Deck 3: The Complete Health History Including Documentation

Question 1

In a genogram,a square that is blackened represents a

A) living female.
B) living male.
C) deceased female.
D) deceased male.

Answer 1

deceased male.

Question 2

It is important to assess the educational level of patients primarily to

A) have a complete profile of the patient for your records.
B) ascertain the patient's level of understanding of science and health-related concepts.
C) determine the patient's ability to comprehend verbal or written instructions about health care.
D) decide how much information you should provide.

Answer 2

determine the patient's ability to comprehend verbal or written instructions about health care.

Question 3

After completing the examination of a newly admitted patient,the nurse would document the patient's chief complaint in terms of

A) signs and symptoms.
B) associated manifestations.
C) the health care provider's own words.
D) the nurse's own words.

Answer 3

signs and symptoms.

Question 4

The PQRSTU mnemonic is a method to remember the characteristics of the chief complaint.If a patient reported tingling in the left arm,the nurse would document this data under which of the following?

A) P, which includes associated manifestation
B) R, for region or radiation.
C) S, where all symptoms are listed
D) T, for tingling

Question 5

During the interview,your patient states that his chest pain started before lunch,when he was painting his house,and it lasted about 15 minutes.According to the patient,the pain was relieved when he rested in a chair,but it reoccurred twice today along with tingling in his left arm while he was walking.You would report the duration of the patient's chest pain as

A) acute.
B) intermittent.
C) severe.
D) sudden.

Question 6

A 14-year-old girl has received treatment for a sexually transmitted disease and has been suspended from school for drug use.You follow the suggested guidelines for addressing sensitive topics in your interview with the adolescent.The guidelines include

A) using a firm tone of voice to emphasize the importance of these issues.
B) avoiding constant direct eye contact to minimize her embarrassment.
C) approaching her with a nonjudgmental demeanor.
D) addressing these topics early in the interview to lessen her anxiety.

Question 7

In 2007,carbamazepine became the first mainstream medication to carry a recommendation by the Food and Drug Administration that patients of Asian descent be tested for the HLA-B*1502 gene before starting drug therapy.Asian patients are almost exclusively carriers of this gene,and if placed on carbamazepine,might develop Stevens-Johnson syndrome.What is the most significant outcome of this recommendation?

A) It will provide for early detection of Stevens-Johnson syndrome.
B) It will give practitioners the ability to make decisions about medications for patients based on their ethnicity and/or race.
C) It will provide a cure for Stevens-Johnson syndrome.
D) It will guide genetically based nursing care.

Question 8

A patient answers "yes" to the nurse's question,"In the past year,have you been hit,kicked,punched,or hurt in other ways by someone close to you?" What next nursing intervention is most important?

A) Conduct a physical exam to assess for signs/symptoms of suspected violence and abuse.
B) Report the suspected violence and abuse to the appropriate state agency.
C) Ask the patient if she feels safe in her current environment or situation.
D) Document physical findings concisely and accurately.

Question 9

Obtaining a complete health history typically requires approximately

A) 10-15 minutes
B) 20-30 minutes.
C) 30-60 minutes.
D) 90-120 minutes.

Question 10

The most effective way to assess the quantity of pain is to ask the patient to

A) describe the pain as minor, moderate, or severe.
B) classify the pain as small, medium, or large.
C) rate the pain on a scale from 0 to 10.
D) compare the pain with pain experienced in the past.

Question 11

Your patient has smoked 1.5 packs of cigarettes a day for the past 15 years.Prior to that he smoked 3.5 packs of cigarettes a day for 30 years.You record his pack/year history as

A) 22.5.
B) 67.5.
C) 105.
D) 127.5.

Question 12

A patient tells you that he periodically takes a prescribed medication to relieve arthritis pain.It was prescribed by his health care provider 5 years ago.What is the nurse's most appropriate response?

A) "You should discard any unused portion of a medication by the stated expiration date because some medications lose their potency and others become toxic."
B) "You need to ask your health care provider if you should continue taking this medication when you experience arthritic pain."
C) "I'll contact your health care provider about your expired medication and ask for a new prescription if she thinks it is appropriate."
D) "Have you tried any herbal products for relief of your pain?"

Question 13

Your patient complains of sneezing accompanied by clear nasal discharge and watering eyes,but he denies having a sore throat,body aches,cough,or fever.The pertinent negative finding(s)in your assessment of the patient include

A) fever.
B) sore throat and cough.
C) clear nasal discharge, sneezing, and tearing.
D) sore throat, body aches, cough, and fever.

Question 14

Which question is most appropriate to elicit the patient's history of her present illness?

A) What caused you to seek health care today?
B) When did you first start experiencing these health problems?
C) How has this condition affected your lifestyle?
D) Describe the condition you are experiencing from the earliest time that it occurred to the present.

Question 15

When interviewing a patient whose health problems are most likely related to exposure to a potentially dangerous substance,which areas should you explore?

A) military service and sexual practices
B) hobbies and economic status
C) work and home environment
D) religion and stress

Question 16

To assess the quality of pain,you would ask the patient

A) "Where are you feeling the pain?"
B) "What does this pain feel like?"
C) "What does it mean to you to have this pain?"
D) "How disabling is this pain?"

Question 17

While conducting the review of systems (ROS),the nurse asks the patient if he has experienced headaches,loss of memory,incoordination,or weakness.In which section of the ROS would this information be recorded?

A) psychological
B) endocrine
C) cardiovascular
D) neurological

Question 18

Your patient is complaining of wheezing and tightness in his chest that started 1 hour ago.Which type of health history is most appropriate in this situation?

