Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Docu, Exams of Nursing

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Health History Tips & Tricks: - correct answerTJ Health Interview Student: Hello! - correct answerDiana Shadow: Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. Student: What is the situation? - correct answerDiana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. Student: What are my objectives in this assessment? - correct answerDiana Shadow: A health history requires you to ask questions related to Ms. Jones' past and present health, from her current foot wound to her pre-existing conditions. You will also want to review Ms. Jones' systems, psychosocial history, and family medical history. These assessments together will give you a comprehensive picture of Ms. Jones' overall health. If you discover any disease states, ask about symptoms and the patient's experiences of them. Your questioning should cover a broad array of the symptoms' characteristics. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Regardless of whether you have assessed Ms. Jones previously, ask all questions that are necessary for obtaining a complete health history. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. After obtaining Ms. Jones' health history, you will complete an information processing activity. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses. Student: What else will this exam involve? - correct answerDiana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Besides Subjective Data Collection, and Education and Empathy, there are activities within the simulation that provide valuable practice for their real-world counterparts, but they are not automatically graded by the simulation. Student: How will I be evaluated? - correct answerDiana Shadow: In this assignment, you will be evaluated on your Subjective Data Collection, as well as your Education and

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Empathy. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. This assignment takes on average between 90 and 110 minutes. This exam may take longer than in real life, because in this safe simulation, students of all experience levels can take time to hone and review their skills. You can pause and resume the assignment at any time; your work is always saved automatically. Student: How does this assignment prepare me for the real world? - correct answerDiana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify areas to improve º identify and prioritize nursing diagnoses º and develop a plan to address nursing diagnoses. Diana Shadow: In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Why is it important to obtain a patient's complete health history? - correct answerStudent: So that you understand if there are any problems related to their chief complaint. Also, to help treat their current condition. Diana Shadow: Time to begin. - correct answer Patient Exam - Vital Signs: - correct answerHeight: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98% Patient Exam - Interview: - correct answer Student: Hello, my name is Catlain, I am your nurse today. - correct answerTina Jones: Hey. Student: Can you confirm your name? - correct answerTina Jones: Tina Jones:. Student: Why did you come in today? - correct answerTina Jones: I got this scrape on my foot a while ago, and it got really infected. It's killing me. Student: What additional symptoms have you experienced? - correct answerTina Jones: I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all that going on.

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Student: Can you rate your current pain level on a scale of 0 to 10? - correct answerTina Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit. Student: Please describe the pain. - correct answerTina Jones: It's throbbing and like, sharp if I try to put weight on it. Student: How did you hurt your foot? - correct answerTina Jones: I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the edge was! Student: Has your foot been draining any liquids? - correct answerTina Jones: Yeah, there's definitely pus. Student: What color was the pus? - correct answerTina Jones: It's... white or maybe off- white. Student: How have you treated the wound? - correct answerTina Jones: I've been taking Advil for my foot for a few days. Student: What did you do to treat your foot after your accident? - correct answerTina Jones: I made sure to clean it and keep it bandaged. And I put Neosporin on it. Student: How effective was the Neosporin? - correct answerTina Jones: Well, I'm here, so I guess it didn't do its job. Student: Can you walk with your foot being injured? - correct answerTina Jones: No, I can't. I can't put any weight on it without like, shooting pain. Student: What preexisting medical conditions do you have? - correct answerTina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot! Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. - correct answerTina Jones: Thanks. Student: When were you diagnosed with diabetes? - correct answerTina Jones: I was diagnosed when I was 24. Student: What do you do to manage your asthma? - correct answerTina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.

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Student: What medications did you take for your diabetes? - correct answerTina Jones: It was metformin. Student: Do you currently take medicine for your diabetes? - correct answerTina Jones: No, I don't take anything for my diabetes anymore. Student: What made you stop taking medication for your diabetes? - correct answerTina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. Student: Do you monitor your blood glucose? - correct answerTina Jones: I have a monitor at home, but to be honest I don't really use it that often. Student: How frequently do you urinate? - correct answerTina Jones: I don't know. Every hour or two when I'm awake? Student: What is your current diet? - correct answerTina Jones: It's pretty good, I think. I'm not a huge health nut or anything. Student: Have you had any change in appetite? - correct answerTina Jones: Yeah, lately I've definitely been much hungrier than usual. Student: Has your weight changed? - correct answerTina Jones: Yeah, I've lost some weight recently. Student: Do you know why you lost weight? - correct answerTina Jones: I don't know what caused it, I just lost weight. Student: How often do you have asthma exacerbations? - correct answerTina Jones: I haven't had a full attack in years. But my breathing definitely acts up.. .not always. Max twice a week. Student: What asthma symptoms have you experienced? - correct answerTina Jones: My chest and throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get enough air into my lungs. Student: How many puffs do you take when using your asthma inhaler? - correct answerTina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]

