Adult Health Assessment CH 4 The Health History

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

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

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.

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 explanation of an injury seems appropriate. A parent allows the adolescent to speak privately with the nurse.

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 review of systems component of the health history is best described as which of the following?

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?

After assessing for cigarette use

The nursing instructor is teaching about the different types of health histories. Students show an understanding of what a comprehensive health history involves when identifying the following as examples: (Select all that apply.) Annual physical examination Emergency department visit Sports participation screening Hospital admission Focus assessment

Annual physical examination Sports participation screening Hospital admission

A client states that the reason he has come into the clinic is for a routine annual physical. In what section of the health history would you document this information?

Chief complaint

While gathering data for the family history portion of the health history, what would you ask about?

Coronary artery disease

When collecting data on the history of the present illness, it is appropriate to include what?

Current medications

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.

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

Excessive bruising Changes in body hair Intolerance to cold

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

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

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

General

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?"

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

Which item would be included in a review of the neurological system? Select all that apply. Memory loss Loss of coordination Numbness Syncope Headaches

Memory loss Loss of coordination Numbness

During the interview process, the nurse obtains what type of data from the client?

Primary

The client is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the client, the nurse is obtaining what other type of data from the client?

Primary

As a nursing student you learn that mastering all the components of the comprehensive history provides what?

Proficiency

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 Employment history Income

Reason for seeking care History of present illness Past health history

The nurse is completing the past medical history information with a client. Which part of the health maintenance information can the nurse assess during the review of systems?

Screening tests

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

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 denies having pain. Client appears disheveled. Client states health concern of medication symptoms. Client is emotionally labile, crying and laughing at times.

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(prejuicios) in the data collected in the health history?

Source of information

The nurse prepares to complete a comprehensive assessment with a client experiencing shortness of breath and lower extremity edema. Which purpose should the nurse keep in mind when completing this assessment? (Select all answer choices that apply) Addresses specific symptoms Strengthens the nurse-client relationship Serves as a baseline for future assessments Provides personalized knowledge about the client Focuses on symptoms restricted to a specific body system

Strengthens the nurse-client relationship Serves as a baseline for future assessments Provides personalized knowledge about the client

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

TRUE

Which of the following describes how the health history interview differs from a social conversation?

The interview focuses on the client's needs to improve health and well-being.

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 Dynamic Timing Character 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 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 To elicit negative family history 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 provide counseling and health teaching in high-risk areas To identify genetic family trends for which the client is at risk

The nurse is the primary care provider for a 21-year-old man who, as the result of a brain injury suffered in a mountain-biking accident in his teens, has the cognitive abilities of a 9-year-old. How should the nurse accommodate the client's cognition and comprehension during assessment?

Use the client's family as a source of information.

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 client comes to the ED complaining of chest pain. This would be considered

subjective primary data