Health Assessment Ch 23

5.0 (1 review)
Which documentation by a nurse is most descriptive?
a. Heart sounds normal.
b. Few ectopic beats heard during auscultation.
c. S1 murmur is heard at second right sternal border.
d. Pulse within normal limits.
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Terms in this set (6)
Which documentation by a nurse is most descriptive?
a. Heart sounds normal.
b. Few ectopic beats heard during auscultation.
c. S1 murmur is heard at second right sternal border.
d. Pulse within normal limits.
ANS: C
Option C is the most descriptive data, specifying what is heard and the location. Option A is not specific
without a description of what is considered "within normal limits" for hair color, texture, length, etc.
Option B is not specific because the number of permanent teeth is not detailed. Option D would be more
descriptive if the pain scale were used to indicate the level of tenderness and if the location on the
abdomen were documented.
The nurse documents which data under the category of present health status?
a. Counts on her friends in stressful times
b. "I only sleep for 2 to 3 hours a night and use diphenhydramine for sleep."
c. Has a physical examination and flu vaccination annually
d. "I feel good about myself most of the time."
ANS: B
The data in option B would be found in the present health history. The description mentioned in Option A
would be found in the mental health assessment in the personal history. This descriptive data mentioned
in option C would be found in the past health history. The description mentioned in Option D would be
found in the psychosocial health history.
Which data do nurses document under the category of past health history?
a. Chronic diseases
b. Immunizations received
c. Allergies to medications or food
d. Causes of death of the patient's parents
ANS: B
Immunizations are documented under the past health history category. Chronic diseases are documented
under the present health status category. Allergies to medications or food are documented under the
present health status category. Causes of death of parents are documented under the family history
category.
A patient reports she has shortness of breath and peripheral edema. Under which
category does the nurse document these data?
a. Review of systems
b. Present health status
c. Past health history
d. Functional ability
ANS: A
In the review systems part of the history, the nurse asks patients whether they have had symptoms from
specific body systems. Patients either deny or admit to having the symptoms. The present health status
category contains data on chronic diseases, medications, and allergies. The past health history category
contains data on childhood diseases, surgeries and hospitalizations, and immunizations. The functional
ability category contains data on patient's activities, including maintaining a home and working full-time.
What data do nurses document under the category general survey?
a. Mental health
b. Functional ability
c. Diet and nutrition
d. Orientation
ANS: D
The general survey is the beginning of the examination when the nurse is collecting data about the patient.
Mental health is described under the heading of personal and psychosocial history. Functional ability data
are collected during the history. Diet and nutrition data are collected during the history.
Which data do nurses document under the category of personal and psychosocial health
history? (Select all that apply.)
a. Allergies to medications or food
b. Diet and foods eaten on a regular basis
c. Type of employment
d. Address and date of birth
e. Activities that promote health
f. Use of tobacco and alcohol
ANS: B, E, F
The data in options B, E, and F are documented under the heading of personal and psychosocial health.
Allergies to medications or food are documented under the present health status category. Type of
employment is documented under the heading of biographic data. Address and date of birth are
documented under the heading of biographic data.