Chapter 4 Flashcards
Which of the following is included in documenting a history source?
Reliability of informant
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:
aggravating factors.
The CAGE test is a screening questionnaire that helps to identify:
excessive or uncontrollable drinking.
The “review of systems” in the health history is:
an evaluation of past and present health state of each body system.
When recording information for the review of systems, the interviewer must document:
the presence or absence of all symptoms under the system heading.
Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include:
education, financial status, and value-belief system.
PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to:
pain presentation.
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:
rephrase the same questions later in the interview.
When taking a health history from an adolescent, the interviewer should:
interview the youth alone with a parent in the waiting area.
What information is included in greater detail when taking a health history on an infant?
Nutritional data
You have reason to question the reliability of the info being provided by a patient. One way to verify the reliability within the context of the interview is to
rephrase the same questions later in the interview
The statement “Reason for seeking care” has replaced the “chief complaint” this change is significant because
the newer term incorporates wellness
During the initial interview, the examiner sys, “ Mrs J. tell me what you do when your headaches occur? This information is an example of what type of information?
aggravating
Which is an appropriate recording of a patients reason for seeking health care
Grabbing chest pain for 2 hours
A genogram is used for which reason
family history
