NUR 3065 - PrepU Chapter 4
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? "What changes do you have to make in order to accommodate your chest pain?" "Would you describe your chest pain as being acute, or is it chronic?" "Do you have any other symptoms together with your chest pain, such as nausea, sweating?" "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?" 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? "How often do you have a hangover?" "Have you ever felt annoyed by criticism about drinking?" "How many days per week do you drink?" "Describe the types of alcohol that you prefer."
"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.
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 the client feel at ease and not worry about being sick - To identify genetic family trends for which the client is at risk - To help identify those diseases for which the client may be at risk - To elicit negative family history - To provide counseling and health teaching in high-risk areas
- 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 nurse recognizes that an example of subjective data would include: Scratching 2-inch scar right lower abdomen A pain rating of 7 100 cc of emesis
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. A pain rating of 7 is an example of subjective data. The client must report the number that represents the intensity of his or her pain. A scar, scratching, and emesis are all data cues the nurse can observe.
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?
Characteristic Explanation: 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.
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.
While gathering data for the family history portion of the health history, what would you ask about?
Coronary artery disease Explanation: Review each of the following conditions and record whether they are present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, as well as symptoms reported by the client
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? This information is not applicable to the other areas of the CAGE questionnaire, specifically, annoyance, cutting down, or guilty feelings.
A genogram is developed to visually show what?
Family health patterns Explanation: 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 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 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.
During the review of systems, a client reports dizziness, tingling, and mood changes. In which area should the nurse document this information? Psychiatric Cardiovascular Neurologic Fluid and electrolytes
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.
The nurse knows that the reason for a complete health assessment in regard to any client is to? Select all that apply. (Select all that apply.) - Obtain accurate and complete data - Plan interventions - Help the nurse diagnose the client's illness - Validate laboratory results - Complete a family history
Plan interventions Explanation: The reason for completing the assessment is to have data that are accurate and complete so that a plan can be developed with interventions that promote health. A nurse does not complete the assessment to help the nurse diagnose the illness, validate laboratory results, or complete a family history.
When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following? - Summarize the client's words. - Quote the client's words. - Describe the client's concerns and health goals. - Paraphrase the client's words.
Quote the client's words. Explanation: When recording the client's chief concern, it is preferable to quote the client's exact words whenever possible.
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.
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 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.
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.
