Chapter 4 (The Complete Health History)

Question 1

Interpersonal relationships and resources such as support systems are assessed during the __________ assessment of the complete health history.

Answer 1

functional

Question 2

Cognition and literacy level is part of the ________ status assessment.

Answer 2

mental

Question 3

Appearance, dress, and hygiene are observations included in the _________ survey.

Answer 3

general

Question 4

The _________ of history is a record of who furnishes the information, how reliable the informant seems, and how willing he or she is to communicate.

Answer 4

source

Question 5

The _______________ will assess lifestyle, including such factors as exercise, diet, risk reduction, and health promotion behaviors.

Answer 5

health history

Question 6

Coping and stress management are assessed during the _______________ of the complete health history.

Answer 6

functional assessment

Question 7

CAGE is a screening questionnaire to identify _________ or uncontrolled __________ .

What does it stand for?

Answer 7

excessive, drinking

(e.g., C = Cut down; A = Annoyed; G = Guilty; E = Eye opener).

Question 8

The purposes of the review of systems are to evaluate the _________ and ________ health state of each body system, to ___________ in case any significant data were omitted in the present illness section, and to _________ health promotion practices.

Answer 8

past and present
double-check
evaluate

Question 9

Review of systems is limited to the patient _________ or ________ data.

Answer 9

statements

subjective

Question 10

When recording information for the review of systems, the interviewer must document the presence or absence of all symptoms under the _____________.

Answer 10

system heading

Question 11

Assessment of self-esteem and self-concept is part of the _________ assessment. Areas covered under self-esteem and self-concept include _________, ___________, and _________.

Answer 11

functional

education, financial status, and value-belief system.

Question 12

Stressors, coping mechanisms, and change in the past year are all related to the coping and stress management section of the ______________.

Answer 12

functional assessment

Question 13

PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to:

What does the mnemonic mean?

Answer 13

Symptoms

P = provocative or palliative
Q = quality or quantity
R = region or radiation
S = severity scale
T = timing
U = understand patient’s perception.

Question 14

When taking a health history from an adolescent, the interviewer should interview the adolescent (alone w/ parent in waiting room) or (w/ parent in examination room)

Answer 14

interview the youth alone with a parent in the waiting area

Question 15

Review of Systems. The purposes of this section are:

Answer 15

(1) to evaluate the past and present health state of each body system,
(2) to double-check in case any significant data were omitted in the Present Illness section, and
(3) to evaluate health promotion practices

Question 16

Functional assessment measures a person’s self-care ability in the areas of general physical health or absence of illness

Answer 16

ADLs, such as bathing, dressing, toileting, eating, walking; instrumental activities of daily living (IADLs), or those needed for independent living, such as housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances; nutrition; social relationships and resources; self-concept and coping; and home environment.

Question 17

Explain F.I.C.A.

Answer 17

Faith: “Does religious faith or spirituality play an important part in your life? Do you consider yourself to be a religious or spiritual person?”

Influence: “How does your religious faith or spirituality influence the way you think about your health or the way you care for yourself?”

Community: “Are you a part of any religious or spiritual community or congregation?”

Address: “Would you like me to address any religious or spiritual issues or concerns with you?”

Question 18

Explain C.A.G.E.

Answer 18

Have you ever thought you should CUT down your drinking?

Have you ever been ANNOYED by criticism of your drinking?

Have you ever felt GUILTY about your drinking?

Do you drink in the morning? (i.e., an EYE opener?)

Question 19

What test is used to screen excessive intake of alcohol?

Answer 19

AUDIT

Question 20

What supplemental information is added to the comprehensive history evaluation format when taking the health history of an infant?

Answer 20

Prenatal and natal history, pattern of growth and development, detailed review of immunizations