Chapter 04: The Complete Health History

Question 1

1. The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history?
   a. To provide an opportunity for interaction between the patient and the nurse
   b. To provide a form for obtaining the patient’s biographic information
   c. To document the normal and abnormal findings of a physical assessment
   d. To provide a database of subjective information about the patient’s past and current health

Answer 1

ANS: D
The purpose of the health history is to collect subjective data—what the person says about him or herself. The other options are not correct.

Question 2

2. When the nurse is evaluating the reliability of a patient’s responses, which of these statements would be correct? The patient:
   a. Has a history of drug abuse and therefore is not reliable.
   b. Provided consistent information and therefore is reliable.
   c. Smiled throughout interview and therefore is assumed reliable.
   d. Would not answer questions concerning stress and therefore is not reliable.

Answer 2

ANS: B
A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct.

Question 3

3. A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having “black stools” for the last 24 hours. How would the nurse best document his reason for seeking care?
   a. J.M. is a 59-year-old man seeking treatment for ulcerative colitis.
   b. J.M. came into the clinic complaining of having black stools for the past 24 hours.
   c. J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked.
   d. J.M. is a 59-year-old man who states that he has been having “black stools” for the past 24 hours.

Answer 3

ANS: D
The reason for seeking care is a brief spontaneous statement in the person’s own words that describes the reason for the visit. It states one (possibly two) signs or symptoms and their duration. It is enclosed in quotation marks to indicate the person’s exact words.

Question 4

4. A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse’s best response?
   a. “Can you point to where it hurts?”
   b. “We’ll talk more about that later in the interview.”
   c. “What have you had to eat in the last 24 hours?”
   d. “Have you ever had any surgeries on your abdomen?”

Answer 4

ANS: A
A final summary of any symptom the person has should include, along with seven other critical characteristics, “Location: specific.” The person is asked to point to the location.

Question 5

5. A 29-year-old woman tells the nurse that she has “excruciating pain” in her back. Which would be the nurse’s appropriate response to the woman’s statement?
   a. “How does your family react to your pain?”
   b. “The pain must be terrible. You probably pinched a nerve.”
   c. “I’ve had back pain myself, and it can be excruciating.”
   d. “How would you say the pain affects your ability to do your daily activities?”

Answer 5

ANS: D
The symptom of pain is difficult to quantify because of individual interpretation. With pain, adjectives should be avoided and the patient should be asked how the pain affects his or her daily activities. The other responses are not appropriate.

Question 6

6. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate?
   a. Patient denies usual childhood illnesses.
   b. Patient states he was a “very healthy” child.
   c. Patient states his sister had measles, but he didn’t.
   d. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat

Answer 6

ANS: D
Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording “usual childhood illnesses” because an illness common in the person’s childhood may be unusual today (e.g., measles).

Question 7

7. A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information?
   a. P-6, B-4, (S)Ab-2
   b. Grav 6, Term 4, (S)Ab-2, Living 4
   c. Patient has had four living babies.
   d. Patient has been pregnant six times.

Answer 7

ANS: B
Obstetric history includes the number of pregnancies (gravidity), number of deliveries in which the fetus reached term (term), number of preterm pregnancies (preterm), number of incomplete pregnancies (abortions), and number of children living (living). This is recorded: Grav _____ Term _____ Preterm _____ Ab _____ Living _____. For any incomplete pregnancies, the duration is recorded and whether the pregnancy resulted in a spontaneous (S) or an induced (I) abortion.

Question 8

8. A patient tells the nurse that he is allergic to penicillin. What would be the nurse’s best response to this information?
   a. “Are you allergic to any other drugs?”
   b. “How often have you received penicillin?”
   c. “I’ll write your allergy on your chart so you won’t receive any penicillin.”
   d. “Describe what happens to you when you take penicillin.”

Answer 8

ANS: D
Note both the allergen (medication, food, or contact agent, such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, or difficulty breathing). With a drug, this symptom should not be a side effect but a true allergic reaction.

Question 9

9. The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include:
   a. Emphysema.
   b. Head trauma.
   c. Mental illness.
   d. Fractured bones.

Answer 9

ANS: C
Questions concerning any family history of heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast and ovarian cancers, colon cancer, sickle cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and tuberculosis should be asked.

Question 10

10. The review of systems provides the nurse with:
    a. Physical findings related to each system.
    b. Information regarding health promotion practices.
    c. An opportunity to teach the patient medical terms.
    d. Information necessary for the nurse to diagnose the patient’s medical problem.

Answer 10

ANS: B
The purposes of the review of systems are to: (1) evaluate the past and current health state of each body system, (2) double check facts in case any significant data were omitted in the present illness section, and (3) evaluate health promotion practices.

Question 11

11. Which of these statements represents subjective data the nurse obtained from the patient regarding the patient’s skin?
    a. Skin appears dry.

b. No lesions are obvious.
c. Patient denies any color change.
d. Lesion is noted on the lateral aspect of the right arm.

Answer 11

ANS: C
The history should be limited to patient statements or subjective data—factors that the person says were or were not present.

