Question 1

Which data do nurses document under the category of personal and psychosocial health history? (Select all that apply.)

Accepted Answer

A)  Allergies to medications or food 
B)  Diet and foods eaten on a regular basis 
C)  Type of employment 
D)  Address and date of birth 
E)  Activities that promote health
F) Use of tobacco and alcohol 
A)  Allergies to medications or food 
B)  Diet and foods eaten on a regular basis 
C)  Type of employment 
D)  Address and date of birth 
E)  Activities that promote health
F) Use of tobacco and alcohol B, E, F

Question 2

What data do nurses document under the category general survey?

Accepted Answer

A)  Mental health 
B)  Functional ability 
C)  Diet and nutrition 
D)  Orientation 
A)  Mental health 
B)  Functional ability 
C)  Diet and nutrition 
D)  Orientation D

Question 3

Which data do nurses document under the category of past health history?

Accepted Answer

A)  Chronic diseases 
B)  Immunizations received 
C)  Allergies to medications or food 
D)  Causes of death of the patient's parents 
A)  Chronic diseases 
B)  Immunizations received 
C)  Allergies to medications or food 
D)  Causes of death of the patient's parents B

Question 4

Which documentation by a nurse is most descriptive?

Accepted Answer

A)  Heart sounds normal. 
B)  Few ectopic beats heard during auscultation. 
C)  S1 murmur is heard at second right sternal border. 
D)  Pulse within normal limits. 
A)  Heart sounds normal. 
B)  Few ectopic beats heard during auscultation. 
C)  S1 murmur is heard at second right sternal border. 
D)  Pulse within normal limits.

Question 5

The nurse documents which data under the category of present health status?

Accepted Answer

A)  Counts on her friends in stressful times 
B)  "I only sleep for 2 to 3 hours a night and use diphenhydramine for sleep." 
C)  Has a physical examination and flu vaccination annually 
D)  "I feel good about myself most of the time." 
A)  Counts on her friends in stressful times 
B)  "I only sleep for 2 to 3 hours a night and use diphenhydramine for sleep." 
C)  Has a physical examination and flu vaccination annually 
D)  "I feel good about myself most of the time."

Question 6

A patient reports she has shortness of breath and peripheral edema. Under which category does the nurse document these data?

Accepted Answer

A)  Review of systems 
B)  Present health status 
C)  Past health history 
D)  Functional ability 
A)  Review of systems 
B)  Present health status 
C)  Past health history 
D)  Functional ability

Which data do nurses document under the category of personal and psychosocial health history? (Select all that apply.)

What data do nurses document under the category general survey?

Which data do nurses document under the category of past health history?

Which documentation by a nurse is most descriptive?

The nurse documents which data under the category of present health status?

A patient reports she has shortness of breath and peripheral edema. Under which category does the nurse document these data?

Introduction to Health Assessment

Obtaining a Health History

Techniques and Equipment for Physical Assessment

General Inspection and Measurement of Vital Signs

Cultural Assessment

Pain Assessment

Mental Health Assessment

Nutritional Assessment

Skin, Hair, and Nails

Head, Eyes, Ears, Nose, and Throat

Lungs and Respiratory System

Heart and Peripheral Vascular System

Abdomen and Gastrointestinal System

Musculoskeletal System

Neurologic System

Breasts and Axillae

Reproductive System and the Perineum

Developmental Assessment Throughout the Life Span

Assessment of the Infant, Child, and Adolescent

Assessment of the Pregnant Patient

Assessment of the Older Adult

Conducting a Head-to-Toe Examination

Adapting Health Assessment to the Hospitalized Patient

Filters

Exam 23: Documenting the Comprehensive Health Assessment

Which data do nurses document under the category of personal and psychosocial health history? (Select all that apply.)

What data do nurses document under the category general survey?

Which data do nurses document under the category of past health history?

Which documentation by a nurse is most descriptive?

The nurse documents which data under the category of present health status?

A patient reports she has shortness of breath and peripheral edema. Under which category does the nurse document these data?

Introduction to Health Assessment

Obtaining a Health History

Techniques and Equipment for Physical Assessment

General Inspection and Measurement of Vital Signs

Cultural Assessment

Pain Assessment

Mental Health Assessment

Nutritional Assessment

Skin, Hair, and Nails

Head, Eyes, Ears, Nose, and Throat

Lungs and Respiratory System

Heart and Peripheral Vascular System

Abdomen and Gastrointestinal System

Musculoskeletal System

Neurologic System

Breasts and Axillae

Reproductive System and the Perineum

Developmental Assessment Throughout the Life Span

Assessment of the Infant, Child, and Adolescent

Assessment of the Pregnant Patient

Assessment of the Older Adult

Conducting a Head-to-Toe Examination

Adapting Health Assessment to the Hospitalized Patient

Filters