Health History & Interview
The phase of the interview occurs before seeing the patient and includes reviewing the chart.
What is the pre-interaction phase?
This is required after caring for a patient with C. difficile.
What is soap and water hand hygiene?
A patient’s respiratory rate is 32/min with nasal flaring and accessory muscle use. The nurse identifies this alteration in respirations.
What is tachypnea?
A patient presents with a raised irregular lesion caused by localized edema after a mosquito bite. This lesion is classified as this type.
What is a wheal?
During visual testing, a patient reads the Snellen chart as 20/40. This means the patient sees at 20 feet what a person with normal vision sees at this distance.
What is 40 feet?
A patient with asthma has high-pitched musical breath sounds during expiration. The nurse documents these sounds as this.
What are wheezes?
A patient reports crushing chest pain radiating to the jaw and left arm with diaphoresis. The nurse suspects this condition.
What is myocardial infarction?
A patient reports calf pain while walking that improves with rest. The nurse identifies this symptom as this.
What is intermittent claudication?
A patient with a BRCA1 mutation is at significantly increased risk for this disease.
What is breast cancer?
A nurse assesses the abdomen in this sequence to avoid altering bowel sounds.
What is inspection, auscultation, percussion, palpation?
A patient can move an extremity through full ROM against gravity only. The nurse documents muscle strength as this grade.
What is 3/5?
A patient correctly identifies person, place, time, and situation. The nurse documents this as this level of orientation.
What is A&O ×4?
The acronym used to assess the history of a present illness includes onset, location, duration, and severity.
What is OLDCARTS?
This PPE item is removed first when doffing equipment.
What are gloves?
A nurse obtains a blood pressure immediately after the patient stands and notices a significant drop accompanied by dizziness. The nurse suspects this condition.
What is orthostatic hypotension?
A nurse identifies a pressure injury with partial-thickness skin loss and an open blister. This pressure injury is classified as this stage.
What is Stage II?
A nurse palpates a lymph node that is hard, fixed, and irregular. These findings are most concerning for this disease process.
What is malignancy?
A patient suddenly develops loud crowing respirations and visible respiratory distress. The nurse recognizes this emergent sound as this.
What is stridor?
A patient with orthopnea and crackles most likely has this type of heart failure.
What is left-sided heart failure?
Cool pale skin, weak pulses, and delayed capillary refill are characteristic findings of this vascular disorder.
What is peripheral arterial disease?
A nurse notes dimpling and nipple retraction during inspection. These findings are suspicious for this disease process.
What is malignancy/breast cancer?
A nurse hears high-pitched gurgling sounds occurring 5–30 times per minute. These findings are considered this type of bowel sound finding.
What are normal bowel sounds? borborygmi?
Pain that worsens with activity and improves with rest is most characteristic of this musculoskeletal disorder.
What is osteoarthritis?
During assessment, an adult patient demonstrates fanning of the toes after plantar stimulation. This abnormal neurological finding is called this sign.
What is a positive Babinski sign?
This type of health history focuses on a current problem or symptom.
What is a focused health history?
The correct order for donning PPE begins with this item.
What is the gown?
A patient’s oxygen saturation is 88%, pulse is 118 bpm, and the patient appears restless. The nurse recognizes these findings as early indicators of this condition.
What is hypoxia?
A lesion with asymmetry, irregular borders, color variation, and diameter greater than 6 mm should make the nurse suspect this condition.
What is melanoma?
A patient reports a sudden “worst headache of my life” accompanied by neck stiffness and neurological changes. The nurse identifies this as this type of headache red flag.
What is a thunderclap headache?
A patient with pneumonia has a harsh grating sound during inspiration and expiration accompanied by pain while breathing. The nurse documents this as this sound.
What is a pleural friction rub?
A patient with JVD, ascites, hepatomegaly, and bilateral edema is most likely experiencing this condition.
What is right-sided heart failure?
A patient presents with warm swollen legs, brown discoloration, and aching worsened by prolonged standing. The nurse suspects this disorder.
What is chronic venous insufficiency?
A nurse palpates the extension of breast tissue into the axilla known as this structure.
What is the Tail of Spence?
A patient reports RLQ pain with rebound tenderness and guarding. The nurse suspects inflammation involving this abdominal structure.
What is the appendix?
A patient with rheumatoid arthritis may develop hyperextension of the PIP joint with flexion of the DIP joint, known as this deformity.
What is swan-neck deformity?
A patient sways and nearly falls after closing the eyes during balance testing. The nurse documents this as this positive cerebellar test.
What is a positive Romberg test?
Data such as blood pressure and temperature are considered this type of data.
What is objective data?
This assessment technique involves tapping the body to assess underlying structures.
What is percussion?
A patient with severe dehydration is most likely to exhibit hypotension, tachycardia, and this neck vessel finding.
What are flat neck veins?
A patient’s nail beds appear cyanotic and capillary refill is delayed greater than 2 seconds. The nurse interprets these findings as evidence of this problem.
What is poor oxygenation/perfusion?
A patient demonstrates unequal pupil constriction after light exposure. Because pupillary constriction is controlled by this cranial nerve, the nurse suspects dysfunction there.
What is CN III (oculomotor)?
A nurse notes asymmetrical chest expansion after trauma. The nurse recognizes this may indicate this serious complication.
What is lung collapse/pneumothorax?
A nurse auscultates the apical pulse at the 5th ICS left midclavicular line. This valve is best heard there.
What is the mitral valve?
A postoperative patient develops unilateral calf warmth, redness, and tenderness. The nurse suspects this vascular complication.
What is deep vein thrombosis?
Orange-peel edema of the breast indicates this underlying pathophysiological process.
What is lymphatic obstruction?
