Patient Health History Taking Flashcards
7 cards from real CELBAN practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Health History Taking flashcards as text
A patient reports taking 'a water pill' every morning. What is the nurse's most appropriate follow-up question?
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.
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?
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.
A patient is asked about allergies and states, 'Penicillin makes me nauseous.' How should the nurse classify this response?
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.
Which question uses the most therapeutic open-ended technique when beginning a patient history?
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.
A patient mentions she recently traveled to Southeast Asia. Which history component makes this information clinically significant?
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.
When asking a male patient about reproductive health history, the nurse should:
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.
A patient with limited English says 'I have sugar' when describing a chronic condition. What should the nurse do first?
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.