CELBAN Patient Health History Taking 2 — Questions and Answers
Question 1: A patient reports taking 'a water pill' every morning. What is the nurse's most appropriate follow-up question?
- How long have you been taking it?
- Can you tell me the name of the medication? (Correct answer)
- Who prescribed it for you?
- Do you take it with food?
Correct answer: Can you tell me the name of the medication?
Identifying the exact medication name is the priority because 'water pill' is a colloquial term that could refer to several different diuretics with different dosages and interactions.
Question 2: During history taking, a patient says her pain is '8 out of 10' but she is smiling and chatting comfortably. How should the nurse document this finding?
- Document pain as 2/10 based on observed behavior
- Document pain as 8/10 as reported by the patient and note the observed discrepancy (Correct answer)
- Ask the patient to reassess her pain score
- Disregard the pain score and rely on observation only
Correct answer: Document pain as 8/10 as reported by the patient and note the observed discrepancy
The nurse must document the patient's self-report as it is the gold standard for pain assessment, while also noting any objective discrepancies for clinical context.
Question 3: A patient is asked about allergies and states, 'Penicillin makes me nauseous.' How should the nurse classify this response?
- True drug allergy — document and apply allergy band
- Adverse drug reaction — document separately from true allergies (Correct answer)
- Intolerance — note it but no allergy band is required
- No clinical significance — omit from the record
Correct answer: Adverse drug reaction — document separately from true allergies
Nausea is an adverse drug reaction or side effect, not an immune-mediated allergy, and should be documented as such to avoid unnecessary withholding of penicillin.
Question 4: Which question uses the most therapeutic open-ended technique when beginning a patient history?
- Do you have any chest pain today?
- Is your pain sharp or dull?
- What brings you in to see us today? (Correct answer)
- Have you had this problem before?
Correct answer: What brings you in to see us today?
'What brings you in today?' is a non-leading open-ended question that allows the patient to describe their chief complaint in their own words.
Question 5: A patient mentions she recently traveled to Southeast Asia. Which history component makes this information clinically significant?
- Surgical history
- Travel and exposure history (Correct answer)
- Occupational history
- Immunization history
Correct answer: Travel and exposure history
Travel and exposure history is used to assess risk for infectious diseases endemic to visited regions, such as malaria or dengue fever.
Question 6: When asking a male patient about reproductive health history, the nurse should:
- Skip this section as it is not relevant to male patients
- Ask only if the patient volunteers the information
- Include it as a standard component of the review of systems (Correct answer)
- Delegate the question to the physician
Correct answer: Include it as a standard component of the review of systems
Reproductive and sexual health is a standard component of the review of systems for all adult patients, regardless of gender.
Question 7: A patient with limited English says 'I have sugar' when describing a chronic condition. What should the nurse do first?
- Document 'diabetes mellitus' immediately
- Ask a clarifying question to confirm the meaning (Correct answer)
- Request a professional interpreter before continuing
- Proceed with the physical assessment
Correct answer: Ask a clarifying question to confirm the meaning
Asking a clarifying question (e.g., 'Do you mean diabetes?') confirms the patient's meaning before documenting, preventing a potentially inaccurate medical record.
CELBAN Patient Health History Taking 2
A patient reports taking 'a water pill' every morning.
What is the nurse's most appropriate follow-up question?