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Student: What are some things that trigger your asthma? - correct answerTina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Student: What allergies do you have? - correct answerTina Jones: I'm allergic to cats. Student: When did you realize you were allergic to cats? - correct answerTina Jones: For as long as I've been around. Student: How effective was your pain medication at home? - correct answerTina Jones: Whatever pain medication the ER gave me is helping. Before I came in, I was just taking Advil. For the past few days, the Advil wasn't doing much for me -- it would only last a couple of hours. Student: What medication allergies do you have? - correct answerTina Jones: I'm allergic to penicillin. Student: What food allergies do you have? - correct answerTina Jones: I don't have any food allergies that I know of. Student: Are you allergic to dust, mold, or pollen? - correct answerTina Jones: Well... I don't know if it's allergies, but sometimes my asthma acts up around dust. Student: What immunizations have you received? - correct answerTina Jones: I got a tetanus booster for work about a year ago. For the other kinds, I got all the required ones when I was a kid, and for college...I'm sure I have a record somewhere at home. Student: Have you received a flu vaccine? - correct answerTina Jones: No. Student: Have you had any prior hospitalizations? - correct answerTina Jones: Well, before this I went a bunch of times when I was little, for asthma attacks. This is the first time I've been in the hospital since I was probably sixteen, though. Student: Have you had any gastrointestinal problems? - correct answerTina Jones: No. I've never really had stomach or bowel problems. Student: Do you have a family history of psychiatric illness? - correct answerTina Jones: No. They're crazy, but nobody's diagnosed with anything. Student: Do you have any neck, throat or gland problems? - correct answerTina Jones: No, not that I noticed.

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Student: Do you have any problems with your head? - correct answerTina Jones: I don't think I have any problems. I get headaches sometimes, but that's all. Student: Any problems with your ears? - correct answerTina Jones: No. Student: Any problems with your eyes and vision? - correct answerTina Jones: I've actually been noticing problems lately. When I'm reading or studying I'll notice that things start to get kind of blurry. Student: Any problems with your nose? - correct answerTina Jones: My nose is fine right now. Sometimes it runs, but not very often. Student: Do you have problems with your mouth? - correct answerTina Jones: No. Student: Do you have a history of cardiovascular problems? - correct answerTina Jones: My heart's fine, thank God! Student: Any problems with your heart? - correct answerTina Jones: No, my heart's always been fine. Student: Have you had any problems with your breasts? - correct answerTina Jones: I haven't noticed any pain there. Student: Have you had any reproductive problems? - correct answerTina Jones: I don't think I have problems in that area. I just get really bad periods, that's all. Student: Have you had any neurological problems? - correct answerTina Jones: No, I haven't. Student: Have you had any musculoskeletal problems? - correct answerTina Jones: No. Student: Do you have a history of skin disease? - correct answerTina Jones: Um, I have acne, if that counts. Student: Does your paternal grandfather have any health problems? - correct answerTina Jones: Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and...I'm pretty sure he had diabetes. And high cholesterol like everyone else in my family. Student: Does your mother have any health problems? - correct answerTina Jones: Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

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Student: Does your father have any health problems? - correct answerTina Jones: Well, he passed away. But he had a couple things... Type 2 diabetes, like me, and high cholesterol and blood pressure. Student: How did your father die? - correct answerTina Jones: He died in a car accident. Student: Where is your wound located? - correct answerTina Jones: It's on the ball of my foot. Student: Do you get thirsty often? - correct answerTina Jones: You know, I did notice lately that I've been really thirsty. Student: What happened with your father's car accident? - correct answerTina Jones: It was last year... I guess a little over a year ago. Student: How long ago was your dad's car accident? - correct answerTina Jones: It was last year... I guess a little over a year ago. Student: How did you cope with your fathers death? - correct answerTina Jones: Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kind of depressed. So, I guess at first I just focused on getting things done--groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kind of helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months. Student: What caused your dads accident? - correct answerTina Jones: He was driving to work, and it was raining...and his car hydroplaned. And hit a tree. So, it was really sudden. Student: How is your paternal grandmother's health? - correct answerTina Jones: Granny's doing good. She's still living on her own. She's slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy. Student: How is your paternal grandfather's health? - correct answerTina Jones: Grandpa Jones passed away when I was really little.

