Assessment
Assessment
is the collection of subjective and objective data about a patient's health.
Subjective data
Subjective data
consist of information provided by the affected individual.
Objective data
Objective data
include information obtained by the health care provider through physical assessment, the patient's record, and laboratory studies.
The database
The
database
is the totality of information available about the patient. The purpose of assessment is to make a judgment or diagnosis.
Diagnostic reasoning
Diagnostic reasoning
is the process of analyzing health data and drawing conclusions to identify diagnoses.
Diagnostic reasoning has which four major components?
Diagnostic reasoning
has which four major components?
(1)
Attending to
initially available
cues
, which are pieces of information, signs, symptoms, or laboratory data;
(2)
Formulating diagnostic hypotheses
, which are tentative explanations for a cue or a
The
nursing process
includes which six phases?
The
nursing process
includes which six phases?
(1)
assessment
,
(2)
diagnosis
,
(3)
outcome identification
,
(4)
planning
,
(5)
implementation
, and
(6)
evaluation
.
It is a dynamic, interactive process in which practitioners move back and forth within th
The
novice nurse
The
novice nurse
has no experience with specific patient populations and uses rules to guide performance.
The
experienced nurse
The
experienced nurse
understands a patient situation as a whole rather than as a list of tasks, attends to an assessment data pattern, and acts without consciously labeling it.
Critical thinking
Critical thinking
is the multidimensional thinking process needed for sound diagnostic reasoning and clinical judgment. Seventeen critical thinking skills have been identified, including
setting priorities.
First-level priority problems
First-level priority problems
are emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing.
Second-level priority problems
Second-level priority problems
are next in urgency. They require prompt intervention to prevent deterioration, and may include a mental status change or acute pain.
Third-level priority problems
Third-level priority problems
are important to the patient's health, but can be addressed after more urgent problems. Examples include lack of knowledge or family coping.
Evidence-based practice
Evidence-based practice is a systematic approach to practice that uses the
best evidence,
the
clinician's experience,
and the
patient's preferences and values
to make decisions about care and treatment.
Every examiner needs to collect
four kinds of databases
based on the situation. What are the four kinds of databases?
Every examiner needs to collect
four kinds of databases
based on the situation. What are the four kinds of databases?
(1) A
complete (or total health) database
includes a complete health history and a full physical examination.
(2) A
focused (or problem-c
The
biomedical model
The
biomedical model
of Western medicine views health as the absence of disease. It focuses on collecting data on biophysical signs and symptoms and on curing disease.
The
holistic health model
The
holistic health model
assesses the whole person because it views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Health depends on all these factors working together.
The concept of health also includes health promotion and disease prevention.
...
Health assessment also should consider what two other factors?
Health assessment also should consider what two other factors?
(1) The usual and expected
developmental tasks
for each age group
(2) the
cultural beliefs and practices
of different people. Obtaining a heritage assessment helps gather data that are accurat
According to the biomedical model, a narrow definition of health is:
A) an optimal functioning of mind, body, and spirit within the environment.
B) the absence of disease.
C) the response of the whole person to actual or potential problems.
D) prevention
According to the biomedical model, a narrow definition of health is:
A) an optimal functioning of mind, body, and spirit within the environment.
Feedback: INCORRECT
Nursing has an expanded concept of health; holistic health includes the mind, body, and sp
What type of data base is most appropriate when a rapid collection of data is required and often compiled concurrently with life-saving measures?
A) Episodic
B) Follow-up
C) Emergency
D) Complete
What type of data base is most appropriate when a rapid collection of data is required and often compiled concurrently with life-saving measures?
A) Episodic
Feedback: INCORRECT
An episodic database is for a limited or short-term problem; this database co
A medical diagnosis is used to evaluate:
A) a person's state of health.
B) the response of the whole person to actual or potential health problems.
C) a person's culture.
D) the cause of disease.
A medical diagnosis is used to evaluate:
A) a person's state of health.
Feedback: INCORRECT
Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state.
B) the response of the whole person to actual or potenti
An example of subjective data is:
A) decreased range of motion.
B) crepitation in the left knee joint.
C) left knee has been swollen and hot for the past 3 days.
D) arthritis.
An example of subjective data is:
A) decreased range of motion.
