Health History & Communication Vocab

Question 1

Active listening

Answer 1

Paying complete attention to what another person is saying; listening closely while showing interest and refraining from interrupting.

Question 2

Biographic data

Answer 2

Information that identifies the client, such as name, address, phone number, gender, and who provided the information.

Question 3

Chief complaint

Answer 3

A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter.

Question 4

Clarification

Answer 4

Offering back to the speaker the essential meaning, as understood by the listener, of what they have just said.

Question 5

Clinical judgment

Answer 5

An iterative decision-making process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, generate the best possible evidence-based solutions in order to deliver safe client care.

Question 6

Confrontation

Answer 6

A communication skill wherein the nurse identifies and responds, provides feedback regarding those discrepancies in a client’s behavior in such a manner that the other person can grow.

Question 7

Context of Care

Answer 7

The elements of a client’s life or living situation that have psychological, social, and/or economic relevance to his or her use of professional health services.

Question 8

Documentation

Answer 8

A record containing a client’s background information or nursing history including assessments, nursing care plan and progress notes.

Question 9

Facilitation

Answer 9

To provide opportunities for personal growth in the patient; to encourage patient to continue speaking.

Question 10

Genogram

Answer 10

A tool that nurses use gather demographic, functional status/resources, and critical events/dynamic data to provide a comprehensive, holistic picture of a client and their environment.

Question 11

Health Promotion

Answer 11

The process of nurses providing patients the information they need to manage and ultimately improve their health enabling people to increase control over their health.

Question 12

Health Protection

Answer 12

Nurses role in preventing the spread of communicable diseases by establishing minimum standards, often in the form of regulations, and sharing information with patients.

Question 13

Objective data

Answer 13

Measurable information obtained by the nurse through observation, physical examination, and laboratory and diagnostic testing.

Question 14

Past Health History

Answer 14

Is information elicited by the nurse about the patient’s childhood illnesses and immunizations, accidents or traumatic injuries, hospitalizations, surgeries, psychiatric or mental illnesses, allergies, and chronic illnesses.

Question 15

Physical Exam

Answer 15

A health assessment that uses inspection, palpation, percussion, and auscultation.

Question 16

Present illness

Answer 16

A description of the present illness, injury, trauma, or chief complaint.

Question 17

Primary Prevention

Answer 17

Prevention of exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur.

Question 18

Primary source data

Answer 18

Information obtained by the nurse from the person who is being examined.

Question 19

Reflection

Answer 19

A therapeutic communication technique that reflects and mirrors what the nurse believes the client’s feelings to be underneath the words.

Question 20

Restatement

Answer 20

A communication technique where the nurse repeats the main idea of what the client has said, confirming that the client’s statement has been heard and understood.

Question 21

Review of Systems

Answer 21

An inventory of the body systems that is obtained by the nurse through a series of questions to identify signs or symptoms that the patient may be experiencing.

Question 22

Subjective data

Answer 22

Information obtained from the client’s point of view, including feelings, perceptions, and concerns.

Question 23

Secondary prevention

Answer 23

A form of early disease detection that identifies individuals with high risk factors or preclinical diseases through screenings and regular care to prevent the onset of disease.

Question 24

Shift assessment

Answer 24

A concise nursing assessment completed at the beginning of each shift where the nurses assesses specific body system(s) relating to the presenting problem or current concern(s) of the patient.

Question 25

Standards of Practice

Answer 25

The “how-to” of the nursing discipline that includes clinical policy statements, standard operating procedures, clinical practice protocols, and clinical procedures.

Question 26

Tertiary Prevention

Answer 26

A focus on people who are already affected by a disease wherein the goal is to improve quality of life by reducing disability, limiting or delaying complications, and restoring function.