Health Assessment PrepU 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 Explanation: Health-maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety are components of the client's 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 Explanation: A focused assessment gathers information about the current health problem. A follow-up assessment evaluates a specific problem after treatment. An emergency assessment focuses on data to quickly resolve the immediate health problem. A comprehensive assessment includes demographic data, a full description of the reason for seeking care, individual health history, family history, functional status, and a history in all physical and psychosocial areas.

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

focused assessment

A pregnant woman comes to the physician's office for her first prenatal visit. The nurse knows the importance of performing a comprehensive health history in this case and understands the following must be included (check all that apply):

information about current pregnancy previous pregnancies obstetrical and gynecological history family history Explanation: It is important on the first prenatal visit to perform a comprehensive health history, which includes information about the present pregnancy, previous pregnancies, obstetrical and gynecological history, the family, and psychosocial profile. Food preferences are part of a nutritional assessment and not necessary at this time.

The nurse is using the COLDSPA mnemonic to assess a client's history of chest pain. What interview question addresses the "A" in this assessment model?

"Do you have any other symptoms together with your chest pain, such as nausea, sweating?" Explanation: The "A" in COLDSPA addresses associated factors, such as dyspnea, diaphoresis, pale clammy skin, nausea, and vomiting.

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?" Explanation: "Have you ever felt annoyed by criticism about drinking?" is one of the four questions that make up the CAGE questionnaire.

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?" Explanation: If the client seems depressed, ask about thoughts of suicide: "Have you ever thought about hurting yourself or ending your life?" The severity of the depression needs to be assessed since it could be lethal. Asking about a job search or finances are not appropriate questions when a client is depressed.

A client who takes oral contraceptives states that she often experiences breast pain just before her menstrual cycle begins. When using the COLDSPA mnemonic to assess the client's pain, the nurse should begin by asking which of the following?

"How would you describe your pain? Is it sharp? Is it an ache?" Explanation: The "C" in COLDSPA elicits the character of the client's pain. C-character O- onset L- location D-duration S- severity P- Pattern A- Associated factors

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. Explanation: 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 preschooler 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 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 Explanation: The review of systems is a systematic method of addressing symptoms, rather than specific diseases, of the major body systems. Because it is an overview, there should not be a large number of questions about each system. Given the focus on identifying symptoms, it is simplistic to describe it as simply a series of head-to-toe questions.

The nurse recognizes that an example of subjective data would include:

A pain rating of 7 Explanation: Subjective data include signs and symptoms the client reports. Objective data are data cues the nurse can observe, while subjective data may not be observable to the nurse.

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 Explanation: Questions about alcohol and other drugs follow naturally after questions about cigarettes. Questions about alcohol intake occurs before the review of systems. Alcohol intake is a risk factor that is assessed after vaccinations. Alcohol use is assessed before completing the family history.

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 Explanation: Risk factors or other pertinent information related to the symptom is frequently relevant, such as risk factors for health problem or a current medication that may have side effects similar to the complaint. Risk factors are not used to determine health teaching, identify a genetic cause, or determine if a family history of the problem exists.

Alexandra, 28 years old, presents to the clinic. She has abdominal pain that she describes as a dull ache, located in the right upper quadrant, and that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago; it lasts for 2 to 3 hours at a time, comes and goes, and seems to be worse a few hours after eating. The client has noticed that the pain starts after eating greasy foods, so she has cut down on this as much as she can. Initially the pain occurred once a week, but now it happens every other day. Nothing makes it better. From this description, which of the attributes of a symptom has been omitted?

Associated symptoms and signs Explanation: The interviewer has not recorded whether nausea, vomiting, fever, chills, weight loss, and so on have accompanied the pain. Associated manifestations are additional symptoms that may accompany the initial chief complaint and that help the examiner to start refining his or her differential diagnosis.

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

C-character O- onset L- location D-duration S- severity P- Pattern A- Associated factors

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 Explanation: 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

Which factor influences the nurse's ability to individualize the health assessment? Select all that apply.

Cultural factors Sensory deficits Age of individual Explanation: Factors that influence the nurse's ability to individualize the health assessment include the age of the individual, sensory deficits (such as decreased vision, hearing, and cultural beliefs and practices. Family history and lifestyle behaviors do not affect the nurse's ability to individualize the health assessment.

The nurse documents that a client completed a 4-year college program and speaks English. How will this information be used?