Feedback: INCORRECT
Objective data is gathered by what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Range of motion
What type of database is most appropriate for an individual who is admitted to a long-term care facility?
A) Episodic
B) Follow-up
C) Emergency
D) Complete
What type of database is most appropriate for an individual who is admitted to a long-term care facility?
A) Episodic
Feedback: INCORRECT
An episodic database is for a limited or short-term problem; this database concerns mainly one problem, one cue compl
Which of the following is considered an example of objective data?
A) Alert and oriented
B) Dizziness
C) An earache
D) A sore throat
Which of the following is considered an example of objective data?
A) Alert and oriented
Feedback: CORRECT
Objective data is what the health professional observes; level of consciousness and orientation are observations.
B) Dizziness
Feedback: INCORRECT
S
An example of objective data is:
A) complaints of left knee pain.
B) crepitation in the left knee joint.
C) left knee has been swollen and hot for the past 3 days.
D) report of impaired mobility from left knee pain as evidenced by an inability to walk, sw
An example of objective data is:
A) complaints of left knee pain.
Feedback: INCORRECT
Subjective data is what the person says about himself or herself during history taking.
B) crepitation in the left knee joint.
Feedback: CORRECT
Objective data is what t
A nursing diagnosis is best described as:
A) a determination of the etiology of disease.
B) a pattern of coping.
C) an individual's perception of health.
D) a concise statement of actual or potential health concerns or level of wellness.
A nursing diagnosis is best described as:
A) a determination of the etiology of disease.
Feedback: INCORRECT
Medical diagnoses determine the etiology (or cause) of disease.
B) a pattern of coping.
Feedback: INCORRECT
Coping patterns would include methods
A complete data base is:
A) used to rapidly collect data and is often compiled concurrently with life-saving measures.
B) used for a limited or short-term problem usually consisting of one problem, one cue complex, or one body system.
C) used to evaluate
A complete data base is:
A) used to rapidly collect data and is often compiled concurrently with life-saving measures.
Feedback: INCORRECT
An emergency database is rapid collection of the data often obtained concurrently with lifesaving measures.
B) used
A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority?
A) Ineffective self-health management
B) Risk for infection
C) Impa
A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority?
A) Ineffective self-health management
Feedback: INCORRECT
Third-lev
In the United States, about __ in __ people are
immigrants
.
In the United States, about
one
in
eight
people are
immigrants.
___ in every ___ residents belongs to a
group other than single-race, non-Hispanic White.
One
in every
three
residents belongs to a
group other than single-race, non-Hispanic White.
Of the emerging majority in the US, _____ are the largest population.
Of the emerging majority in the US,
Hispanics
are the largest population.
The second largest population is _____ followed by ____, _____, _____, _____, and _____.
The second largest population is
Asians
followed by
Blacks
, American Indians, Alaska natives, Native Hawaiians, and other Pacific islanders.
Many new immigrants have
little understanding of
the modern
health care
system and medical and nursing practices and interventions. Many also speak and
understand little or no English.
...
The
National Standards for Culturally and Linguistically Appropriate Services in Health Care
state that health care organizations should ensure that patients receive
effective, understandable, and respectful care
in a manner compatible with their
cultural
...
When people with limited English proficiency seek health care, services cannot be denied to them.
...
The most
common non-English languages
spoken at home are Spanish, Chinese, French, German, and Tagalog.
...
Cultural care
Cultural care
is professional health care that is culturally sensitive, appropriate, and competent. To develop cultural care, you must have knowledge of
your personal heritage
and the
heritage of the nursing profession, the health care system, and the pat
Heritage consistency
Heritage consistency
is the degree to which
a person's lifestyle reflects his or her traditional heritage.
A person can possess values that are consistent with the norms of the traditional culture or that are modern (or acculturated to the norms of the do
Culture
has which four characteristics?
Culture
has the following four characteristics:
(1) it is
learned
from birth through language acquisition and socialization.
(2) it is
shared
by all members of the same cultural group.
(3) it is
adapted
to specific conditions related to environmental and
Ethnicity
Ethnicity
pertains to membership in a social
group that claims to possess a common
geographic origin, migratory status, religion, race, language, shared values, traditions or symbols, and food preferences. One's cultural background is a fundamental compon
Religion
Religion
is the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator or ruler of the universe.
