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 a past surgical history of an 'appendix removal 10 years ago.' The nurse should document this as:
Answer: Appendectomy
Surgical removal of the appendix is called an appendectomy, and using the correct medical terminology ensures accurate documentation and communication.
During review of systems, a patient denies shortness of breath but reports sleeping with three pillows. What should the nurse recognize this as?
Answer: A possible sign of orthopnea, suggesting cardiac or respiratory compromise
Orthopnea is difficulty breathing when lying flat, and sleeping on multiple pillows is a compensatory behavior that may indicate heart failure or other cardiorespiratory conditions.
A patient is asked about immunization history but cannot recall specific vaccines. What is the nurse's most appropriate action?
Answer: Document 'immunization history unknown' and request records from previous healthcare providers
When a patient cannot recall immunization history, the nurse should document this accurately and attempt to retrieve records, as re-vaccination without records may be indicated later.
When screening a patient for depression during history taking, the PHQ-2 asks about which two core symptoms?
Answer: Depressed mood and loss of interest or pleasure
The PHQ-2 screens for the two cardinal symptoms of major depressive disorder: depressed mood and anhedonia (loss of interest or pleasure in activities).
A patient reports taking herbal supplements daily. Why is this information particularly important in the health history?
Answer: Herbal supplements can interact with prescribed medications
Many herbal supplements, such as St. John's Wort or ginkgo biloba, can interact with prescribed medications, so documenting them is essential for safe medication management.
A patient is asked about alcohol use and reports 'a couple of drinks on weekends.' Which standardized tool should the nurse use to further assess alcohol consumption?
Answer: AUDIT-C
The AUDIT-C (Alcohol Use Disorders Identification Test - Concise) is a validated three-question screen specifically designed to identify hazardous or harmful alcohol use.
During pediatric history taking, which information is uniquely important compared to adult history taking?
Answer: Developmental milestones and birth history
Developmental milestones and birth history (prenatal, perinatal, and postnatal history) are components unique to pediatric assessment and not typically collected for adult patients.