Question 1

A patient tells the nurse at the clinic, "I can never seem to get warm lately and feel tired all the time." The nurse records these data under which section of the health history?
A) Past health history
B) Present health status
C) Reason for seeking care (chief complaint)
D) Subjective assessment data

Accepted Answer

The reason for seeking care (chief complaint) is the patient's reason for seeking care (also called the presenting problem). The patient's reason for seeking care is often recorded as a direct quote. The past health history includes data about immunizations, surgeries, accidents, and childhood illnesses. The present health status includes data the nurse obtains from the patient, often using a symptom analysis in which more data are collected about the patient's reason for seeking care. Subjective assessment data include information from the patient. In this example, the patient expresses the reason for seeking care, which is directly quoted and placed in quotation marks in the chief complaint section of the data sheet so that the patient's reason for seeking care can be easily identified.

Question 2

A nurse is interviewing a male patient who reports he has not had a tetanus immunization in about 15 years because he had a "bad reaction" to the last tetanus immunization. What is the most appropriate response by the nurse in this case?
A) Notify the health care provider that this immunization cannot be given.
B) Document that the patient is allergic to the tetanus vaccine.
C) Give the vaccine after explaining that adverse reactions are rare.
D) Ask the patient to describe the "bad reaction" to the vaccine in more detail.

Accepted Answer

The nurse needs to collect more data about the reaction from the patient to determine the type of reaction experienced. The nurse is trying to assess the relationship between the "reaction" reported by the patient and an allergic reaction. The immunization should not be eliminated at this time. Additional facts are needed to determine the type of reaction the patient experienced. Documenting an allergy to the tetanus vaccine may be an error because there are insufficient data to make that determination at this time. Giving the vaccine may be an error if the patient is allergic to the vaccine and additional data indicates that may be the case.

Question 3

An example of a health promotion question included in the health history is:
A) "Do you have any allergies?"
B) "How often are you exercising?"
C) "What are you doing to relieve your leg pain?"
D) "What kind of herbs are you using?"

Accepted Answer

"How often are you exercising?" is a question about activities patients regularly perform to maintain health. "Do you have any allergies?" is a question for the present health status rather than health promotion. "What are you doing to relieve your leg pain?" is a question that is part of the symptom analysis. "What kind of herbs are you using?" is a question for the present health status rather than health promotion.

Question 4

A nurse is getting a history from a patient who is disabled from rheumatoid arthritis. Which question will provide data about this patient's functional ability?
A) "When did your arthritis symptoms begin?"
B) "How has your arthritis affected your daily life?"
C) "Why did you come to the clinic today?"
D) "How do you feel about your diagnosis of rheumatoid arthritis?"

Accepted Answer

"How has your arthritis affected your daily life?" is a question that leads to data about the patient's ability to perform self-care activities or functional abilities. "When did your arthritis symptoms begin?" is a question asked as part of the history, but does not collect data about functional ability. "Why did you come to the clinic today?" is a question asked to obtain the chief complaint about a current problem, but does not focus directly on the functional assessment. "How do you feel about your diagnosis of rheumatoid arthritis?" is a question to ask in the psychosocial history, but does not focus directly on the functional assessment.

Question 5

Which data do nurses document under the heading of Personal and Psychosocial History? (Select all that apply.)
A) Walks for 45 minutes each day
B) Eats meats, vegetables, and fruit at two meals daily
C) Is allergic to milk and milk products
D) Is married and has two daughters whom he is close to
E) Smokes marijuana once a week
F) Grandfather died from prostate cancer

Accepted Answer

Walks for 45 minutes each day is documented under health promotion activity in Personal and Psychosocial History; eats meats, vegetables, and fruit at two meals daily is documented about diet activity in Personal and Psychosocial History; is married and has two daughters whom he is close to is documented under family and social relationship activity in Personal and Psychosocial History; smokes marijuana once a week is documented under personal habits activity in Personal and Psychosocial History. Allergic to milk and milk products is an allergy, which is documented under the heading Present Health Status; Grandfather died from prostate cancer is documented under the heading Family History.

Question 6

Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports breathing problems? (Select all that apply.)
A) How long have you had this problem with your breathing?
B) Do you have a family history of breathing problems?
C) Does this breathing problem come and go or is it constant?
D) What do you do to make your breathing better?
E) How does this breathing problem affect your work or daily activities?
F) How many packs of cigarettes do you smoke a day?

Accepted Answer

How long have you had this problem with your breathing?, Does this breathing problem come and go or is it constant?, What do you do to make your breathing better?, and How does this breathing problem affect your work or daily activities? are questions asked in a symptom analysis. Use the mnemonic of OLD CARTS (e.g., onset of symptoms, location and duration of symptoms, characteristics, aggravating factors, related symptoms, treatment used, and severity of symptoms). Do you have a family history of breathing problems? This question relates to the patient's history; How many packs of cigarettes do you smoke a day? This question relates to the patient's history.

Question 7

Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports a headache? (Select all that apply.)
A) Describe what the headache feels like.
B) When was your last eye examination?
C) What makes the headaches worse?
D) How do you rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain ever)?
E) Do you have any symptoms with the headaches, such as nausea?
F) When did you first notice the headaches?

Accepted Answer

Describe what the headache feels like?, What makes the headaches worse?, How do you rate the headaches on a scale of 0 (meaning no pain) to 10 (meaning the worse pain ever)?, Do you have any symptoms with the headaches, such as nausea?, and When did you first notice the headaches? are questions asked in a symptom analysis. Use the mnemonic of OLD CARTS (e.g., onset of symptoms, location and duration of symptoms, characteristics, aggravating factors, related symptoms, treatment used, and severity of symptoms). When was your last eye examination? assumes that the headaches are related to a vision problem. Last eye examination is documented in the history under the heading of Past Health History.

