chapter 4

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): obstetrical and gynecological history family history food preferences information about current pregnancy previous pregnancies

information about current pregnancy previous pregnancies obstetrical and gynecological history family history

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? "Would you describe your chest pain as being acute, or is it chronic?" "What changes do you have to make in order to accommodate your chest pain?" "In your experience, what kinds of activities tend to cause your chest pain?" "Do you have any other symptoms together with your chest pain, such as nausea, sweating?"

"Do you have any other symptoms together with your chest pain, such as nausea, sweating?

The review of systems component of the health history is best described as which of the following? A focus on diseases of the major body systems A large number of questions about major body systems A series of questions that start at the head and finish at the feet A focus on symptoms related to each of the different body systems

A focus on symptoms related to each of the different body systems

While completing a history of present illness the nurse asks the client about risk factors. In which way should the nurse use this information? Determine if a family history of the problem exists Speculate a genetic reason for the health problem Analyze as a contributing factor to the current problem Use to determine health teaching to prepare

Analyze as a contributing factor to the current problem

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? Emergent Focused Comprehensive Follow-up

Focused

The nurse is assessing a female client's reproductive area during the review of systems. Which information should the nurse document within this section? (Select all answer choices that apply) Age at menarche Polyuria Hematuria Dysmenorrhea Age at menopause

Dysmenorrhea Age at menarche Age at menopause

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? Initial information Risk factors Health maintenance General information

Health maintenance

The nurse is taking a health history on a new client. The nurse first collects demographic data. What data would the nurse collect next? Family history History of present illness Past medical history Medication history

History of present illness

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

Numbness Loss of coordination Memory loss

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.) Pain intensity Pain duration When coughing began Pain location what was eaten for the last three meals

Pain intensity Pain duration When coughing began Pain location

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. Perform objective assessments rather than eliciting subjective information. Rely on the client's documented history rather than the client interview. Address interview questions to the client's mother rather than the client.

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

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 Quality Setting in which the symptom occurs Timing

associated symptoms and signs

A client is being admitted to a medical unit with an acute illness. The nurse would plan to gather information using which tool? problem-oriented assessment follow-up history comprehensive health history emergency history

comprehensive health history

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? Head-to-toe Emergency Focused Comprehensive

emergency

The nurse asks the client about whether other family members have been diagnosed with diabetes. Which component of the comprehensive health history is the nurse addressing? Family history Genogram Past health history Demographic data

family history

A nurse is performing a client assessment in an urgent care clinic. The most likely tool being used is the focused assessment comprehensive health history emergency history follow-up history

foccussed

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? intensity of the pain previous medical and surgical problems aggravating factors of the pain duration of the pain

previous medical and surgical problems

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? Objective Tertiary Primary Secondary

primary

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: gender sexual history and pattern culture spirituality

sexual history and pattern

When teaching students how to perform an assessment, the nurse informs the students that the reason this information needs to be accurate and complete is: to develop a plan with interventions that promote health to allow for the client to spend more time with the nurse to allow for the client to focus on the illness to allow the nurse more time to know the client

to develop a plan with interventions that promote health

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 To obtain primary data To obtain demographic data To assess if the client is a reliable historian

to establish an accurate diagnosis