Module 1: ATI Health Assess 3.0 Health History

What does the PLEASE acronym stand for in a health interview?

Past medical hx, Last oral intake, Events leading to illness, Allergies (+ reaction), Symptoms/chief complaint, Each medication (Rx, OTC, herbal)

What are the three stages of a health history interview?

Opening (introduce, rapport), information gathering (body), closing (thank, answer questions, summarize)

How far should the nurse sit from the client, and in what position?

About 2–3 ft, face-to-face, not significantly higher than the client

What should the nurse do if the client is in pain before the interview?

Intervene to relieve it, allow time to take effect, document the intervention

What does PQRST stand for in pain assessment?

Pattern/precipitating factors, Quality, Radiates, Severity (0–10), Time and Treatment

When is a directive interview the best choice?

When precise details are needed fast (e.g., trauma before emergency surgery); nurse controls, closed-ended questions

When is a nondirective interview the best choice?

Building rapport or education/lifestyle teaching; client controls the pace, open-ended questions

What are the pros and cons of closed-ended questions?

Pro: fast, less threatening, easy to document. Con: little depth, may seem disinterested

What are the pros and cons of open-ended questions?

Pro: detail, conveys caring. Con: takes time, harder to document, may need redirecting

Why should the nurse avoid "why" questions?

They sound judgmental and make the client defensive

What is wrong with "You're worried about your results, aren't you?"

It's a leading question; it pushes an expected answer and reduces accuracy

Why shouldn't a family member interpret?

It can violate the client's privacy; use a professional interpreter or language line

How should the nurse speak when using an interpreter?

First person, directly to the client, short sentences, no jargon; interpreter beside or slightly behind client

How is the reason for seeking care documented?

In the client's own words, in quotation marks, with duration

What does OLD CARTS stand for?

Onset, Location, Duration, Characteristics, Aggravating/alleviating, Related symptoms, Treatment, Severity

In what order is the history of present illness documented?

Chronologically, from the first event to the present

What are the five key social determinants of health?

Economic stability, education, social/community context, health care access/quality, neighborhood and built environment

Which medication reactions should be documented as allergies?

Only true allergic reactions, not side effects like nausea or diarrhea

What does GTPAL stand for?

Gravida (total pregnancies), Term, Preterm (>2 wk before due date), Abortions (spontaneous or induced), Living children

Which relatives does the family history cover?

Three generations of blood relatives: grandparents, parents, siblings (age and cause of death if deceased)

What should the nurse do if a client reports pain during the review of systems?

Make addressing the painful symptom the priority

What does a functional assessment determine?

The client's ability to care for themselves when not acutely ill (lifestyle, environment, ADLs)

What are the four components of self-concept?

Self-esteem, body image, role performance, personal identity

What question screens health literacy?

What is the highest level of schooling you have completed?

What does FICA stand for?

Faith, Influence, Community, Address

Who should be screened for maltreatment, and how?

All clients, asked when the client is alone

Which five phrases should be avoided in an assessment?

"You should," "Why haven't," "Surely you don't," "Don't worry," "If I were you" (also "Let's discuss this later")