Question 8

A patient comes to the ambulatory surgery center for an elective procedure this morning. While giving the admission history, the patient states she is allergic to latex. What is the most appropriate response by the nurse at this time?
A) Removing all latex products from the patient's room
B) Using powdered gloves when providing care to this patient
C) Informing the surgeon that the patient has type I hypersensitivity to latex
D) Questioning the patient about symptoms experienced in the past with latex

Accepted Answer

Questioning the patient about symptoms experienced in the past with latex is the appropriate response. When patients indicate an allergy to a medication or substance, ask them to describe what happens with exposure to determine whether the reaction is a side effect or an allergic reaction. Removing all latex products from the patient's room is unnecessary at this time because the latex allergy has not been confirmed. Using powdered gloves when providing care to this patient is unnecessary at this time because the latex allergy has not been confirmed. Informing the surgeon that the patient has type I hypersensitivity to latex is unnecessary at this time because the latex allergy has not been confirmed.

Question 9

Which questions are pertinent for a nurse to ask a patient while performing a review of the cardiovascular system? (Select all that apply.)
A) Do you remember what your last cholesterol value was?
B) Have you had chest pain or shortness of breath?
C) Do you have trouble breathing when you lie down?
D) Are your feet cold, numb, or do they change color?
E) How much do you weigh?
F) Have you noticed edema in your ankles at the end of the day?

Accepted Answer

Have you had chest pain or shortness of breath?, Do you have trouble breathing when you lie down?, Are your feet cold, numb, or do they change color?, and Have you noticed edema in your ankles at the end of the day? are questions asked to give the patient an opportunity to report symptoms of the cardiovascular system. Do you remember what your last cholesterol value was? relates to a lab value, which is objective data not documented in the history; How much do you weigh? is objective data not documented in the history.

Question 10

Which data do nurses document under the heading of Past Health History? (Select all that apply.)
A) Father has Alzheimer disease.
B) Last tetanus in 2009
C) Had chicken pox as a child
D) Drinks three to four beers each day
E) Had a dental examination 6 months ago

Accepted Answer

Last tetanus is an immunization, chicken pox as a child is a childhood illness, and last examinations, including dental, are documented under the heading of Past Health History. Family History documents father's Alzheimer disease; patient drinking three to four beers each day refers to alcohol use, which is documented under the heading Personal and Psychosocial History.

Question 11

The patient reports having a persistent cough for the past 2 weeks and that the cough disrupts sleep and has not been helped by over-the-counter cough medicines. Which question is most appropriate for the nurse to ask next?
A) "So what do you think is causing this persistent cough?"
B) "Have you tried taking sleeping pills to help you sleep?"
C) "Did you think this will just go away on its own?"
D) "What other symptoms have you noticed related to this cough?"

Accepted Answer

"What other symptoms have you noticed related to this cough?" is part of a symptom analysis to provide more data. The answer to the question "So what do you think is causing this persistent cough?" is a guess by the patient and does not provide useful data. "Have you tried taking sleeping pills to help you sleep?" does not focus on the cough, which is what is disturbing the patient's sleep. "Did you think this will just go away on its own?" does not provide useful data and criticizes the patient's lack of action.

Question 12

A patient admitted with pneumonia reports that she takes insulin for diabetes mellitus. In which section of the history does the nurse document the insulin and diabetes?
A) Past health history
B) Present health status
C) Reason for seeking care (chief complaint)
D) History of present illness

Accepted Answer

The present health status documents the current health conditions, which include chronic diseases and medications taken. In this case, diabetes and taking insulin are not the reason for seeking care, but need to be managed while the patient's pneumonia is being treated because they may affect the patient's recovery from pneumonia. The past health history includes categories of childhood illness, surgeries, hospitalizations, accidents or injuries, immunizations, and obstetric history. The reason for seeking care (chief complaint) is a brief statement of the patient's purpose for requesting the services of a health care provider. History of present illness further investigates the history of the present problem; best accomplished by conducting a symptom analysis.

Quiz 2: Obtaining a Health History

A patient tells the nurse at the clinic, "I can never seem to get warm lately and feel tired all the time." The nurse records these data under which section of the health history?

A nurse is interviewing a male patient who reports he has not had a tetanus immunization in about 15 years because he had a "bad reaction" to the last tetanus immunization. What is the most appropriate response by the nurse in this case?

An example of a health promotion question included in the health history is:

A nurse is getting a history from a patient who is disabled from rheumatoid arthritis. Which question will provide data about this patient's functional ability?

Which data do nurses document under the heading of Personal and Psychosocial History? (Select all that apply.)

Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports breathing problems? (Select all that apply.)

Which questions are pertinent to ask when obtaining a symptom analysis from a patient who reports a headache? (Select all that apply.)

A patient comes to the ambulatory surgery center for an elective procedure this morning. While giving the admission history, the patient states she is allergic to latex. What is the most appropriate response by the nurse at this time?

Which questions are pertinent for a nurse to ask a patient while performing a review of the cardiovascular system? (Select all that apply.)

Which data do nurses document under the heading of Past Health History? (Select all that apply.)

The patient reports having a persistent cough for the past 2 weeks and that the cough disrupts sleep and has not been helped by over-the-counter cough medicines. Which question is most appropriate for the nurse to ask next?

A patient admitted with pneumonia reports that she takes insulin for diabetes mellitus. In which section of the history does the nurse document the insulin and diabetes?