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Student: How is your maternal grandfather's health? - correct answerTina Jones: Well, Poppa died about five years ago. Student: How is your maternal grandmother's health? - correct answerTina Jones: Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. Student: How is your brother's health? - correct answerTina Jones: He's a healthy guy. Kind of big like me. Student: How is your sister's health? - correct answerTina Jones: She's pretty healthy. She has asthma too, but she almost never has attacks. Student: Does your family have a history of obesity? - correct answerTina Jones: No, I don't think so. My brother and my dad are kind of big, but I wouldn't say they were obese or anything. Student: Does your family have a history thyroid issue? - correct answerTina Jones: No, I don't think so. Student: Does your family have a history of substance abuse? - correct answerTina Jones: One person in the family, my dad's brother, has an alcohol problem, but we never see him. Student: Does your family have a history of headaches? - correct answerTina Jones: No, not that I know of. Student: How much alcohol do you drink? - correct answerTina Jones: I only have a few drinks when I go out. Student: What is your level of education? - correct answerTina Jones: Well, I'm finishing up my bachelor's degree right now. Student: What are stressors? - correct answerTina Jones: I feel really stressed out right now! Honestly, I didn't realize that I'd be admitted to the hospital for my foot. I don't want to miss work or school but now it looks like I'll have to. And I want my foot to stop hurting. I know I need sleep, too. Student: We are going to take care of everything as quickly as possible. - correct answerTina Jones: Thanks. Student: Where do you live? - correct answerTina Jones: Right now, I'm living at my mom's place, which is out in the suburbs a bit. It's like a half hour from here.

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Student: What is your belief system? - correct answerTina Jones: I'm Baptist. My faith is a big part of my life--when things get hard like they've been this past year, I know I can trust that God's looking out for me. I've been going to the same church since I was a kid, too, so the people at church are practically part of my family. Student: Have you experienced abuse? - correct answerTina Jones: I've never had been in any kind of situation like that... It's scary to think about. Student: Have you used illicit drugs? - correct answerTina Jones: Well, I used to smoke pot... but I don't do that anymore. Student: What type of drugs did you use? - correct answerTina Jones: Um...I've smoked pot before. In high school, and after high school... I definitely don't anymore, though. Student: Have you used drugs other than marijuana? - correct answerTina Jones: No. Student: When did you last use drugs? - correct answerTina Jones: I haven't smoked pot since I was twenty or twenty-one. Student: Have you ever smoked cigarettes? - correct answerTina Jones: No. I think it's gross. Student: Have you been around people that are smoking? - correct answerTina Jones: Some of my friend's smoke when we go out drinking. But I don't smoke, and nobody at home smokes. Student: How old were you when your father died? - correct answerTina Jones: He died last year, so I was 27. Student: Did your father die from any disease? - correct answerTina Jones: He died in a car accident. Student: Can you tell me about your father's health? - correct answerTina Jones: He had high blood pressure and cholesterol. And diabetes -- we have diabetes in common. Student: I can't even imagine how you feel about losing your father - correct answerTina Jones: Thanks. Student: Tell me about your father. - correct answerTina Jones: Dad was a little stricter than Mom growing up... he would sometimes get kind of mad at us when we did something wrong. But he never hit us or anything. He would just get really calm and quiet and tell us to go to our rooms without supper, or that we were grounded when we

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were older. Or like, he'd make us rake the yard or wash his car or something. It's pretty sad to Student: How old was your father when he died? - correct answerTina Jones: Last year when Dad passed, he was only 58. Subjective Data Collection - Checklist: - correct answer Chief Complaint - correct answer Finding: Established chief complaint - correct answer Finding: Reports pain (Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. - correct answerExample Question: Do you have any pain? Finding: Reports foot wound (Found)Pro Tip: If a patient mentions pain, it's important to determine what specifically is causing her pain, if she knows. - correct answerExample Question: What's causing your pain? History of Presenting Illness - correct answer Finding: Asked to rate current pain level on a scale - correct answer Finding: Reports current pain is 7/10 (Found)Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care. - correct answerExample Question: Can you rate the pain on a scale of 0 to 10? Finding: Asked for details about the pain - correct answer Finding: Reports pain is throbbing (Found)Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain. - correct answerExample Question: Can you please describe the pain? Finding: Reports pain is sharp when she attempts to stand (Found)Pro Tip: Determining what physical activities and movements exacerbate the patient's pain can help you better understand the problems and assess treatment needs. This can also alert you if a patient's activities of daily living are hindered. - correct answerExample Question: What is the pain like when you stand on your foot?

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Finding: Reports pain has increased in the past 2 days (Available)Pro Tip:Finding out how the patient's pain has changed will give you insight into the acceleration of infection. - correct answerExample Question: How has the pain changed over time? Finding: Reports feeling pain radiating into ankle (Available)Pro Tip: Asking about where else the patient's pain radiates can help determine the progression of infection. - correct answerExample Question: Does the pain radiate anywhere else? Finding: Reports pain prevents bearing weight on foot (Found)Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care. - correct answerExample Question: Can you bear weight on your foot? Finding: Asked location of wound - correct answer Finding: Reports right foot is injured (Found)Pro Tip: Confirming which extremity an injury is located is a best practice for your patient's safety. - correct answerExample Question: Which foot is in pain? Finding: Reports wound is on the plantar surface of her foot (Found)Pro Tip: Confirming where a wound is located ensures you are aware of your patient's biggest complaint. - correct answerExample Question: Where is the wound? Finding: Asked details of the injury - correct answer Finding: Reports she scraped foot on bottom rung of a step stool (Found)Pro Tip: Discovering how an injury happened helps to assess your patient's risk factors for injury.