Determine health literacy Explanation: Knowledge of the client's education level and primary language will help assess the client's health literacy level which is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Education level and primary language are not used to validate the client's age, understand the choice of occupation, or to analyze the client's lifestyle patterns.

The nurse is collecting information regarding the individual's medications. Which nursing activities does the nurse perform during this component of the health history? Select all that apply.

Differentiate among adverse versus allergic responses to medications Validate names and dosages of medications currently being taken Assess the individual's understanding of each medication's purpose Explanation: Nursing activities include validating the names and dosages of medications currently being taken, assessing the individual's understanding of each medication's purpose, and differentiating among adverse versus allergic responses to medications. The nurse does not document any adverse effect as an allergic response to protect the client and note the pharmaceutical company making the client's medications.

An adult client is brought to the ED after falling 12 feet from a ladder. The client has an obvious deformity to his left lower leg. What kind of assessment is the nurse going to perform?

Emergency Explanation: An emergency assessment occurs when the client's condition is unstable. A focused assessment covers one subject, usually the current illness. A comprehensive assessment covers every system in the body, including a past history and a family history. A head-to-toe assessment is a complete physical assessment of the body.

A client arrives at the Emergency Department reporting shortness of breath. She is cyanotic with bilateral wheezing. The client 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?

Emergency Explanation: The nurse is performing an emergency health history, the purpose of which is to collect the most important information and defer obtaining details until the client is stable. The focused health history involves questions that relate to the current situation. The comprehensive health history takes place during an annual physical examination. There is not a primary health history for clients.

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 Explanation: The client drinking alcohol in the morning would be applicable to the area on eye-openers specifically the question "Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? C=cutting down (have you felt the need to cut down?) A=Annoyed by others criticisms G=guilty feelings about drinking E=Eye openers-do you feel the need to drink in the morning?

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 Explanation: A focused or problem-oriented assessment focuses on the client's current problem. The client's symptoms, age, and this history will determine the extent of the physical examination to perform. An emergent or emergency assessment focuses on a specific problem that may be life-threatening. This type of assessment focuses on circulation, airway, and breathing (CAB) when cardiac arrest is suspected. A follow-up history is a form of a focused assessment. The client is returning to have a problem evaluated after treatment. Data is gathered to evaluate if the

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 Explanation: A follow-up history is a form of a focused assessment. The client is returning to have a problem evaluated after treatment. Data is gathered to evaluate if the treatment plan was successful. A focused or problem-oriented assessment focuses on the client's current problem. The client's symptoms, age, and this history will determine the extent of the physical examination to perform. A comprehensive assessment is completed when admitting a client to a facility.

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

General Explanation: Information to document under the general area includes usual weight, recent weight change, any clothes that fit more tightly or loosely than before, weakness, fatigue, or fever. Information about weight and fatigue is not documented under the gastrointestinal system. Appetite and rest and sleep are not areas within the review of systems.

A client comes to the Emergency Department with bruises on her upper and lower body and appears to be withdrawn. The injuries do not appear consistent with the explanations for them. The client's boyfriend refuses to leave the examination room and is overly protective of her. The nurse suspects:

Human violence Explanation: The indications should raise the nurse's suspicions of abuse of the client by the boyfriend. Commonly, abusers are overly protective in the presence of others and will not leave the examination room. Hypertension, inability to perform ADLs, and the eating disorder anorexia nervosa are not indicated in this scenario of bruising and withdrawal.

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 Explanation: The nurse prioritizes, collects, and analyzes subjective and objective data and summarizes and states the two to three most important patterns or problems might be. The nurse's priority is not use the data gathered in the client interview as a baseline for interviewing the family or for communicating to the physician or other staff members.

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

Neurologic Explanation: Dizziness, tingling, and mood changes would be documented under neurologic. Nervousness, tension, depression, memory change, and suicide attempts should be documented under psychiatric. This information is not appropriate to document under cardiovascular or fluid and electrolytes.

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

Primary Explanation: 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.

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 Explanation: Subjective data given by the client are considered primary data. Charts and family are sources of secondary data, while objective data are based upon tests, vital signs, and examinations. At present, no data are called tertiary.

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

Proficiency Explanation: Mastery of all the components of the comprehensive history provides proficiency and the ability to select the elements most pertinent to the client encounter.

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

Reason for seeking care History of present illness Past health history Explanation: Usually the nurse collects demographical data first and then elicits from clients a complete description of their reason for seeking care, because that information usually is most important. The nurse collects information about the present illness by beginning with open-ended questions and having clients explain symptoms. A complete description of the present illness is essential to an accurate diagnosis.

