Chapter 4: The Health History

When using the CAGE questionnaire, the nurse elicits three affirmative responses when asking the client about alcohol use. The question most appropriate to ask next would be

"Do you ever drink then drive?"

A nurse is interviewing a client complaining of abdominal pain for the last 2 weeks. Why is a history of the present illness vital to treating this client?

A complete description of the present illness is essential to an accurate diagnosis The nurse collects information about the present illness by beginning with open-ended questions and have the client explain symptoms. A complete description of the present illness is essential to an accurate diagnosis. Nurses do not diagnose the problem for which the client is seeking medical help; even if knowing where the pain is, it is necessary for a nurse to take a complete health history. It is important to know not only where the pain started but also the quality and intensity of the pain as well as what aggravates or alleviates the pain.

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 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.

A client is being admitted to a rehabilitation facility after having a stroke. Which type of assessment should the nurse complete with this client?

Comprehensive When admitting a client to facility, a comprehensive assessment is completed. This assessment includes current health problems, past history, family history, a review of body systems, and health patterns. It provides a basis for assessing client concerns, health status, risk factors, and health promotion. 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 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.

The nurse is assessing a client's sexual history. Which question should be included regardless of the presenting problem?

Concerns about HIV or AIDS It is important to ask all clients, "Do you have any concerns about HIV infection or AIDS?" even if no explicit risk factors are evident. Questions may be asked about birth control, last sexual experience, and partner preference according to the situation.

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 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 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.

A client recovering from surgery develops acute chest pain. Which type of assessment should the nurse complete with this client?

Emergent 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 focused 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 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 comprehensive assessment is completed when admitting a client to a facility.

A genogram is developed to visually show what?

Family health patterns A common tool used to understand family health patterns is the genogram. This graphic representation allows the nurse to map family structures and compile a large amount of information visually. Genograms make it easier for the nurse to identify the complexity of families and validate patterns pertinent to clients. A genogram is much more than a family tree showing family relationships or nationalities of family members.

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 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 treatment plan was successful. 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 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 nurse at the local free clinic is collecting data on a 16-year-old boy who has come to the clinic. Under what component of the health history would the nurse place data on whether the teen routinely uses seat belts when in a vehicle?

Health maintenance Health Maintenance—Safety measures: seat belts in cars, smoke/carbon monoxide detectors, sports helmets or padding, etc.

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 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.

A client is describing a very personal part of her history very quickly and in great detail. How should the nurse react to this?

Push away from the keyboard or put down the pen. This is a common event in clinical practice. It is much more important to listen actively with good eye contact at this time than to document the story verbatim. The nurse wants to minimize interruptions, such as asking the client to repeat phrases. It is usually not appropriate to ask a client to go over the written note, but it would be a good idea to repeat back to her verbally the main ideas once she has completed her story. By putting down the pen or pushing away from the keyboard, the nurse lets the client know that her story is the most important thing at this moment.

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. When recording the client's chief concern, it is preferable to quote the client's exact words whenever possible.

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

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

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 A complete description of the present illness is essential to an accurate diagnosis.

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

True

A client is being admitted to a medical unit with an acute illness. The nurse would plan to gather information using which tool?

comprehensive health history