• correct answerExample Question: How did your injury happen? Finding: Reports injury occurred 1 week ago (Available)Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute. - correct answerExample Question: When did your injury occur? Finding: Denies other injuries besides foot wound (Available)Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury. - correct answerExample Question: Did you injure anything besides your foot? Finding: Reports being barefoot at the time of injury (Available)Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances. - correct answerExample Question: Were you wearing shoes when you fell?

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Finding: Denies seeing a healthcare provider for the injury until now (Available)Pro Tip: It's crucial to ask whether your patient has seen another provider for the injury, because any previous medical intervention will help you understand the progression of the wound. - correct answerExample Question: Have you seen a healthcare provider for this injury? Finding: Asked about drainage from the foot wound - correct answer Finding: Reports that the wound bled a little after sustaining the injury (Available)Pro Tip: Asking about bleeding helps you determine the characteristics of a wound. - correct answerExample Question: Did your foot bleed? Finding: Reports seeing pus draining from wound (Found)Pro Tip: Asking about discharge helps you determine the characteristics of a wound. - correct answerExample Question: Did you notice any discharge from the wound? Finding: Reports noticing pus 2 days ago (Available)Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began. - correct answerExample Question: When did you first notice the pus? Finding: Followed up on drainage - correct answer Finding: Reports pus as white or yellow (Found)Pro Tip: The color of discharge from a wound can provide insight into its severity and characteristics. - correct answerExample Question: What color is the drainage from your wound? Finding: Denies odor from the wound (Available)Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics. - correct answerExample Question: Does the wound have an odor? Finding: Asked about home treatment of foot wound - correct answer Finding: Reports wound care regimen of bandaging (Available)Pro Tip: Asking specifically how often a patient changed a bandage will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar. - correct answerExample Question: How often do you change your bandage? Finding: Reports cleaning wound twice a day (Available)Pro Tip: Asking specifically how often a patient cleaned a wound will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar. - correct answerExample Question: How often did you clean the wound?

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Finding: Reports applying bacitracin, neomycin and polymyxin B (Neosporin) (Found)Pro Tip: Determining what products a patient used to sterilize or treat a wound establishes home care routines and health literacy. - correct answerExample Question: Did you use any ointment on the wound? Finding: Followed up on effectiveness of ointment - correct answer Finding: Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective (Found)Pro Tip: Understanding the effect of a home medication can help you determine the severity of the wound. Tina's diabetes diagnosis will have a large impact on her body's healing ability, which should be taken into consideration during your exam. - correct answerExample Question: Did the ointment help? Finding: Asked about other foot wound symptoms - correct answer Finding: Reports swelling around foot wound (Found)Pro Tip: Asking about the presence of swelling helps you gather information about your patient's complaint, as well as potential related illnesses. - correct answerExample Question: Is there swelling around the wound? Finding: Reports swelling worsened in the past 2 days (Available)Pro Tip:Finding out how long swelling appeared will help you understand the timeline for the infection progression. - correct answerExample Question: How long have you noticed swelling around the wound? Finding: Reports redness around the wound (Found)Pro Tip: Asking about redness will help you understand the timeline for the infection progression. - correct answerExample Question: Did you notice any redness around the wound? Finding: Reports that the wound feels warm (Found)Pro Tip: Asking about warmth will help you understand the timeline for the infection progression. - correct answerExample Question: Does the wound feel warm? Finding: Explored impact of patient's foot injury on activities of daily living - correct answer Finding: Reports pain affects ability to walk (Available)Pro Tip: Understanding the impact of your patient's wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can walk or not, as a lack of mobility can compromise quality of life. - correct answerExample Question: Does your injury impact your ability to walk?

