Chapter 02: Obtaining a Health History Wilson: Health Assessment for Nursing Practice, 6th Edition

Chapter 02: Obtaining a Health History Wilson: Health Assessment for Nursing Practice, 6th Edition 2. 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 ANS: A, B, D, E 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. DIF: Cognitive Level: Understand REF: p. 16 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Psychosocial Integrity: Therapeutic Communications 3. 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? ANS: A, C, D, E 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 ofUOLSD CNARTTS (e.gO., 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. DIF: Cognitive Level: Apply REF: p. 17 | Box 2-3 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 4. 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? ANS: A, C, D, E, F 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. DIF: Cognitive Level: Apply REF: p. 15 | Box 2-3 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 5. 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? ANS: B, C, D, F 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 cardiovUascSularNsysTtem. DoOyou 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. DIF: Cognitive Level: Remember REF: p. 18 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments