OpenStax Clinical Nursing Skills Nursing Test Bank
Chapter 4: Obtaining a Complete Health History
OpenStax Clinical Nursing Skills
Nursing Test Bank
Chapter 4: Obtaining a Complete Health History
Review Questions
Multiple Choice
1. What phase of the nursing process focuses on collecting patient data and documenting it in
the health record?
A. assessment*
B. diagnosis
C. outcome identification
D. evaluation
LO: 04.1.1
Difficulty: Easy
Blooms: Remember
AACN: 1.1a
2. In health care, what process focuses on delivering quality care by a coordinated provider-
led medical team with the common goal of positive patient outcomes?
A. outcome identification
B. health history documentation
C. continuity of care*
D. planning and implementation
LO: Easy
Difficulty: 04.1.1
Blooms: Remember
AACN: 1.1a
3. Andrew developed hives and visited multiple doctors in different healthcare systems to
determine the cause of his condition and resolve the problem. What feature of EHRs
enabled Andrew’s doctors to share his medical information even though they work in
different healthcare systems?
A. health information exchange
B. healthcare portability
C. continuity of care
D. interoperability*
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, OpenStax Clinical Nursing Skills Nursing Test Bank
Chapter 4: Obtaining a Complete Health History
LO: 04.1.2
Difficulty: Difficult
Blooms: Remember, Understand, Apply
AACN: 1.1b
4. When nurses see a patient for the first time, they collect and analyze patient information in
a systematic and purposeful manner. What is this process called?
A. initial health assessment*
B. health history evaluation
C. health information exchange
D. patient data assessment
LO: 04.1.2
Difficulty: Moderate
Blooms: Remember, Understand
AACN: 1.1a
5. What document informs patients about their rights and what they can expect when they
receive medical care?
A. Medical Power of Attorney
B. Advance Directive
C. Patient Care Partnership*
D. Electronic Health Record
LO: 04.1.3
Difficulty: Easy
Blooms: Remember
AACN: 1.1a
6. In U.S. states that fall under federal guidelines, who owns medical records and the
information contained in them?
A. Both the medical records and the information contained in them belong to the patient.
B. The medical records belong to the patient, while the information in the medical records
belongs to the healthcare entity that created the record.
C. The medical records belong to the healthcare entity that created the record, while the
information in the medical records belongs to the patient.*
D. Both the medical records and the information contained in them belong to the healthcare
entity that created the record.
LO: 04.1.3
Difficulty: Moderate
Blooms: Remember, Understand
AACN: 1.1a
For more free, peer-reviewed, openly licensed resources visit OpenStax.org.
2 1/29/2026
Chapter 4: Obtaining a Complete Health History
OpenStax Clinical Nursing Skills
Nursing Test Bank
Chapter 4: Obtaining a Complete Health History
Review Questions
Multiple Choice
1. What phase of the nursing process focuses on collecting patient data and documenting it in
the health record?
A. assessment*
B. diagnosis
C. outcome identification
D. evaluation
LO: 04.1.1
Difficulty: Easy
Blooms: Remember
AACN: 1.1a
2. In health care, what process focuses on delivering quality care by a coordinated provider-
led medical team with the common goal of positive patient outcomes?
A. outcome identification
B. health history documentation
C. continuity of care*
D. planning and implementation
LO: Easy
Difficulty: 04.1.1
Blooms: Remember
AACN: 1.1a
3. Andrew developed hives and visited multiple doctors in different healthcare systems to
determine the cause of his condition and resolve the problem. What feature of EHRs
enabled Andrew’s doctors to share his medical information even though they work in
different healthcare systems?
A. health information exchange
B. healthcare portability
C. continuity of care
D. interoperability*
For more free, peer-reviewed, openly licensed resources visit OpenStax.org.
1 1/29/2026
, OpenStax Clinical Nursing Skills Nursing Test Bank
Chapter 4: Obtaining a Complete Health History
LO: 04.1.2
Difficulty: Difficult
Blooms: Remember, Understand, Apply
AACN: 1.1b
4. When nurses see a patient for the first time, they collect and analyze patient information in
a systematic and purposeful manner. What is this process called?
A. initial health assessment*
B. health history evaluation
C. health information exchange
D. patient data assessment
LO: 04.1.2
Difficulty: Moderate
Blooms: Remember, Understand
AACN: 1.1a
5. What document informs patients about their rights and what they can expect when they
receive medical care?
A. Medical Power of Attorney
B. Advance Directive
C. Patient Care Partnership*
D. Electronic Health Record
LO: 04.1.3
Difficulty: Easy
Blooms: Remember
AACN: 1.1a
6. In U.S. states that fall under federal guidelines, who owns medical records and the
information contained in them?
A. Both the medical records and the information contained in them belong to the patient.
B. The medical records belong to the patient, while the information in the medical records
belongs to the healthcare entity that created the record.
C. The medical records belong to the healthcare entity that created the record, while the
information in the medical records belongs to the patient.*
D. Both the medical records and the information contained in them belong to the healthcare
entity that created the record.
LO: 04.1.3
Difficulty: Moderate
Blooms: Remember, Understand
AACN: 1.1a
For more free, peer-reviewed, openly licensed resources visit OpenStax.org.
2 1/29/2026