Spirituality
Spirituality
is borne out of each person's unique life experience and his or her personal effort to find purpose and meaning in life. Spirituality may be used to
find meaning and purpose for illnesses.
Socialization
Socialization
is the process of being raised within a culture and acquiring the characteristics of the group. Education is a form of socialization.
You
assess factors related to heritage
to determine the depth to which you and the patient identify with a traditional heritage, that is, the cultural beliefs and practices of the family, extended family, and an ethnoreligious community.
...
Before you can understand the role that beliefs and values play in a person's life, you must understand culturally dominant values and personal values.
...
Cultural conflicts
Cultural conflicts
between nurses and patients from diverse backgrounds are related to
different time and relationship perceptions
. For example, in some cultures, the past may influence health practices. When making decisions about health, patients may r
In a multicultural country, you must accept that
differences exist
and be open to the
importance of these practices
to the patient.
...
The
meaning of health and illness is determined
, in part,
by the way members of a person's culture define them.
The perceived causes of illness and symptoms can be culturally based and may be viewed as
biomedical
(or scientific),
naturalistic
(or holisti
...
In times of illness,
religion and spirituality may be a source of comfort
for patients and their significant others. Religion and spiritual leaders may strongly influence the perception of health, illness, and practices.
...
Religious beliefs may influence the person's:
Religious beliefs may influence the person's:
(1) Explanation of the
cause of illness
(2) Perception of its
severity
(3) And choice of
healers.
Each person responds differently
to the same stimuli, regardless of the primary culture and value system. You should
guard against stereotyping
individuals. You should also understand
culture-bound syndromes,
which may have no equivalent from a biomedical
...
Each culture has its own healers who usually:
A) speak at least two languages.
B) own and operate specialty community clinics.
C) cost less than traditional or biomedical providers.
D) recommend folk practices that are dangerous.
ach culture has its own healers who usually:
A) speak at least two languages.
Feedback: INCORRECT
Most healers speak the person's native tongue.
B) own and operate specialty community clinics.
Feedback: INCORRECT
Most healers make house calls.
C) cost les
While evaluating the health history, the nurse determines that the patient subscribes to the hot/cold theory of health. Which of the following will most likely describe this patient's view of wellness?
A) Good is hot.
B) Evil is hot.
C) The humors must be
While evaluating the health history, the nurse determines that the patient subscribes to the hot/cold theory of health. Which of the following will most likely describe this patient's view of wellness?
A) Good is hot.
Feedback: INCORRECT
Beverages, foods,
Before determining whether cultural practices are helpful, harmful, or neutral, nurses must first understand:
A) the logic of the traditional belief systems.
B) the beliefs of the patients family.
C) their personal belief models.
D) the risk of disease in
Before determining whether cultural practices are helpful, harmful, or neutral, nurses must first understand:
A) the logic of the traditional belief systems.
B) the beliefs of the patients family.
C) their personal belief models.
D) the risk of disease in
On the basis of median age:
A) the non-Hispanic white population tends to be younger.
B) the Hispanic population tends to be older.
C) the Asian population tends to be younger.
D) minorities tend to be older than non-Hispanic white populations.
On the basis of median age:
A) the non-Hispanic white population tends to be younger.
Feedback: INCORRECT
The non-Hispanic, single-race white population was older than the population as a whole; the respective median ages were 40.8 and 36.6 years.
B) the
Spirituality is defined as:
A) participating in religious services on a regular basis.
B) a personal effort to find meaning and purpose in life.
C) the process of being raised within a culture.
D) a social group that claims to possess variable traits.
Spirituality is defined as:
A) participating in religious services on a regular basis.
Feedback: INCORRECT
Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe.
B) a personal effort to find meaning an
Which of the following is true regarding language barriers and health care?
A) There are laws addressing language barriers and health care.
B) Limited English proficiency is associated with a higher quality of care.
C) English proficiency is associated wi
Which of the following is true regarding language barriers and health care?
A) There are laws addressing language barriers and health care.
Feedback: CORRECT
Title VI of the Civil Rights Act of 1964 provides people with limited English proficiency access
What is the yin/yang theory of health?