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. Explanation: When abuse is suspected, nurses are obligated to report their concerns to a supervisor and obtain assistance from social services for further assessment. It is not in the nurse's scope of practice to call social services directly, and the nurse should never call the police independently. Also confronting the client will only isolate her and make her more uncomfortable.

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 Explanation: Charts and family members are considered secondary data sources. The client is the source of primary data. Subjective data are data provided to the nurse by the client; objective data are data that the nurse observes.

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 Explanation: Charts and family members are considered secondary data sources. Primary data would be directly from the client. Subjective data are based on the signs and symptoms that the client reports; they may not be perceived by observers.

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 Explanation: The interviewer did not record the severity of the symptom, so we have no understanding as to how bad the symptom is for this client. The client could have been asked to rate his pain on a 0 to 10 scale or according to one of the other standardized pain scales available. This allows the comparison of pain intensity before and after an intervention.

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 Explanation: If the chief complaint involves genitourinary symptoms, include questions about sexual health as part of "expanding and clarifying" the client's story. Lifestyle, medication, and substance use can be contributing factors but gathering a sexual history is the priority action at this time.

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

Source of information Explanation: Designating the source helps the nurse and reader assess the type of information provided and possible biases.

The nurse prepares to complete the review of systems with a client. On which area should the nurse focus when completing this part of the assessment?

Symptoms Explanation: Most review of systems questions pertain to symptoms. This section of the assessment does not focus on risk factors, health maintenance, or past medical history.

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?

The seven attributes of a symptom should be assessed. The mnemonic OLD CART is used to ensure are all areas are included. Pain is documented under characteristic of the symptom. Onset identifies when the symptom began. Location is the body area including any radiation. Duration is the length of time the symptom lasts.

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 Explanation: A complete description of the present illness is essential to 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 Explanation: The nurse asks the client about the health of close family members (i.e., 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.

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 the elements that are important to assess with a symptom Explanation: OLDCARTS is one example and stands for onset, location, duration, character, associated/aggravating factors, relieving factors, timing, and severity. OLDCARTS does not help a nurse remember the parts of a focused assessment, order of assessment, or how to document findings.

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

True

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. Explanation: Limitations on intelligence often require the clinician to use the client's family as a source of assessment data, though it is still appropriate to direct questions to the client himself. It would be simplistic to downplay the interview and rely solely on the written history or to categorically reject subjective assessment.

Student nurses are practicing taking comprehensive health histories from one another. What components should be included in a comprehensive health history? (Select all that apply.)

When coughing began Pain location Pain duration Pain intensity Explanation: Location, duration, intensity, description, aggravating factors, alleviating factors, and functional impairment are components of a comprehensive health history. Asking the client what was eaten for the last three meals does not fall into the definition of a comprehensive health history

A past history is being taken by the nurse for a client with COPD. The nurse includes which elements in this part of the health history? Select all that apply.

allergies childhood illnesses health maintenance

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 client says that food is not important and meals are not enjoyable. Where should the nurse document this information?

nutrition health pattern Explanation: Information about diet and intake should be documented within the nutrition health pattern. There is no evidence to support that this is the a past or present health problem for the client. It would not be appropriate to document this information within the gastrointestinal review of systems.

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 Explanation: The past health history includes asking about previous medical and surgical problems along with their dates. Aggravating factors, duration, and intensity of the pain are all part of the history of present illness.

When doing a complete health history, the nurse usually collects demographical data first and a reason for seeking care. What additional data the nurse collects depends upon (check all that apply):

reason for the visit pertinence of the data time restrictions within the setting Explanation: The nurse determines what data to collect beyond the minimum required and bases this decision on the reason for the visit, pertinence of the data, and time restrictions within the setting. The time of day and the client's diet have nothing to do with the information collected in the health history.

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 Explanation: There are many opportunities for the nurse to promote healthy behaviors. When assessing high-risk clients with multiple partners, the nurse can seize this opportunity to provide information that can prevent disease and illness. Gender, culture, and spirituality are not generally factors in teaching about health promotion.

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

subjective primary data Explanation: The individual client is considered the primary data source. When possible, clients provide subjective information regarding their health behaviors and situations. Subjective information is from the perspective of the client.

The nurse understands that when performing a health history it is important to include subjective data, which includes:

symptoms that the client reports Explanation: Subjective data are based on the signs and symptoms that the client reports. They may not be perceived by the observer and are not taken from values of lab reports or vital signs.