WEEK 1- HEALTH HISTORY

Question 1

Differentiate between subjective & objective data.

Answer 1

subjective- what the patient says, we can use “..” for things they say, pain, describes reason for seeking care

objective data- things we can measure, height, weight, BMI

Question 2

Outline components of the distinct health history types: Complete, focused, follow up & emergency.

Answer 2

Complete: everything
Episodic/Problem-Centred/Focused- focused on specifics
Follow-Up- updates on past
Emergency- immediate and focused

Question 3

Describe how the complete history incorporate psychosocial, developmental, sexual, cultural & spiritual components

Question 4

what to avoid in interview

Question 5

developmental considerations

Question 6

techniques in communication

Answer 6

Sending
Receiving
Attending to power differentials
Communication skills
Unconditional positive regard
Empathy
Active listening

Question 7

health assessment

Answer 7

health history (objective/subjective data)

physical exam

documentation

Question 8

Health History

Answer 8

biographical data

reason for seeking care

current illnesses

Past Health

Family History

Review of Systems

Functional Assessment

Perception of Health

Question 9

biographical data

Answer 9

Name
Address & phone number
Age and birth date
Birthplace
Gender
Marital Status
Ethnocultural background
Occupation
Primary Language

Question 10

source of history

Answer 10

Record who furnishes the information
Reliability of informant
Special circumstances (e.g., interpreter)

Question 11

reason for seeking care

Answer 11

Ask patient what prompted them to seek care
Symptom/sign
Use of quotation marks

Question 12

current health

Answer 12

O Onset
P Provocative or palliative
Q Quality or quantity
R Region or radiation
S Severity scale
T Timing
U Understand patient’s perception

Question 13

the working phase

Answer 13

Introducing the interview
The working phase
Open-ended and closed questions

Question 14

communication

Answer 14

Responses: assisting the narrative
Facilitation
Silence
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary

Question 15

nonverbal skills

Answer 15

Nonverbal skills
Physical appearance
Posture
Gestures
Facial expression
Eye contact
Voice
Touch

Question 16

challenging situations

Answer 16

Hearing-impaired patients
Acutely ill patients
Patients under the influence of alcohol or drugs
Personal questions asked of the clinician
Dealing with sexual advances
Patients who are crying
Angry patients
Patients who threaten violence
Anxious patients

Question 17

The nurse is required to do a health history and physical assessment on a client who does not speak English. What is the best strategy?

Answer 17

• get a staff member to translate

Question 18

The nurse has completed the initial assessment on the client. The nurse documents some of the assessment findings: Temp 36.9◦C, P 68, Bp 123/75, and Respirations 14. This data is best described as:

Answer 18

objective data

Question 19

The nurse is conducting an environmental assessment on a 52 year old male client who works in a chemical processing plant. What would this environmental assessment include?

Answer 19

type of exposure

Question 20

The nurse is admitting is assessing a new client. What would be the best type of assessment to perform?

Answer 20

comprehensive assessment

Question 21

The nurse is taking a comprehensive health history on a new client. The nurse knows that a complete description of the present illness is necessary:

Answer 21

to obtain primary data