A) Health exists when all aspects of the person are in perfect balance.
B) Health exists when physical, psychologic, spiritual, and social needs are met.
C) Health exists in the absence of illness.
D) Health exists w
What is the yin/yang theory of health?
A) Health exists when all aspects of the person are in perfect balance.
Feedback: CORRECT
In the yin/yang theory, health is believed to exist when all aspects of the person are in perfect balance.
B) Health exists wh
Which theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage?
A) Behavior theory
B) Heritage consistency
C) Congruence mechanism
D) Socialization experience
Which theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage?
A) Behavior theory
Feedback: INCORRECT
Behavior theory or behaviorism is a learning theory.
B) Heritage consistency
Fe
What symptom is greatly influenced by a person's cultural heritage?
A) hearing loss
B) pain
C) breast lump
D) food intolerance
What symptom is greatly influenced by a person's cultural heritage?
A) hearing loss
Feedback: INCORRECT
Hearing loss is more common in whites than in blacks.
B) pain
Feedback: CORRECT
Pain is a very private, subjective experience that is greatly influence
When considering cultural competence, there are discrete areas that the nurse must develop knowledge of to understand the health care needs of others. These discrete areas include understanding of: (Select all that apply.)
A) his or her own heritage.
B) c
When considering cultural competence, there are discrete areas that the nurse must develop knowledge of to understand the health care needs of others. These discrete areas include understanding of: (Select all that apply.)
A) his or her own heritage.
B) c
Empathy
Empathy
means viewing the world from the other person's inner frame of reference while remaining yourself.
A health
interview
A health
interview
is a structured interaction between you and the patient. The
rules
governing this interaction should be
clearly outlined and agreed on
by you and the patient at the start of the interview. Your mutual
goal
is the
patient's optimal healt
Communication
Communication
carries you and the patient through the interview. Communication is the
exchange of information
so that each person clearly understands the other.
A two-person interaction usually has two roles:
sender and receiver
. When exchanging information, both individuals engage in
verbal and nonverbal communication
. Internal and external factors can affect communication.
...
Internal factors
Internal factors
are what
you
bring to the interview.
Three internal factors promote good communication:
Three internal factors promote good communication:
(1)
liking others
,
(2)
expressing empathy
, and
(3)
having the ability to listen.
External factors
External factors
relate mainly to the
physical setting.
You can foster good communication with which external factors?
You can foster good communication with certain external factors, such as by
ensuring privacy
,
preventing interruptions
,
creating a conducive environment
, and
documenting responses
without interfering with the conversation.
The interview has
three phases
:
The interview has
three phases
:
(1)
introduction
,
(2)
working phase
,
(3)
closing.
During the first phase of an interview
During the first phase,
introduce the interview.
During the working phase of an interview
During the working phase,
gather data.
Start with
open-ended questions,
which ask for narrative information. Then use
closed questions,
which ask for specific information in short, one- or two-word answers.
During the closing phase of an interview
During the closing,
signal that the interview is ending
, which gives the patient one last chance to share concerns or express himself or herself. Also briefly
summarize what you learned
during the interview.
You can use different
types of verbal responses
to assist the narrative and help gather data. Each response plays a role in the interview process, but practice is needed to use them effectively and move among them smoothly.
...
Through
facilitation
,
silence
,
reflection
,
empathy
, and
clarification
, you react to the facts or feelings the patient has communicated. Your response
focuses on the patient's frame of reference.
...
Through
confrontation
,
interpretation
,
explanation
, and
summary
, your response
focuses on your own frame of reference
, thoughts, and feelings.
...
10 traps of interviewing
10 traps of interviewing
. These nonproductive verbal messages include:
(1) Providing false assurance or reassurance,
(2) Giving unwanted advice,
(3) Using authority,
(4) Using avoidance language,
(5) Engaging in distancing,
(6) Using professional jargon,
Nonverbal modes of communication
Nonverbal modes of communication
include:
- Physical appearance,
- Posture,
- Gestures,
- Facial expression,
- Eye contact,
- Voice, and
- Touch.
Nonverbal communications convey messages
from the sender to the receiver. Work to develop the ability to read patients' nonverbal behaviors and to monitor your own nonverbal communication.
...
