Health History, Substance Use, and Violence Assessment

These question-and-answer flashcards cover core lecture points on obtaining a health history, differentiating sex and gender in care, PQRST symptom analysis, substance use definitions, addiction concepts, alcohol and drug screening tools, legal BAC limits, intimate partner violence, elder abuse, mandated reporting, and human trafficking awareness.

What is the key difference between the general survey and the complete health history?

The general survey is objective data observed by the nurse, whereas the complete health history is subjective data reported by the patient.

How is "health history" defined in clinical practice?

A systematic collection of the patient’s subjective information about past and present health, lifestyle, and risk factors.

List at least four items included in biographical data.

Name, address/phone, age/date of birth, sex assigned at birth, gender identity, relationship status, ethnicity/race, primary language, occupation.

Why must nurses know the sex assigned at birth of a patient?

Because specific body parts (e.g., prostate, cervix) determine risk‐based screenings and interventions.

What is the main nursing purpose in asking a patient’s preferred pronouns?

To build rapport and provide respectful, patient-centered care.

Why is documenting a patient’s primary reading language important?

Discharge instructions must be understandable; many patients converse in English but cannot read it fluently.

Give two reasons for collecting occupational information.

Identify environmental hazards/repetitive motions and understand physical activity level.

How should the reason for seeking care be documented?

In the patient’s own words, in quotation marks, without medical jargon or diagnosis terms.

Define a clinical "sign" versus a "symptom."

A sign is objective and measurable (e.g., fever); a symptom is subjective, describing how the patient feels (e.g., feeling hot).

What does each letter in PQRST stand for when analyzing symptoms?

P: Provokes/Palliates, Q: Quality/Quantity, R: Region/Radiation, S: Severity (scale), T: Timing.

Why is childhood chickenpox relevant in an adult health history?

Varicella virus can reactivate later as shingles, causing long-term complications.

When a patient lists a drug 'allergy,' what follow-up question is critical?

"What reaction did you have?"—to distinguish true allergy (e.g., hives) from side-effects (e.g., nausea).

Why must over-the-counter and herbal products be documented?

They can interact with prescriptions, and herbal supplements are not FDA-regulated.

Who are "first-degree relatives" for family history purposes?

Parents, siblings, and children.

What are Activities of Daily Living (ADLs)?

Basic self-care tasks such as eating, bathing, dressing, toileting, transferring, and walking.

Describe a 24-hour diet recall.

The patient lists everything eaten and drunk in the previous 24 hours to assess nutritional patterns.

Name at least three common sources of patient support assessed in health history.

Family, friends, religious community, workplace, clubs/organizations.

Define moderate drinking limits for men and women.

Men: ≤2 drinks/day; Women: ≤1 drink/day.

Which three cancers are associated even with moderate alcohol use?

Breast, oral, and esophageal cancers.

Define heavy drinking for men and women.

Men: ≥15 drinks/week; Women: ≥8 drinks/week.

What is the definition of binge drinking?

Consuming ≥5 drinks (men) or ≥4 drinks (women) in about 2 hours.

Why is addiction considered a brain disease?

Long-term substance use alters brain chemistry, affecting reward pathways and executive function.

Which illicit drug is most commonly used in the U.S.?

Marijuana.

Why is fentanyl-laced street drug use especially dangerous?

Fentanyl is potent, often undisclosed, and harder to reverse with standard Narcan dosing.

What is the federal policy for nurses regarding marijuana use?

Any detectable marijuana is prohibited for employees of federal agencies, regardless of state law.

What must a nurse do if a prescribed medication (e.g., Adderall) appears as a positive drug screen?

Disclose the prescription and dosage; impairment is still not allowed while practicing.

Is any amount of alcohol safe during pregnancy?

No—alcohol is teratogenic; fetal exposure can cause lifelong harm.

Define Fetal Alcohol Syndrome (FAS).

A pattern of physical deformities, growth deficits, and neurobehavioral problems caused by prenatal alcohol exposure.

What does the AUDIT screening tool assess?

Hazardous or harmful alcohol consumption over time.

What are the four CAGE questions used for?

Quick screening for lifetime alcohol misuse: Cut down, Annoyed, Guilty, Eye-opener.

What is the legal blood-alcohol concentration (BAC) limit for driving in the U.S.?

0.08% (80 mg/dL).

Explain the 'upper vs. downer' rule for withdrawal symptoms.

Withdrawal effects are generally the physiological opposite of the drug’s intoxication effects.

At what age should routine intimate-partner-violence (IPV) screening begin, according to Joint Commission recommendations?

All women of child-bearing age (≈14 years and older).

Give two behaviors that constitute stalking.

Unwanted repeated phone calls/texts and showing up uninvited at the victim’s location, causing fear.

Who are the most common perpetrators of elder abuse?

Family members or caregivers closely related to the victim.

What is a nurse’s legal obligation if elder or child abuse is suspected?

File a report immediately; nurses are mandated reporters and can be liable for failure to report.

Define human trafficking in a healthcare context.

Exploitation of individuals through force, fraud, or coercion for labor or sex, depriving them of freedom.

Why might trafficking victims hesitate to disclose their situation?

Fear of retaliation, loss of shelter/food, or deportation.

What is an "angel shot" and why is it important for nurses to know?

A coded request at bars for help; e.g., 'angel shot neat' signals the patron needs a safe escort.

When documenting injury photos for possible violence cases, what must be obtained first?

Written patient consent, unless the patient is incapacitated and policy permits documentation.

How can bruising descriptions stay objective in documentation?

Record location, size, and color (e.g., 3 cm purple ecchymosis) without interpreting age or cause.

What is the normal (expected) blood or breath alcohol level in a non-drinking individual?

0.00%

State one key limitation of the CAGE questionnaire.

It does not distinguish between past and current alcohol problems.