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Finding: Reports pain affects ability to stand at work for long periods of time (Available)Pro Tip: Understanding the impact of your patient's wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can stand or not, as this can compromise quality of life and impact job performance. - correct answerExample Question: Does your foot pain affect your work? Finding: Reports pain prevented her from being able to walk to class (Available)Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don't fall behind. - correct answerExample Question: Has your injury prevented you from going to class? Past Medical History - correct answer Finding: Asked about preexisting medical conditions - correct answer Finding: Reports diabetes (Found)Pro Tip: It is important to identify any existing medical conditions, as that information is an integral part of a complete health history. Existing conditions can also inform your treatment and understanding of the patient's current health issues. In Tina's case, it is important to identify her diabetes diagnosis because that condition has a direct relationship with her current foot infection. - correct answerExample Question: Do you have any existing conditions? Finding: Reports asthma (Found)Pro Tip: It is important to identify any existing medical conditions, such as Tina's asthma, because that information is an integral part of her health history. Existing conditions can also inform your treatment and understanding of the patient's current health issues. - correct answerExample Question: Do you have any other conditions? Finding: Followed up on diabetes diagnosis - correct answer Finding: Reports specific age of diagnosis was 24 (Found)Pro Tip: Learning the diagnosis date of your patient's illness is an essential element of the illnesses history. - correct answerExample Question: At what age were you diagnosed with diabetes? Finding: Reports that her diabetes is Type 2 (Available)Pro Tip: The type of diabetes your patient has will drastically affect how you care for her. - correct answerExample Question: Do you know what type of diabetes you have? Finding: Asked about diabetes management through lifestyle changes - correct answer Finding: Reports staying away from sweets (Available)Pro Tip: Asking your patient specifically about sugar intake can help you understand the history of her diabetes as

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well as her health literacy. - correct answerExample Question: Tell me more about any sugars you consume. Finding: Reports drinking diet coke instead of regular (Available)Pro Tip: Particularly for diabetic patients, asking about intake of drinks that contain sugar can reveal additional sources of carbohydrates that the patient may not consider. - correct answerExample Question: Do you drink sugary drinks? Finding: Asked about current diabetes medication use - correct answer Finding: Reports that she does not currently take medication for diabetes (Found)Pro Tip: Asking about diabetes medication is important to understanding if your patient's disease is under control. - correct answerExample Question: Do you take prescribed medication for your diabetes? Finding: Asked about past diabetes medication use - correct answer Finding: Reports that she used to take diabetes medication (Found)Pro Tip: Asking about Tina's medication history for asthma will provide a timeline of treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. - correct answerExample Question: Have you ever taken medication for your diabetes? Finding: Reports previous medication was prescription metformin (Found)Pro Tip: Asking about a patient's medication history for a particular condition, such as Tina's past prescription for metformin, will provide a timeline of her asthma treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. - correct answerExample Question: Do you remember what you were prescribed for diabetes? Finding: Reports last use of medication was 3 years ago (Available)Pro Tip: It important to discover when Tina stopped taking any medications and what caused her to stop. Discovering her reason for noncompliance will allow you to make a more informed decision about current treatment. - correct answerExample Question: When was the last time you took your diabetes medication on a regular basis? Finding: Followed up on stopping diabetes regimen - correct answer Finding: Reports disliking diabetes medication side effects (Found)Pro Tip: Asking about side effects from medication can provide information about your patient's reaction to treatment. - correct answerExample Question: Did the metformin cause any side effects?

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Finding: Reports that she didn't like checking sugar and taking daily pills (Found)Pro Tip: Asking reasons for noncompliance can reveal information about your patient's health literacy, side effects, financial situation, and more. - correct answerExample Question: What's preventing you from taking your diabetes medication? Finding: Asked about blood glucose monitoring - correct answer Finding: Reports infrequent blood glucose monitoring (Found)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. - correct answerExample Question: Tell me about your blood sugar monitoring. Finding: Reports she last checked blood sugar a month ago (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. - correct answerExample Question: How often do you check your blood sugar? Finding: Reports confusion about what the numbers mean (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. If you find gaps in the patient's literacy, that is your opportunity to provide education. - correct answerExample Question: What are your usual blood sugar levels? Finding: Asked about thirst - correct answer Finding: Reports increased thirst (Found)Pro Tip: Your patient's thirst can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - correct answerExample Question: Have you been more thirsty lately? Finding: Reports increased water intake (Available)Pro Tip: Your patient's fluid intake can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - correct answerExample Question: Are you drinking more water than normal? Finding: Asked about frequency of urination - correct answer Finding: Reports more frequent urination (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - correct answerExample Question: Have you been urinating more often than usual?

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Finding: Reports urinating every hour or two during the day (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - correct answerExample Question: How often do you urinate during the day? Finding: Reports urinating 2 to 3 times during the night (Available)Pro Tip: Discovering if Tina has nocturia can offer insight into underlying medical conditions and general health. - correct answerExample Question: How often do you wake up at night to urinate? Finding: Asked about diet - correct answer Finding: Reports eating a bowl of cereal for breakfast yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient's typical dietary patterns. This can be achieved by asking for a 24-hour diet recall. - correct answerExample Question: What did you eat for breakfast yesterday? Finding: Reports eating mac and cheese for lunch yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient's typical dietary patterns. This can be achieved by asking for a 24-hour diet recall. - correct answerExample Question: What did you eat for lunch yesterday? Finding: Reports eating chicken and roll for dinner yesterday (Available)Pro Tip:Finding out the foods a patient last ate can provide evidence for any current stomach upset and for their current level of hunger and blood sugar status and can affect medications given while in your care. - correct answerExample Question: What did you eat for your last meal? Finding: Asked about change in appetite - correct answer Finding: Reports increased appetite (Found)Pro Tip: Identifying if a patient has recently experienced a change in appetite is important, as it could indicate an underlying endocrine or psychiatric condition. - correct answerExample Question: Have you noticed an increase in appetite? Finding: Reports change in appetite began a month ago (Available)Pro Tip: Determining the onset of appetite change can reveal important details about underlying health conditions. - correct answerExample Question: When did you notice the increase in your appetite? Finding: Asked about weight change - correct answer