Modify communication techniques based on each
patient's developmental stage,
including parents, infants, young children, adolescents, and older adults.
...
Learn to communicate effectively with
patients who have special needs
, such as those with a hearing impairment, acute illness, or intoxication and those who are sexually aggressive, angry, anxious, violent, or in tears.
...
When a
patient comes from a different culture,
modify your approach as needed. Behaviors that one culture views positively may have different, possibly negative, connotations in another culture.
...
For a patient with
limited English proficiency
, use a
bilingual team member or a trained medical interpreter
whenever possible. Avoid using a family member or close friend as an interpreter because this violates the patient's confidentiality.
...
Facilitation
Facilitation
These responses encourage the patient to say more, to continue with the story ("mm-hmm, go on, continue, uh-huh"). Also called general leads, these responses show the person you are interested and will listen further. Simply maintaining eye c
Silence
Silence is golden after open-ended questions. Your silent attentiveness communicates that the patient has time to think, to organize what he or she wishes to say without interruption from you.
Reflection
Reflection.
This response echoes the patient's words. Reflection is repeating part of what the person has just said.
Clarification
Clarification.
Use this when the person's word choice is ambiguous or confusing (e.g., "Tell me what you mean by 'tired blood.' "). Clarification also is used to summarize the person's words, simplify the words to make them clearer, and then ask if you ar
Confrontation
Confrontation.
These responses now include your own thoughts and feelings. Use this only when merited by the situation. If you use it too often, you take over at the patient's expense. In the case of confrontation, you have observed a certain action, feel
Interpretation
Interpretation.
This statement is not based on direct observation as with confrontation, but it is based on your inference or conclusion. It links events, makes associations, or implies cause: "It seems that every time you feel the stomach pain, you have
Explanation
Explanation.
With these statements, you inform the person. You share factual and objective information. This may be for orientation to the agency setting: "Your dinner comes at 5:30 PM." Or, it may be to explain cause: "The reason you cannot eat or drink
When preparing the physical setting for an interview, the interviewer should:
A) set the room temperature between 64 and 66� F.
B) reduce noise by turning the volume on the television or radio down.
C) conduct the interview at eye level and at a distance
When preparing the physical setting for an interview, the interviewer should:
A) set the room temperature between 64 and 66� F.
Feedback: INCORRECT
The room temperature should be set at a comfortable level; a temperature between 64 and 66� F is too cool.
Parents or caretakers accompany children to the health care setting. Starting at ___ years of age, the interviewer asks the child directly about his or her presenting symptoms.
A) 5
B) 7
C) 9
D) 11
Parents or caretakers accompany children to the health care setting. Starting at ___ years of age, the interviewer asks the child directly about his or her presenting symptoms.
A) 5
Feedback: INCORRECT
Refer to feedback in option B.
B) 7
Feedback: CORRECT
Which of the following statements, if made by the interviewer, would be an appropriate response?
A) "I know just how you feel."
B) "If I were you, I would have the surgery."
C) "Why did you wait so long to make an appointment?"
D) "Tell me what you mean b
Which of the following statements, if made by the interviewer, would be an appropriate response?
A) "I know just how you feel."
Feedback: INCORRECT
This response is an inappropriate communication technique referred to as false reassurance.
B) "If I were y
While discussing the treatment plan, the nurse infers that the patient is uncomfortable asking the physician for a different treatment because of fear of the physician's reaction. In this situation, the nurse's verbal interpretation:
A) affects the nurse-
While discussing the treatment plan, the nurse infers that the patient is uncomfortable asking the physician for a different treatment because of fear of the physician's reaction. In this situation, the nurse's verbal interpretation:
A) affects the nurse-
The use of euphemisms to avoid reality or to hide feelings is known as:
A) distancing language.
B) sympathetic language.
C) avoidance language.
D) ethnocentric language.
The use of euphemisms to avoid reality or to hide feelings is known as:
A) distancing language.
Feedback: INCORRECT
Distancing is the use of impersonal speech to put space between a threat and the self.
B) sympathetic language.
Feedback: INCORRECT
Empathy
When addressing a toddler during the interview, the health care provider should:
A) ask the child, before the caretaker, about symptoms.
B) use nonverbal communication.
C) use short, simple, concrete sentences.