A nurse percusses over the liver and expects to hear this percussion sound.
A nurse percusses over the liver and expects to hear this percussion sound.
A nurse asks a patient to push against resistance while assessing ROM and bilateral strength. This component of the exam is being assessed.
What is muscle strength?
A patient cannot correctly perform rapid alternating hand movements. The nurse recognizes impairment involving this area of the nervous system.
What is the cerebellum?
During this interview phase, the nurse establishes rapport and identifies the patient using two identifiers.
What is the introduction phase?
This body system is assessed in the order of inspection, auscultation, percussion, palpation.
What is the abdomen?
A nurse prepares to take a manual blood pressure but notices the cuff is too small for the patient’s arm. This error will most likely cause this inaccurate result.
What is a falsely elevated blood pressure?
A patient with COPD demonstrates nail clubbing with an angle greater than 180 degrees. The nurse recognizes this finding as associated with this chronic condition.
What is chronic hypoxia?
A patient reports ringing in the ears without external stimuli. The nurse documents this symptom as this condition.
What is tinnitus?
A patient with heart failure develops fine crackles, dyspnea, and pink frothy sputum. The nurse recognizes these findings as pulmonary congestion caused by this condition.
What is left-sided heart failure/pulmonary edema?
A patient develops hypotension, diaphoresis, tachycardia, and chest pressure. The nurse recognizes these as classic manifestations of this cardiovascular emergency.
What is myocardial infarction?
A patient with dehydration is expected to have weak pulses, hypotension, and this urinary finding.
What is decreased urine output?
A nurse instructs a patient to raise both arms overhead during inspection to better visualize this abnormal breast finding caused by underlying tissue fixation.
What is dimpling/retraction?
A nurse auscultates no bowel sounds for 2 minutes. According to correct assessment technique, the nurse should do this next.
What is continue auscultating for a total of 5 minutes?
A patient with warm swollen joints, morning stiffness, and pain at rest most likely has this inflammatory disorder.
What is rheumatoid arthritis?
A nurse asks the patient to say “ahh” while assessing uvula rise and gag reflex. These cranial nerves are primarily being tested.
What are CN IX and X?
A patient states, “My chest hurts.” This is classified as this type of data.
What is subjective data?
This assessment technique uses a stethoscope to assess movement of air or fluid.
What is auscultation?
A postoperative patient suddenly becomes bradypneic with a respiratory rate of 8/min and difficult arousal. The nurse identifies this as a priority because it may indicate this complication.
What is respiratory depression?
A nurse notes thickened skin caused by repeated scratching and chronic irritation. This secondary lesion is known as this.
What is lichenification?
During confrontation testing, the patient fails to identify fingers entering the peripheral visual field. The nurse suspects impairment in this aspect of vision.
What is peripheral vision?
A patient with COPD demonstrates a widened costal angle and pursed-lip breathing. The widened costal angle indicates this underlying respiratory change.
What is hyperinflation?
A patient has severe dyspnea, crackles, and pink frothy sputum. The nurse should prioritize intervention because these findings suggest this complication.
What is pulmonary edema?
A patient suddenly develops chest pain, dyspnea, tachycardia, and anxiety after prolonged immobility. The nurse suspects this complication of DVT.
What is pulmonary embolism?
risk factors for breast cancer
what is age, brca 1 and 2, alcohol use, increased estrogen, Postmenopausal weight gain, family history
A nurse auscultates over the abdomen and hears a vascular swishing sound instead of normal bowel sounds. The nurse documents this abnormal finding as this.
What is a bruit?
A nurse notes decreased bone density, kyphosis, muscle atrophy, and decreased ROM in an older adult. These findings are associated with this process.
What are age-related musculoskeletal changes?
A patient suddenly develops unilateral weakness, facial droop, slurred speech, and confusion. The nurse recognizes these findings as this neurological emergency.
What is a stroke/CVA?
This section of the health history reviews symptoms related to all body systems.
What is the review of systems (ROS)?
A nurse wipes alcohol hand rub off before it dries. This infection-control principle was violated.
What is allowing alcohol rub to air dry completely?
A patient develops cyanosis, confusion, tachycardia, and oxygen saturation of 82%. The nurse should prioritize intervention for this life-threatening condition.
What is acute respiratory distress/hypoxia?
A bedridden patient scores low in sensory perception, mobility, and nutrition on the Braden Scale. The nurse recognizes the patient is at high risk for this complication.
What is pressure injury formation?
A patient demonstrates difficulty swallowing, uvula deviation, and impaired gag reflex. The nurse suspects dysfunction involving these cranial nerves.
What are CN IX and X?
A postoperative patient suddenly develops dyspnea, tachycardia, anxiety, and chest pain. The nurse suspects this life-threatening complication.
What is pulmonary embolism?
A patient with fluid volume overload presents with bounding pulses, crackles, hypertension, and JVD. The nurse identifies this overall condition.
What is fluid volume excess?
A patient with fluid overload develops crackles, dyspnea, hypertension, and pink frothy sputum. The nurse recognizes this severe complication.
What is pulmonary edema?
age you should start mammograms and how often
what is 45-55, annually?
To assess abdominal anatomy correctly, the nurse should recognize that this quadrant contains the liver, gallbladder, and duodenum; this quadrant contains the stomach, spleen, and pancreas; this quadrant contains the cecum, appendix, and right ovary.
What are:
A patient demonstrates painful enlargement of DIP joints with Heberden nodes. The nurse recognizes these findings as most consistent with this disorder.
What is osteoarthritis?
A patient opens eyes only to pain, makes incomprehensible sounds, and withdraws from painful stimuli. The nurse uses this neurological scale to quantify the patient’s LOC.
What is the Glasgow Coma Scale?