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Finding: Reports recent loss of 10 lbs (Available)Pro Tip: Determining the exact amount of weight loss can indicate whether it's within expected ranges, or extreme, which may indicate an underlying health problem. Example Question: How much weight have you lost? - correct answer Finding: Reports weight loss occurred over the past month (Available)Pro Tip:Finding out the timeline for weight loss can indicate if it's sudden or gradual. - correct answerExample Question: How long did it take you to lose 10 pounds? Finding: Followed up on reason for weight change - correct answer Finding: Reports weight loss was unintentional (Found)Pro Tip: Unintentional weight loss can be a sign of underlying medical conditions or a reflection of unhealthy lifestyle choices. Asking your patient about this can inform your care plan. - correct answerExample Question: Was your weight loss intentional? Finding: Asked about history of asthma exacerbations - correct answer Finding: Reports last asthma attack was in high school (Available)Pro Tip: Discovering the patient's most recent asthma attack can provide a timeline of exacerbations and help you better understand the patient's condition and effectiveness of any treatments. - correct answerExample Question: When was your last asthma attack? Finding: Reports last exacerbation was three days ago (Available)Pro Tip: Discovering the patient's most recent exacerbation can provide a timeline of asthma symptoms and help you better understand the patient's condition and effectiveness of any treatments. - correct answerExample Question: When did you last have issues with asthma? Finding: Asked about asthma symptoms - correct answer Finding: Reports chest tightness during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as chest tightness. - correct answerExample Question: What do your asthma symptoms feel like? Finding: Reports difficulty breathing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as difficulty breathing. - correct answerExample Question: Do you have trouble breathing? Finding: Reports wheezing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition

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by asking about symptoms during an exacerbation, such as wheezing. - correct answerExample Question: Do you ever wheeze? Finding: Asked about prior hospitalizations - correct answer Finding: Reports past hospitalizations (Found)Pro Tip: Finding out if the patient has any past hospitalizations is the first step in understanding any past serious medical issues. In Tina's case, it will help you better understand her asthma and create a timeline. - correct answerExample Question: Have you been hospitalized in the past? Finding: Reports last hospitalization was for asthma (Available)Pro Tip: Finding out if Tina has any past hospitalizations is the first step in understanding any past serious medical issues. In Tina's case, it will help you better understand her asthma and create a timeline. - correct answerExample Question: Why were you hospitalized last time? Finding: Reports last hospitalization was age 16 (Available)Pro Tip: Finding out the date of Tina's last hospitalization is important for understanding the timeline of her medical issues, asthma in particular. - correct answerExample Question: When was your last hospitalization? Finding: Reports about 5 total hospitalizations for asthma as a child and teen (Available)Pro Tip: Finding out the number of Tina's previous hospitalizations is important for understanding the history of her asthma. - correct answerExample Question: How many times have you been hospitalized? Finding: Reports past nebulizer use (Available)Pro Tip: Finding out what treatments Tina received during her hospitalizations will give you a fuller picture of the history of her condition. - correct answerExample Question: Have you ever used a nebulizer? Finding: Asked about asthma diagnosis - correct answer Finding: Reports specific age of diagnosis is 2.5 years old (Available)Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the patient's history of the condition, including the age of diagnosis. - correct answerExample Question: At what age were you diagnosed with asthma? Finding: Asked about asthma management - correct answer Finding: Reports using an inhaler (Found)Pro Tip: Asking how your patient treats her asthma can provide important information about her medical history and health literacy.

• correct answerExample Question: How do you manage your asthma?