D) use detailed explanations.
When addressing a toddler during the interview, the health care provider should:
A) ask the child, before the caretaker, about symptoms.
Feedback: INCORRECT
For a younger child such as a toddler, the parent will provide all or most of the history.
B) use
Nonverbal communication is the primary form of communication for which group of individuals?
A) Infants
B) Preschoolers
C) Adolescents
D) Older adults
Nonverbal communication is the primary form of communication for which group of individuals?
A) Infants
Feedback: CORRECT
Nonverbal communication is the primary form of communication method for infants.
B) Preschoolers
Feedback: INCORRECT
Preschooler's co
Viewing the world from another person's inner frame of reference is called:
A) reflection.
B) empathy.
C) clarification.
D) sympathy.
Viewing the world from another person's inner frame of reference is called:
A) reflection.
Feedback: INCORRECT
Reflection is repeating part of what the person has just said.
B) empathy.
Feedback: CORRECT
Empathy means viewing the world from the other pers
An example of an open-ended question or statement is:
A) "Tell me about your pain."
B) "On a scale of 1 to 10, how would you rate your pain?"
C) "I can see that you are quite uncomfortable."
D) "You are upset about the level of pain, right?
An example of an open-ended question or statement is:
A) "Tell me about your pain."
Feedback: CORRECT
Open-ended questions and statements ask for narrative information; they state the topic to be discussed, but only in general terms. This type of question
The most appropriate introduction to use to start an interview with an older adult patient is:
A) "Mr. Jones, I want to ask you some questions about your health so that we can plan your care."
B) "David, I am here to ask you questions about your illness;
The most appropriate introduction to use to start an interview with an older adult patient is:
A) "Mr. Jones, I want to ask you some questions about your health so that we can plan your care."
Feedback: CORRECT
An older adult should be addressed by the la
The
purpose of the complete health history
is to
collect subjective data
, which is what the person says about himself or herself. By combining this subjective data with objective data from the physical examination and diagnostic tests, you create a datab
...
For
sick patients
, the health history includes a detailed, chronologic record of the
health problem.
...
For
all patients
, it is a
screening tool
for abnormal symptoms, health problems, and concerns. It also records the patient's responses to health problems.
...
No matter what form is used to record the health history, plan to
gather data in eight categories.
...
complete health history data category 1.
complete health history data category 1.
First, collect
biographic data
, such as the patient's name, address, and date of birth as well as language and communication needs.
complete health history data category 2.
complete health history data category 2.
Second, note the
source of the history
, which is usually the patient, but may be someone else, such as a relative or interpreter.
complete health history data category 3.
complete health history data category 3.
Third, obtain the
reason for seeking care
, formerly known as the chief complaint. In the patient's own words, briefly describe the reason for the visit.
complete health history data category 4.
complete health history data category 4.
Fourth, record the
present health or history of present illness
. For a well person, briefly note the general state of health. For a sick person, chronologically record the reason for seeking care. When a patient r
PQRSTU
PQRSTU
stands for
P
rovocative or palliative,
Q
uality or quantity,
R
egion or radiation,
S
everity scale,
T
iming, and
U
nderstanding the patient's perception of the problem.
complete health history data category 5.
complete health history data category 5.
Fifth, investigate
past health events
, such as illnesses, injuries, hospitalizations, and allergies as well as current medications.
complete health history data category 6.
complete health history data category 6.
Sixth, gather a
family history
to help detect health risks for the patient. To aid in this process, draw a pedigree or genogram.
complete health history data category 7.
complete health history data category 7.
Seventh, perform a
review of systems
to evaluate the past and present health of each body system, double-check for significant data, and assess health promotion practices. For each body system, assess for symptoms
complete health history data category 8.
complete health history data category 8.
Finally, perform a
functional assessment
, including activities of daily living, such as bathing dressing, toileting, eating, walking, housekeeping, shopping, cooking, and other factors.
The
depth of information
obtained for each health history category may vary from one setting to another. However, you should
address all categories
before making a diagnosis or judgment about the patient's health status.
...
