Patient Health History Taking Flashcards

A nurse is interviewing a patient who uses a professional interpreter. Which technique ensures accurate history taking?

Answer: Speak directly to the patient and pause for interpretation

The nurse should speak directly to the patient using normal speech, pausing for the interpreter, to preserve the therapeutic relationship and ensure the patient remains the focus of the interaction.

A patient reports that their primary care physician 'changed my blood pressure medication last month.' What follow-up is most important?

Answer: Confirm the name, dose, frequency, and route of the new medication

Confirming the complete details of the current medication (name, dose, frequency, route) ensures the accurate medication reconciliation required for safe care.

When asking about tobacco use, a patient reports quitting five years ago. How should this be documented?

Answer: Former smoker with cessation date noted

A patient who formerly smoked but has quit should be documented as a former smoker, including the quit date and, ideally, pack-year history, as past tobacco use remains clinically relevant.

A patient admits to recreational drug use but asks that it not be written down. How should the nurse respond?

Answer: Explain that accurate documentation is required for safe care and it will be kept confidential within the healthcare team

The nurse must explain that information shared is confidential within the care team and that accurate documentation is necessary to prevent harmful drug interactions and ensure safe care.

A culturally sensitive nurse is aware that some patients may not disclose mental health history due to stigma. The best approach is to:

Answer: Frame mental health questions in a non-stigmatizing, matter-of-fact way alongside other health history questions

Normalizing mental health questions by asking them in the same tone and sequence as physical health questions reduces stigma and increases the likelihood of accurate disclosure.

A patient with diabetes reports checking blood sugar 'sometimes.' What follow-up question most effectively clarifies this?

Answer: How many times per week do you typically check your blood sugar?

Asking how many times per week provides a quantifiable, non-judgmental answer that clarifies the patient's monitoring pattern without leading or shaming.

During a health history, the nurse asks about advance directives. A patient asks what that means. The best nurse response is:

Answer: 'These are legal documents that state your wishes for medical care if you become unable to speak for yourself.'

A clear, neutral explanation of advance directives as legal documents stating care preferences when the patient cannot communicate is accurate, respectful, and encourages informed participation.