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Finding: Reports inhaler is albuterol (Proventil) (Found)Pro Tip: Finding out the specific medication type or brand is essential in understanding whether it's a maintenance or rescue medication. - correct answerExample Question: What is the name of the inhaler prescription? Finding: Reports last use of inhaler was 3 days ago (Available)Pro Tip: Determining the patient's last use of an inhaler clues you in to any recent breathing problems. - correct answerExample Question: When did you last use your inhaler? Finding: Reports using inhaler no more than 2 times per week (Available)Pro Tip: Discovering the frequency with which your patient uses her inhaler is an important aspect of determining the severity of her condition. - correct answerExample Question: How often do you use your inhaler? Finding: Asked about number of puffs when using asthma inhaler - correct answer Finding: Reports recommended dose is 1-3 puffs as needed (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. - correct answerExample Question: How many puffs of your inhaler are you prescribed? Finding: Reports typically taking 2 puffs (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. - correct answerExample Question: How many puffs do you typically take? Finding: Reports sometimes needing 3 puffs to control symptoms (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. - correct answerExample Question: What's the most puffs you ever take? Finding: Asked about asthma triggers - correct answer Finding: Reports asthma triggered by cats (Found)Pro Tip: Discovering occasional environmental triggers, such as animal allergies, gives you insight into exacerbating factors of your patient's condition. - correct answerExample Question: What triggers your asthma problems? Finding: Reports asthma triggered by dust (Found)Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. - correct answerExample Question: Does dust trigger your asthma?

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Finding: Denies seasonal triggers (Available)Pro Tip: Asking about seasonal triggers can help you understand a patient's complete set of asthma triggers over the course of a year. - correct answerExample Question: Do you have seasonal asthma triggers? Finding: Asked about general allergies - correct answer Finding: Reports allergy to cats (Found)Pro Tip: Asking general questions about allergies is the first step to a conversation with a patient about her complete set of allergies. - correct answerExample Question: What allergies do you have? Finding: Followed up on cat allergy symptoms - correct answer Finding: Reports sneezing, itchy eyes, and wheezing (Available)Pro Tip: Determining a patient's reaction to an allergen is essential to gauge if the allergy is life-threatening. - correct answerExample Question: What is your reaction to cats? Finding: Asked about latex allergy - correct answer Finding: Denies latex allergy (Available)Pro Tip: Confirming absence or presence of a latex allergy is essential in a hospital setting, where some instruments have latex parts.

• correct answerExample Question: Are you allergic to latex? Finding: Asked about medication allergies - correct answer Finding: Reports penicillin allergy (Found)Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patient's safety while she is in your care, as it affects what medications will be safe and appropriate. - correct answerExample Question: What medication allergies do you have? Finding: Asked about penicillin reaction - correct answer Finding: Reports that penicillin resulted in hives (Available)Pro Tip: Determining a patient's reaction to an allergen is essential to gauge if the allergy is life-threatening. - correct answerExample Question: What is your reaction to penicillin? Finding: Reports last penicillin reaction was in childhood (Available)Pro Tip: Determining a patient's last reaction to penicillin is part of gathering thorough information about her allergy. - correct answerExample Question: When was your last penicillin reaction? Finding: Asked about food allergies - correct answer

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Finding: Denies food allergies (Found)Pro Tip: Inquiring about food allergies is important for an admitted patient, who will be receiving food during her stay. - correct answerExample Question: Do you have any food allergies? Finding: Asked if the patient has allergies to dust, mold, or pollen - correct answer Finding: Reports reaction to dust (Found)Pro Tip: Dust is a common allergen and discovering its effect on asthmatic patients is particularly important. - correct answerExample Question: Do you have any reaction to dust? Finding: Reports dust causes sneezing, itchy eyes, and wheezing (Available)Pro Tip: Dust is a common allergen and discovering its effect on asthmatic patients is particularly important. - correct answerExample Question: Do you have any environmental allergies? Finding: Denies seasonal allergies (Available)Pro Tip: Asking about seasonal allergies can help you understand a patient's complete set of allergies over the course of a year.

• correct answerExample Question: Do you have any seasonal allergies? Finding: Asked about general immunizations received - correct answer Finding: Reports being up to date on shots (Found)Pro Tip: Discovering your patient's immunization history is important to her safety and reveals any susceptibilities she may have to infectious disease. - correct answerExample Question: Are your immunizations current? Finding: Asked about childhood immunizations - correct answer Finding: Reports receiving measles-mumps-rubella shot (Available)Pro Tip: Discovering what childhood immunizations a patient has received reveals information about both her medical history and her susceptibility to infectious disease. - correct answerExample Question: Did you receive the measles vaccine? Finding: Reports receiving polio shot (Available)Pro Tip: Discovering if a patient received a childhood polio vaccination reveals information about both her medical history and her susceptibility to infectious disease. - correct answerExample Question: Did you receive the polio vaccine? Finding: Reports receiving varicella shot (Available)Pro Tip: Discovering if a patient has received a childhood varicella shot reveals information about both her medical history and her susceptibility to infectious disease. - correct answerExample Question: Did you receive the chicken pox vaccine?