When obtaining a
child's health history
, use the same structure you would use for an adult, but make pertinent modifications or additions. Additions include:
When obtaining a
child's health history
, use the same structure you would use for an adult, but make pertinent modifications or additions. Additions include:
- A prenatal and perinatal history,
- The parents' description of the present problem,
- Any chi
When assessing
functional abilities
, consider the child's environment and his or her function or role in the environment.
...
When taking an
older adult's health history
, also ask additional questions. For example, explore
changes in activities of daily living
that may result from the aging process or chronic illness.
...
Remember that the
impact or burden of a disease
may be more important to an older adult than the actual disease diagnosis or pathology. So be sure to record the person's reason for seeking care, not your assumption about the problem.
...
The
Comprehensive Older Person's Evaluation
is particularly useful because it addresses:
The
Comprehensive Older Person's Evaluation
is particularly useful because it addresses: Basic and instrumental
activities of daily living
,
Functional assessments
, And physical, social, psychologic, demographic, financial, and legal
issues
.
CAGE
test identify what?
CAGE
test is a screening questionnaire to identify excessive or uncontrolled drinking, such as:
-
C
Cut down - Have you ever thought you should cut down your drinking?
-
A
Annoyed - Have you ever been annoyed by criticism of your drinking?
-
G
Guilty - Ha
Which of the following is included in documenting a history source?
A) Appearance, dress, and hygiene
B) Cognition and literacy level
C) Documented relationship of support systems
D) Reliability of informant
Which of the following is included in documenting a history source?
A) Appearance, dress, and hygiene
Feedback: INCORRECT
Appearance, dress, and hygiene are observations included in the general survey.
B) Cognition and literacy level
Feedback: INCORRECT
C
A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about:
A) the patient's perception of p
A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about:
A) the patient's perception of p
The CAGE test is a screening questionnaire that helps to identify:
A) unhealthy lifestyle behaviors.
B) personal response to stress.
C) excessive or uncontrollable drinking.
D) depression.
The CAGE test is a screening questionnaire that helps to identify:
A) unhealthy lifestyle behaviors.
Feedback: INCORRECT
The health history will assess lifestyle, including such factors as exercise, diet, risk reduction, and health promotion behaviors.
B)
The "review of systems" in the health history is:
A) an evaluation of past and present health state of each body system.
B) a documentation of the problem as perceived by the patient.
C) a record of objective findings.
D) a short statement of general heal
The "review of systems" in the health history is:
A) an evaluation of past and present health state of each body system.
Feedback: INCORRECT
The purposes of the review of systems are to evaluate the past and present health state of each body system, to do
When recording information for the review of systems, the interviewer must document:
A) physical findings, such as skin appearance, to support historic data.
B) "negative" under the system heading.
C) the presence or absence of all symptoms under the syst
When recording information for the review of systems, the interviewer must document:
A) physical findings, such as skin appearance, to support historic data.
Feedback: INCORRECT
Recording physical findings in the review of systems is incorrect; review of
Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include:
A) education, financial status, and value-belief system.
B) exercise and activity, leisure activities, and level of
Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include:
A) education, financial status, and value-belief system.
Feedback: CORRECT
Functional assessment measures a person's
PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to:
A) severity of dementia.
B) substance use and abuse.
C) symptoms.
D) the ability to perform activities of daily living (ADLs).
PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to:
A) severity of dementia.
Feedback: INCORRECT
Tests used to assess for dementia include the Mini-Mental State Examination, the Set Test, the Short Portable Me
The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to:
A) review previous medical records.
B) rephrase the same questions later in the interview.
C) ask the p
The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to:
A) review previous medical records.
Feedback: INCORRECT
This option is not within the context of the in
When taking a health history from an adolescent, the interviewer should:
A) ask about violence and abuse before asking about alcohol and drug use.
B) have at least one parent present during the interview.
C) interview the youth alone with a parent in the
When taking a health history from an adolescent, the interviewer should:
A) ask about violence and abuse before asking about alcohol and drug use.
Feedback: INCORRECT
Questions should move from expected and less-threatening questions to those that are mor
What information is included in greater detail when taking a health history on an infant?
A) nutritional data
B) history of present illness
C) family history
D) environmental hazards
What information is included in greater detail when taking a health history on an infant?
A) nutritional data
Feedback: CORRECT
The amount of nutritional information needed depends on the child's age; the younger the child is the more detailed and specifi