Question 12

12. The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?
    a. “Do you perform testicular self-examinations?”
    b. “Have you ever noticed any pain in your testicles?”
    c. “Have you had any problems with passing urine?”
    d. “Do you have any history of sexually transmitted diseases?”

Answer 12

ANS: A
Health promotion for a man would include the performance of testicular self-examinations. The other questions are asking about possible disease or illness issues.

Question 13

13. Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast?
    a. “I broke my right leg in a car accident 2 weeks ago.”
    b. “The pain is decreasing, but I still need to take acetaminophen.”
    c. “I check the color of my toes every evening just like I was taught.”
    d. “I’m able to transfer myself from the wheelchair to the bed without help.”

Answer 13

ANS: D

Functional assessment measures a person’s self-care ability in the areas of general physical health or absence of illness. The other statements concern health or illness issues.

Question 14

14. In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate?
    a. “This has been a difficult year for you.”
    b. “I don’t know how anyone could handle that much stress in 1 year!”
    c. “What did you do to cope with the loss of both your husband and mother?”
    d. “That is a lot of stress; now let’s go on to the next section of your history.”

Answer 14

ANS: C
Questions about coping and stress management include questions regarding the kinds of stresses in one’s life, especially in the last year, any changes in lifestyle or any current stress, methods tried to relieve stress, and whether these methods have been helpful.

Question 15

15. In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information?
    a. This information is necessary to determine the patient’s reliability.
    b. Alcohol can interact with all medications and can make some diseases worse.
    c. The nurse needs to be able to teach the patient about the dangers of alcohol use.
    d. This information is not necessary unless a drinking problem is obvious.

Answer 15

ANS: B
Alcohol adversely interacts with all medications and is a factor in many social problems such as child or sexual abuse, automobile accidents, and assaults; alcohol also contributes to many illnesses and disease processes. Therefore, assessing for signs of hazardous alcohol use is important. The other options are not correct.

Question 16

16. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response?
    a. “Maybe she is just teething.”
    b. “I will check her ear for an ear infection.”
    c. “Are you sure she is really having pain?”
    d. “Describe what she is doing to indicate she is having pain.”

Answer 16

ANS: D
With a very young child, the parent is asked, “How do you know the child is in pain?” A young child pulling at his or her ears should alert parents to the child’s ear pain. Statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination.

Question 17

17. During an assessment of a patient’s family history, the nurse constructs a genogram. Which statement best describes a genogram?
    a. List of diseases present in a person’s near relatives

b. Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members
c. Drawing that depicts the patient’s family members up to five generations back
d. Description of the health of a person’s children and grandchildren

Answer 17

ANS: B
A genogram (or pedigree) is a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations (parents, grandparents, siblings). The other options do not describe a genogram.

Question 18

18. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure?

a. Child’s birth weight
b. Age at which he crawled
c. Whether the child has had the measles
d. Child’s reactions to previous hospitalizations

Answer 18

ANS: D
How the child reacted to previous hospitalizations and any complications should be assessed. If the child reacted poorly, then he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure.

Question 19

19. As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make?
    a. No further MMR immunizations are needed.
    b. MMR vaccination needs to be repeated at 4 to 6 years of age.
    c. MMR immunization needs to be repeated every 4 years until age 21 years.
    d. A recommendation cannot be made until the physician is consulted.

Answer 19

ANS: B
Because of recent outbreaks of measles across the United States, the American Academy of Pediatrics (2006) recommends two doses of the MMR vaccine, one at 12 to 15 months of age and one at age 4 to 6 years.

Question 20

20. In obtaining a review of systems on a “healthy” 7-year-old girl, the health care provider knows that it would be important to include the:
    a. Last glaucoma examination.

b. Frequency of breast self-examinations.
c. Date of her last electrocardiogram.
d. Limitations related to her involvement in sports activities.

Answer 20

ANS: D
When reviewing the cardiovascular system, the health care provider should ask whether any activity is limited or whether the child can keep up with her peers. The other items are not appropriate for a child this age.

Question 21

21. When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed?
    a. Family history
    b. Review of systems
    c. Functional assessment
    d. Reason for seeking care

Answer 21

ANS: C
Functional assessment includes interpersonal relationships and home environment. Family history includes illnesses in family members; a review of systems includes questions about the various body systems; and the reason for seeking care is the rationale for requesting health care.

Question 22

22. The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time?
    a. Obstetric history
    b. Childhood illnesses
    c. General health for the past 20 years
    d. Current health promotion activities

Answer 22

ANS:D

It is important for the nurse to recognize positive health measures, such as what the person has been doing to help him or herself stay well and to live to an older age. The other responses are not pertinent to a patient of this age

Question 23

23. The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation?
    a. The questions asked are identical for all ages.
    b. The interviewer will start incorporating different questions for patients 70 years of age and older.
    c. Questions that are reflective of the normal effects of aging are added.
    d. At this age, a review of systems is not necessary—the focus should be on current problems.

Answer 23

ANS: C
The health history includes the same format as that described for the younger adult, as well as some additional questions. These additional questions address ways in which the activities of daily living may have been affected by the normal aging processes or by the effects of chronic illness or disability.