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Finding: Reports receiving Hepatitis A and B shot (Available)Pro Tip: Discovering if a patient has received a childhood Hepatitis A and B vaccination reveals information about both her medical history and her susceptibility to infectious disease. - correct answerExample Question: Did you receive the Hepatitis vaccine? Finding: Reports receiving meningococcal shot (Available)Pro Tip: Discovering if a patient has received a childhood meningococcal vaccination reveals information about both her medical history and her susceptibility to infectious disease. - correct answerExample Question: Did you receive the meningitis vaccine? Finding: Reports receiving HPV vaccine series (Available)Pro Tip: Discovering if a patient has received the HPV vaccination reveals information about both her medical history and her susceptibility to infectious disease. - correct answerExample Question: Did you receive the HPV vaccine? Finding: Asked if the patient has received a flu vaccine - correct answer Finding: Denies receiving annual flu vaccine (Found)Pro Tip: The flu virus can be particularly hazardous in a hospital setting. It is important to ask your patient about the flu vaccine. - correct answerExample Question: Did you get a flu shot this year? Finding: Asked if the patient received a tetanus immunization - correct answer Finding: Reports last tetanus vaccination was in the past year (Found)Pro Tip: For a patient with a recent scrape on a metal surface, confirming the last date of a tetanus shot is essential to prevent any diseases from contact. - correct answerExample Question: When was your last tetanus booster? Finding: Asked about use of pain medication - correct answer Finding: Reports taking ibuprofen (Advil) at home (Found)Pro Tip: Discovering how a patient has been medicating for pain is a crucial element of understanding and treating her condition or injury. - correct answerExample Question: What pain medication have you been taking? Finding: Reports ER administered pain medication (Found)Pro Tip: The differences between prescription and over-the-counter pain medications can be vast and asking about the type of pain medication your patient has been using will help you fully understand her home treatment habits. - correct answerExample Question: Have you taken any prescription pain medications? Finding: Followed up on home pain medication - correct answer

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Finding: Reports taking ibuprofen (Advil) for 2 days (Found)Pro Tip: Discovering how long your patient has been taking pain medication is a crucial part of the history of her condition or injury. - correct answerExample Question: How many days have you needed pain medication? Finding: Reports taking doses at morning, noon and night (Available)Pro Tip: The frequency with which your patient takes pain medication can indicate the severity of her condition or injury. - correct answerExample Question: How many times a day do you take pain medication? Finding: Reports taking 2 pills each time (Available)Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. - correct answerExample Question: How many pain pills do you take at a time? Finding: Reports ibuprofen is regular strength (Available)Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. - correct answerExample Question: What is the dose of the pain medication? Finding: Asked about the effectiveness of pain medication at home - correct answer Finding: Reports ibuprofen helped a little (Found)Pro Tip: The efficacy of pain medication varies from patient to patient. Discovering a patient's individual response to pain medication is an important factor in your overall treatment plan. - correct answerExample Question: How effective is the pain medication? Finding: Reports pain returned in full every few hours (Found)Pro Tip: The efficacy of pain medication varies from patient to patient. Discovering a patient's individual response to pain medication is an important factor in your overall treatment plan. - correct answerExample Question: How long does the pain medication last? Finding: Asked about prescription medications - correct answer Finding: Reports only prescription is an inhaler (Available)Pro Tip: Determining what, if any, prescription medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions. - correct answerExample Question: What prescription medications do you take? Finding: Asked about use of OTC medication - correct answer Finding: Reports occasionally taking ibuprofen for cramps (Available)Pro Tip: Finding out about your patient's use of over-the-counter medications, vitamins, and supplements

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will help you get a complete health history and avoid unwanted drug interactions. - correct answerExample Question: Do you take any over the counter medications? Finding: Reports occasionally taking acetaminophen (Tylenol) for headaches (Available)Pro Tip: Finding out about your patient's use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions. - correct answerExample Question: Do you take any over the counter medications? Finding: Denies taking supplements (Available)Pro Tip: Finding out about your patient's use of supplements will help you get a complete health history and avoid unwanted drug interactions. - correct answerExample Question: Do you take any supplements? Finding: Denies taking herbals (Available)Pro Tip: Finding out about your patient's use of herbals will help you get a complete health history and avoid unwanted drug interactions. - correct answerExample Question: Do you take any herbal supplements? Social History - correct answer Finding: Asked about patient's level of education - correct answer Finding: Reports currently working toward undergraduate degree (Found)Pro Tip: Finding out a patient's level of education can give you a baseline for her health literacy.

• correct answerExample Question: What is your highest level of education? Finding: Reports her major is accounting (Available)Pro Tip: Asking about a patient's course of study is a good practice to establish rapport with your patient. - correct answerExample Question: What do you study? Finding: Asked about stressors - correct answer Finding: Reports she is currently under high stress (Found)Pro Tip: Stress can cause both physical and mental health problems and complications. Determining your patient's stress level is part of an overall picture of her health. - correct answerExample Question: Can you tell me about your stress level? Finding: Asked about patient's living situation - correct answer Finding: Reports living with mother and sister (Available)Pro Tip: Learning about your patient's living situation helps develop rapport and gives you a broad picture of her lifestyle. - correct answerExample Question: Does anyone live at home with you?