A) complete
B) emergency
C) episodic
D) interval or follow-up

Question 19

A patient with appendicitis reports gastric or periumbilical pain that over the past 4 hours has localized to the right upper quadrant.The patient denies nausea,vomiting,anorexia,or a low-grade fever.What term characterizes lack of nausea,vomiting,anorexia,and low-grade fever?

A) chief complaint
B) associated manifestations
C) aggravating factors
D) pertinent negatives

Question 20

The patient's past health history includes which of the following?

A) childhood illnesses, allergies, alcohol use
B) religion, sexual practice, and surgeries
C) work environment, injuries and accidents, and tobacco use
D) medications, immunizations, and communicable diseases

Question 21

Mr.J is complaining of wheezing and tightness in his chest that started 1 hour ago.The type of health history most appropriate in this situation is the ____________________ health history.

Question 22

You are caring for a client with complaints of headache.Which of the following questions would you ask the patient in order to determine aggravating factors?

A) "How long do the headaches last?"
B) "Have these symptoms occurred before?"
C) "Have you done anything that makes your headache worse? What?"
D) "Have you done anything that decreases the severity of the headache? What?"

Question 23

Ms.M incorporates specific stress-management techniques into her lifestyle.This is documented in the __________________________________ section of the health history.

Question 24

Which of the following entries is documented correctly?

A) At 0900 hours, a triple lumen catheter was inserted.
B) The catheter is draining appropriately.
C) The patient is more comfortable now that the chest tube has been inserted.
D) At 0900 hours, Dr.Green inserted a chest tube in the right pleural cavity.

Question 25

The nurse makes a mistake when charting in the patient's record.To correct this mistake the nurse should

A) use correction fluid to cover the mistake and make the correct entry.
B) blot out the error with black ink and make the correct entry.
C) erase the error and write over it.
D) cross out the error with a single line, then date, time, and sign the correction.

Question 26

Which of the following is one of the prescription narcotics that is abused?

A) diazepam
B) oxycodone
C) methylphenidate
D) alprazolam

Question 27

To obtain biographical information about a patient,the nurse would ask

A) "What is the reason for your visit today?"
B) "Have you had any operations in the past?"
C) "What is your name, address, phone number, date of birth, or other identifying information?"
D) On a scale from 1 to 10 with 1 being "poor" and 10 being "ideal," how would you rate your health?"

Question 28

By asking Ms.K the question,"Have you done anything that makes you sneeze more?" you are determining if there are any ____________________ factors.

Question 29

The nurse is planning to discuss a patient's exercise habits.Which of the following questions would be appropriate to ask during the examination.Select all that apply.

A) "What type of exercise do you do?"
B) "How long do you exercise (in minutes)?"
C) "Why don't you spend more time exercising?"
D) "How long have you been involved with this exercise program?"
E) "Does your health pose any restrictions on your ability to exercise?"
F) "Do you participate in a formal or informal exercise program?"

Question 30

A patient reports that she has a gynecological examination including a Pap smear every year.You should record this information in which section of the health history?

A) past health history
B) medical history
C) social history
D) health checkups

Question 31

The term that describes negative,harmful stress is ____________________.

Question 32

The American Heart Association Guidelines (2011)suggests that an individual should do how many minutes of moderate exercise each week?

A) 30 minutes
B) 60 minutes
C) 90 minutes
D) 150 minutes

Question 33

If a service has a high certainty that the benefit is substantial,the U.S.Preventive Services Task Force will give the service which of the following grades?

A) Grade A
B) Grade B
C) Grade C
D) Grade D

Question 34

During the examination the patient tells the nurse that he is allergic to the prescribed medication.Which of the following would indicate a drug allergy? Select all that apply.

A) Nausea
B) Headache
C) Urticaria
D) Anaphylaxis
E) Vomiting
F) Breathing difficulty

Question 35

The U.S.Preventive Services Task Force has formulated preventive services guidelines related to which aspect of cancer? Select all that apply.

A) Prevention
B) Screening
C) Chemoprevention
D) Counseling
E) Treatment
F) Genetic risk assessment

Question 36

The nurse is preparing to conduct a health history of a newly admitted client.The nurse would hypothesize that which of the following topics would be the most sensitive? Select all that apply.

A) Family history
B) Nutritional practices
C) Exercise pattern
D) Alcohol use
E) Drug use
F) Sexual practices

Question 37

After interviewing your patient,you document "patient denies hoarseness,change in voice,dysphagia." In which sections of the review of systems is this information recorded?

A) nose and sinuses
B) mouth
C) throat and neck
D) gastrointestinal

Question 38

The genogram and a list of familial diseases would be documented in the ________________________ section of the health history.

Question 39

Two days ago a patient fell while jogging and hurt his left foot.Since then his left foot has remained painful.Which of the following chart entries is documented correctly?

A) Mass the size of an egg on the left ankle.
B) Pain in left foot appears to be worse today.
C) Occasionally takes ibuprofen for pain.
D) Left foot with 2+ nonpitting edema.

Question 40

Which of the following would indicate that a patient is the victim of intimate partner violence? Select all that apply.

A) Vaginal/rectal bleeding
B) Vague symptoms such as chronic pain
C) Refusal of the patient to discuss the injury
D) Multiple ecchymoses in various stages of healing
E) Previous injuries for which the individual did not seek health care
F) Injury is inconsistent with the patient's report of how it occurred

Question 41

The type of health history that documents the patient's progress or recovery from illness is ____________________ or ____________________.