Chapter 3: Health History and Physical Examination

Database

a collection of organized data that allows access, retrieval, and use of data

Biographical Data

Name

Address and phone number

Age and birth date

Birthplace

Sex

Marital status

Race

Ethnic origin

Occupation: usual and present

Health History

a collection of subjective information that provides information about the patient's health status

Family Health History

a record of any illnesses or medical conditions that have afflicted members of a person's family

Review of Systems

description of individual body systems in order to discover any symptoms not directly related to the main problem

General Survey

physical appearance, body structure, mobility, behavior

1. The patient's health history and physical examination findings enable the nurse with information to primarily take which action?

a. Diagnose a medical condition.

b. Investigate the client's signs and symptoms.

c. Classify subjective and objective client data.

d. Identify nursing diagnoses and collaborative problems.

d. Identify nursing diagnoses and collaborative problems.

2. The nurse would place information about the patient's concern that his illness is threatening his job security in which functional health pattern?

a. Role-relationship

b. Cognitive-perceptual

c. Coping-stress tolerance

d. Health perception-health management

a. Role-relationship

3. The nurse is preparing to examine a patient's abdomen. Place in order the proper steps for an abdominal assessment, using the numbers 1-4, with 1 = the first technique and 4 = the last technique.

___ Inspection

___ Palpation

___ Percussion

___ Auscultation

Inspection

Auscultation

Percussion

Palpation

4. Which situation would require the nurse to perform a focused assessment? (Select all that apply.)

a. A patient denies a current health issue.

b. A patient reports a new symptom during rounds.

c. A previously identified health issue needs reassessment.

d. A baseline health maintenance examination is required.

e. An emergency condition is identified during physical examination.

b. A patient reports a new symptom during rounds.

c. A previously identified health issue needs reassessment.