CELBAN Patient Health History Taking 2

Question 1

A patient reports taking 'a water pill' every morning. What is the nurse's most appropriate follow-up question?

Accepted Answer

Can you tell me the name of the medication?

Answer

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?

Accepted Answer

Document pain as 8/10 as reported by the patient and note the observed discrepancy

Answer

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?

Accepted Answer

Adverse drug reaction — document separately from true allergies

Answer

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?

Accepted Answer

What brings you in to see us today?

Answer

'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?

Accepted Answer

Travel and exposure history

Answer

Travel and exposure history is used to assess risk for infectious diseases endemic to visited regions, such as malaria or dengue fever.

(CELBAN) Canadian English Language Benchmark Assessment for Nurses Practice Test

(CELBAN) Canadian English Language Benchmark Assessment for Nurses Practice Test

CELBAN Patient Health History Taking 2