practices under the biographic data section. The patient's name and the languages the patient knows are personal details and therefore are recorded under biographic data. The information related to past illness will be included under the past history section. The family history section will contain all of the information related to family members. Functional assessment includes the patient's daily activities. p. 45