HEALTH HISTORY Flashcards

1
Q

Which of the following is a close-ended question?

A

“What time do you usually get up in the morning?”

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2
Q

Play’s the steps in the correct order to record information when using the GTPAL format

A
Number of pregnancies
Number of term deliveries
Number of preterm deliveries
Number of voluntary or involuntary abortions
Current number of living children
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3
Q

Which of the following are research validated reasons to conduct a health history using an interpreter? (Select all that apply)

A

To increase the accuracy of communication

To increase the client’s satisfaction with care

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4
Q

How many generations should you collect medical history about?

A

3

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5
Q

For which of the following diseases should you obtain family history?

A
Head
Eyes
Ears
Nose
Mouth
Neck
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6
Q

A nurse is collecting data during a review of systems and ask the client how many pillows are required to sleep comfortably at night. This question involves assessment of which of the following systems?

A

Cardiovascular

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7
Q

Which of the following factors are included in health literacy? (select all that apply)

A

Basic reading skills
Competency using numbers
Ability to follow verbal instructions

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8
Q

Which aspect of life is assessed using the FICA approach?

A

Spirituality

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9
Q

Which of the following is a purpose of obtaining a health history?

A

To establish a baseline of the client’s health status

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10
Q

Drag the dialogue statement to place it in the correct interview technique category

A

Directive
How often do you exercise?
Did the medication help your discomfort?
Have you had an influenza vaccination this year?
When was the last time you had anything to eat or drink?
What causes you to become short of breath?

Nondirective
Tell me about the voices you are hearing
What questions do you have for me?
How do you feel about the diagnosis?
Please describe the chest pain
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11
Q

Match each question to its correct question type

A

Closed-ended
Do you have any numbness or tingling in your hand?
When was your last bowel movement?
Can you rate your pain on a scale of 0 to 10 with zero being no pain and 10 being the worst pain you can imagine?
How many flights of stairs can you climb before you become short of breath?

Open-ended
What is your goal for treatment?
How are you feeling today?
What brings you to the clinic?
Do you have questions about your scheduled surgery?
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12
Q

Review of Systems (ROS)

A

physical examination of all body systems in a systematic manner as part of the nursing assessment

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13
Q

Social History (SH)

A

information about the patient’s tobacco use, alcohol and drug use, sexual history, relationship status, and other significant social facts that may contribute to the care of the patient

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14
Q

Family History (FH)

A

The family history reviews the medical events in the patient’s family. It includes the health status or cause of death of parents, brothers and sisters, and children; specific diseases that are related to the patient’s chief complaint or the patient’s diagnosis; and the presence of any known hereditary diseases.

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15
Q

Past Medical History (PMH)

A

A listing of any illnesses the patient may have had in the past; includes treatments and procedures performed.

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16
Q

History of Present Illness (HPI)

A

the story of the patient’s problem

17
Q

Chief Complaint (CC)

A

specific symptom or problem for which the patient is seeing the provider today

18
Q

Order of Health History

A

Chief Complaint (CC), History of Present Illness (HPI), Past Medical History (PMH), Family History, FH Social History (SH), Review of System (ROS)

19
Q
Gravida: # of pregnancies
Term: # of term deliveries
Pre-term:# of pre-term deliveries
Abortions:# of abortions, elective or spontaneous
Living:# of living children
A

what is GTPAL?

20
Q

childhood illnesses, injuries, chronic illness, hospitalization, surgeries, immunizations, last medical exam, allergies, current meds, alcohol, tobacco/ nicotine use, caffeine, patterns of exercise, nutrition, sleep, recreational or prescription drug use

A

general data includes (14)

21
Q

severity: how severe symptoms are

A

OLD CARTS: S means

22
Q

treatment: what treatments have been tried

A

OLD CARTS: T means

23
Q

related symptoms: other symptoms present

A

OLD CARTS: R means

24
Q

aggravating and alleviating factors: what affects the symptoms

A

OLD CARTS: A means

25
Q

characteristics: characteristics of symptoms

A

OLD CARTS: C means

26
Q

duration: how long symptoms last

A

OLD CARTS: D means

27
Q

location: where symptoms occur

A

OLD CARTS: L means

28
Q

onset: when symptoms began

A

OLD CARTS: O means

29
Q

Non-directive interview

A

An interview in which the applicant is allowed the maximum amount of freedom in determining the course of the discussion, while the interviewer carefully refrains from influencing the applicant’s remarks

30
Q

open-ended questions

A

questions that allow respondents to answer however they want

31
Q

close-ended questions

A

Questions that can be answered in short or single word responses.

32
Q

Directive interview

A

a highly structured interview that uses closed questions to elicit specific information