Question 24

24. A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be:
    a. “Can you tell me what they look like?”
    b. “Don’t worry about it. You are only taking two medications.”
    c. “How long have you been taking each of the pills?”
    d. “Would you have a family member bring in your medications?”

Answer 24

ANS: D
The person may not know the drug name or purpose. When this occurs, ask the person or a family member to bring in the drug to be identified. The other responses would not help to identify the medications.

Question 25

25. The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask?
    a. “Do you wear glasses?”
    b. “Are you able to dress yourself?”
    c. “Do you have any thyroid problems?”
    d. “How many times a day do you have a bowel movement?”

Answer 25

ANS: B
Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. The other responses do not relate to functional assessment.

Question 26

26. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment?
    a. The functional assessment assesses how the individual is coping with life at home.
    b. It determines how children are meeting developmental milestones.
    c. The functional assessment can identify any problems with memory the individual may be experiencing.
    d. It helps determine how a person is managing day-to-day activities.

Answer 26

ANS: D
The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.

Question 27

27. The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom?

a. Chest pain
b. Clammy skin
c. Serum potassium level at 4.2 mEq/L
d. Body temperature of 100 F

Answer 27

ANS: A
A symptom is a subjective sensation (e.g., chest pain) that a person feels from a disorder. A sign is an objective abnormality that the examiner can detect on physical examination or in laboratory reports, as illustrated by the other responses.

Question 28

28. A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms?
    a. “It is a sharp, burning pain in my stomach.”
    b. “I also have the sweats and nausea when I feel this pain.”
    c. “I think this pain is telling me that something bad is wrong with me.”
    d. “This pain happens every time I sit down to use the computer

Answer 28

ANS: D
The setting describes where the person is or what the person is doing when the symptom starts. Describing the pain as “sharp and burning” reflects the character or quality of the pain; stating that the pain is “telling” the patient that something bad is wrong with him reflects the patient’s perception of the pain; and describing the “sweats and nausea” reflects associated factors that occur with the pain.

Question 29

29. During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two of the questions. What could this be indicating?
    a. The patient is an alcoholic.

b. The patient is annoyed at the questions.
c. The patient should be thoroughly examined for possible alcohol withdrawal symptoms.
d. The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.

Answer 29

ANS: D
The CAGE test is known as the “cut down, annoyed, guilty, and eye-opener” test. If a person answers “yes” to two or more of the four CAGE questions, then the nurse should suspect alcohol abuse and continue with a more complete substance abuse assessment.

Question 30

30. The nurse is incorporating a person’s spiritual values into the health history. Which of these questions illustrates the “community” portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions?
    a. “Do you believe in God?”
    b. “Are you a part of any religious or spiritual congregation?”
    c. “Do you consider yourself to be a religious or spiritual person?”
    d. “How does your religious faith influence the way you think about your health?”

Answer 30

ANS: B
The “community” is assessed when the nurse asks whether a person is part of a religious or spiritual community or congregation. The other areas assessed are faith, influence, and addressing any religious or spiritual issues or concerns.

Question 31

31. The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins?
    a. “Please stay during the interview; you can answer for her if she does not know the answer.”

b. “It would help to interview the three of you together.”
c. “While I interview your daughter, will you please stay in the room and complete these c. family health history questionnaires?”
d. “While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?”

Answer 31

ANS: D
The girl should be interviewed alone. The parents can wait outside and fill out the family health history questionnaires.

Question 32

32. The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history?
    a. “Why did you come to the United States?”
    b. “When did you come to the United States and from what country?”
    c. “What made you leave your native country?”
    d. “Are you planning to return to your home?”

Answer 32

ANS: B
Biographic data, such as when the person entered the United States and from what country, are appropriate additions to the health history. The other answers do not reflect appropriate questions

Question 33

1. The nurse is assessing a patient’s headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply.
   a. “Where is the headache pain?”
   b. “Did you have these headaches as a child?”
   c. “On a scale of 1 to 10, how bad is the pain?”
   d. “How often do the headaches occur?”
   e. “What makes the headaches feel better?”
   f. “Do you have any family history of headaches?”

Answer 33

ANS: A, C, D, E
The mnemonic PQRSTU may help the nurse remember to address the critical characteristics that need to be assessed: (1) P: provocative or palliative; (2) Q: quality or quantity; (3) R: region or radiation; (4) S: severity scale; (5) T: timing; and (6) U: understand the patient’s perception. Asking, “Where is the pain?” reflects “region.” Asking the patient to rate the pain on a 1 to 10 scale reflects “severity.” Asking “How often…” reflects “timing.” Asking what makes the pain better reflects “provocative.” The other options reflect health history and family history.

Question 34

2. The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply.
   a. “How much junk food does your child eat?”
   b. “How many teeth has he lost, and when did he lose them?”
   c. “Is he able to tie his shoelaces?”
   d. “Does he take a children’s vitamin?”
   e. “Can he tell time?”
   f. “Does he have any food allergies?”

Answer 34

ANS: B, C, E
Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history.