Health Assessment- Interview- Questions to ask Subjective Info

Question 1

A comprehensive assessment looks at what? When is it typically done?

Answer 1

Assessment of the WHOLE person
physical
psychological
social
spiritual
- Done at admission

Question 2

PMH stands for

Answer 2

Past medical history

Question 3

Why are assessments done?

Answer 3

Establish a data base/ baseline
Identify risk factors
Identify the chief complaint(s)9

Question 4

What does information from nursing assessment help formulate?

Answer 4

The NURSING diagnosis

Question 5

Types of health assessements

Answer 5

Functional- grouped into Gordons 11 functional health patterns
Head to Toe- collecting data in organized system from head to toe
Body System- focuses on the pathophysiology of a specific body system; used by providers

Question 6

First step of any assessment would be ____

Answer 6

An introduction

Question 7

During the introduction of a health assessment you should,

Answer 7

introduce yourself to pt and introduce pt to the room
- obtain patient demographics
-obtain PMH/past health history
-Cultural considerations/need for interpreter, etc

Question 8

How does a nurse prepare patient the environment?

Answer 8

• Organization; Have patient room prepared with necessary items in advance
• Ensure PRIVACY, warmth, quite
• Have patients use bathroom prior/ensure their comfort
  -Prioritize how assessment will be done based on pt chief complaint (acknowledge distress & focus on primary problem when pt is uncomfortable or acutely ill)

Question 9

Which comes first? Patient Interview or Physical Assessment?

Answer 9

Patient Interview

Question 10

What info is obtained in the health history interview portion of assessment?

Answer 10

Subjective information from pt
Health History
Chief Complaint
Pain assessment
Pt perception of their own health
Immunizations
Smoking
Diet
Meds/Allergies
Chronic illness & Diagonoses
Screening for Violence/Safety

Question 11

What other info is obtained in the interview portion of assessment?

Answer 11

Activity and Exercise
Steadiness/Gait/ Balance
Mobility
Respiratory Funtcions
Cardiovascular Functions
Nutrition/Diet/ Metabolism/ Weight Changes
Intake/Output
Sleep Patterns
Nuero/ Mental Status/ Sensory/ Cognition Assessment
Self Perception/Relationships/Cope & Stress/ Sexual & Reproductive
Spiritual/Values/ Beliefs

Question 12

How does nurse completed an Assessment of Activity and Exercise?

Answer 12

Inspect spine for posture (kyphosis, scoliosis, lordosis)
Inspect client’s gait, steadiness, ambulation and balance
Inspect patient’s feet for bunions, ulcers, calluses etc and inspect pt’s use of mobility aides if it applies

Question 13

Questions to ask pt about mobility?

Answer 13

-Describe your usual activities in a normal day (or week).
-What limitations in ability do you have (eating, toileting, walking, dressing, bathing)?
-Have you recently fallen or consider yourself to be at risk for falling?
-Do you experience fatigue or discomfort during activity?

Question 14

Assessment of general respiratory status occurs every time the nurse interacts with the patient. T or F

Answer 14

True- nurse should be be constantly assessing the ABCs and pain; pt’s chief complaint

Question 15

Respiratory function assessment should focus on

Answer 15

risk factors for lung disease
S&S of respiratory dysfunction
-Impact of respiratory syx on ADLs
- Adaptive measures for dysfunctions (what do they to help w/ the resp syx)

Question 16

Questions to ask about respiratory function

Answer 16

-Have you had allergies, asthma, bronchitis, emphysema, COVID-19, tuberculosis, or other lung problems?
- Do you have chest pains, SOBs? Frequency?
-How often do you cough? Frequency? Describe the sputum.
-Do any breathing difficulties limit your activity? What are they?
-What position do you assume for sleeping?

Question 17

Actions of nurse for respiratory function assessment

Answer 17

Count respirations
Auscultate/listen to lung sounds
Look at pt color/ look for cyanosis

Question 18

Cardiovascular function assessment should focus on

Answer 18

-any risk factors for cardiovascular disease (hypertension, elevated cholesterol smoking)
S&S of cardiovascular dysfunction like pain, dizziness, palpitations
-change/impact in ADLs

Question 19

Questions to ask about cardiovascular function

Answer 19

-Describe your normal activity or exercise pattern.
-Any history of heart attack, heart rhythm problems, high blood pressure, or high cholesterol?
-Have you had any chest pain; shortness of breath, cough, swelling in the legs or calf or leg pain, fluttering in the heart, or fatigue?

Question 20

Nutrition and metabolism assessment should focus on

Answer 20

normal food and fluid intake
alterations in normal eating patterns
how dietary changes have affected daily living

Question 21

Questions to ask about nutrition/ metabolism function

Answer 21

-Tell me what you’ve eaten in the last 24 hours.
-What is your usual weight? Any rapid weightloss or weight gain?
Do you have any problems with tasting, chewing, or swallowing food? Describe them.

Question 22

Actions of nurse for nutrition/metabolism assessemnt

Answer 22

Assess fluid intake and patient output (stool, emesis, urine- may get samples of output)

Question 23

How is weight used to measure fluid intake?

Answer 23

Rapid, unexplained weight loss or gain + or - 10 lbs in ~2 weeks can suggest fluid imbalance.

Question 24

Assessment of sleep and rest focuses on …

Answer 24

-patient’s normal sleep patterns, -alterations from the normal pattern, -pt satisfaction with quality of their rest and sleep
-Snoring, sleep apnea?

Question 25

How should nurse assess neurologic and mental status?

Answer 25

Nurse should focus on patient’s
-ability to think
-clarity and appropriateness of patient responses
- assess for sensory loss (5 senses)

Question 26

Questions nurse can ask to assess neurologic and mental status?

Answer 26

Tell me your name
Where are you right now
What is today’s date

Question 27

Questions to ask to assess for sensory loss?

Answer 27

How is your vision?
Do you have glasses, contact lenses, or a prosthesis?
How is your hearing? Do you use a hearing aid?
Do you have any numbness or tingling in your hands or feet?
Have you noticed any changes in your taste or smell?

Question 28

Questions to ask patient for assessment of self perception/ self image?

Answer 28

What are you most concerned about in relation to your health?
-How would you describe yourself?
-How has being sick made you feel differently about yourself?

Question 29

Questions to ask patient for assessment of roles and relationships?

Answer 29

Are you employed? Retired? Disabled?
With whom do you live ?
Whom do you ask for help when you need it?

Question 30

Questions to ask patient for assessment of coping and stress?

Answer 30

Any changes in your life causing stress?
How do you usually handle stress?

Question 31

Questions to ask patient for assessment of sexual health?

Answer 31

“Have you had intimate contact, oral sex, or penile-rectal intercourse in the past year?”
“How many sexual partners have you had in the past year?”
“With which gender(s) do you prefer to have sex?”
“What measures do you take to protect yourself from sexually transmitted infections? Pregnancy?”

Question 32

Questions to ask women about reproductive health

Answer 32

-What was the date of your last menstrual cycle?
-How many times have you been pregnant? How many children do you have?
-Do you examine your breasts? How often?
-Do you have a family history of breast cancer?

Question 33

Questions to ask men about reproductive health

Answer 33

Do you examine your testicles? How often?
Do you have any concerns about sexual function?