Download Shadow Health - Tina Jones, Health History with Complete Solution (Latest Question Bank) and more Exams Nursing in PDF only on Docsity! Shadow Health - Tina Jones, Health History with Complete Solution (Latest Question Bank)Guaranteed A+ 1. Health History Tips & Tricks: - Correct answer TJ Health Interview 2. Student: Hello! - Correct answer Diana 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. 3. Student: What is the situation? - Correct answer Diana 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. 4. Student: What are my objectives in this assessment? - Correct answer Diana 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 8. 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 answer Student: So that you understand if there are any problems related to their chief complaint. Also, to help treat their current condition. 9. Diana Shadow: Time to begin. - Correct answer 10. Patient Exam - Vital Signs: - Correct answer Height: 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% 11. Patient Exam - Interview: - Correct answer 12. Student: Hello, my name is Catlain, I am your nurse today. - Correct answer Tina Jones: Hey. 13. Student: Can you confirm your name? - Correct answer Tina Jones: Tina Jones:. 14. Student: Why did you come in today? - Correct answer Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It's killing me. 15. Student: What additional symptoms have you experienced? - Correct answer Tina 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. 16. Student: Can you rate your current pain level on a scale of 0 to 10? - Correct answer Tina Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit. 17. Student: Please describe the pain. - Correct answer Tina Jones: It's throbbing and like, sharp if I try to put weight on it. 18. Student: How did you hurt your foot? - Correct answer Tina 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! 19. Student: Has your foot been draining any liquids? - Correct answer Tina Jones: Yeah, there's definitely pus. 20. Student: What color was the pus? - Correct answer Tina Jones: It's... white or maybe off-white. 21. Student: How have you treated the wound? - Correct answer Tina Jones: I've been taking Advil for my foot for a few days. 22. Student: What did you do to treat your foot after your accident? - Correct answer Tina Jones: I made sure to clean it and keep it bandaged. And I put Neosporin on it. 23. Student: How effective was the Neosporin? - Correct answer Tina Jones: Well, I'm here, so I guess it didn't do its job. 24. Student: Can you walk with your foot being injured? - Correct answer Tina Jones: No, I can't. I can't put any weight on it without like, shooting pain. 36. Student: Has your weight changed? - Correct answer Tina Jones: Yeah, I've lost some weight recently. 37. Student: Do you know why you lost weight? - Correct answer Tina Jones: I don't know what caused it, I just lost weight. 38. Student: How often do you have asthma exacerbations? - Correct answer Tina Jones: I haven't had a full attack in years. But my breathing definitely acts up. . .not always. Max twice a week. 39. Student: What asthma symptoms have you experienced? - Correct answer Tina 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. 40. Student: How many puffs do you take when using your asthma inhaler? - Correct answer Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] 41. Student: What are some things that trigger your asthma? - Correct answer Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. 42. Student: What allergies do you have? - Correct answer Tina Jones: I'm allergic to cats. 43. Student: When did you realize you were allergic to cats? - Correct answer Tina Jones: For as long as I've been around. 44. Student: How effective was your pain medication at home? - Correct answer Tina 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. 45. Student: What medication allergies do you have? - Correct answer Tina Jones: I'm allergic to penicillin. 46. Student: What food allergies do you have? - Correct answer Tina Jones: I don't have any food allergies that I know of. 47. Student: Are you allergic to dust, mold, or pollen? - Correct answer Tina Jones: Well. . . I don't know if it's allergies, but sometimes my asthma acts up around dust. 48. Student: What immunizations have you received? - Correct answer Tina 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. 49. Student: Have you received a flu vaccine? - Correct answer Tina Jones: No. 50. Student: Have you had any prior hospitalizations? - Correct answer Tina 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. 63. Student: Have you had any neurological problems? - Correct answer Tina Jones: No, I haven't. 64. Student: Have you had any musculoskeletal problems? - Correct answer Tina Jones: No. 65. Student: Do you have a history of skin disease? - Correct answer Tina Jones: Um, I have acne, if that counts. 66. Student: Does your paternal grandfather have any health problems? - Correct answer Tina 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. 67. Student: Does your mother have any health problems? - Correct answer Tina Jones: Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. 68. Student: Does your father have any health problems? - Correct answer Tina Jones: Well, he passed away. But he had a couple things... Type 2 diabetes, like me, and high cholesterol and blood pressure. 69. Student: How did your father die? - Correct answer Tina Jones: He died in a car accident. 70. Student: Where is your wound located? - Correct answer Tina Jones: It's on the ball of my foot. 71. Student: Do you get thirsty often? - Correct answer Tina Jones: You know, I did notice lately that I've been really thirsty. 72. Student: What happened with your father's car accident? - Correct answer Tina Jones: It was last year... I guess a little over a year ago. 73. Student: How long ago was your dad's car accident? - Correct answer Tina Jones: It was last year... I guess a little over a year ago. 74. Student: How did you cope with your fathers death? - Correct answer Tina 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. 75. Student: What caused your dads accident? - Correct answer Tina Jones: He was driving to work, and it was raining...and his car hydroplaned. And hit a tree. So, it was really sudden. 76. Student: How is your paternal grandmother's health? - Correct answer Tina 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 88. Student: What are stressors? - Correct answer Tina 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. 89. Student: We are going to take care of everything as quickly as possible. - Correct answer Tina Jones: Thanks. 90. Student: Where do you live? - Correct answer Tina 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. 91. Student: What is your belief system? - Correct answer Tina 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. 92. Student: Have you experienced abuse? - Correct answer Tina Jones: I've never had been in any kind of situation like that... It's scary to think about. 93. Student: Have you used illicit drugs? - Correct answer Tina Jones: Well, I used to smoke pot. . . but I don't do that anymore. 94. Student: What type of drugs did you use? - Correct answer Tina Jones: Um...I've smoked pot before. In high school, and after high school... I definitely don't anymore, though. 95. Student: Have you used drugs other than marijuana? - Correct answer Tina Jones: No. 96. Student: When did you last use drugs? - Correct answer Tina Jones: I haven't smoked pot since I was twenty or twenty-one. 97. Student: Have you ever smoked cigarettes? - Correct answer Tina Jones: No. I think it's gross. 98. Student: Have you been around people that are smoking? - Correct answer Tina Jones: Some of my friend's smoke when we go out drinking. But I don't smoke, and nobody at home smokes. 99. Student: How old were you when your father died? - Correct answer Tina Jones: He died last year, so I was 27. 100. Student: Did your father die from any disease? - Correct answer Tina Jones: He died in a car accident. 101. Student: Can you tell me about your father's health? - Correct answer Tina Jones: He had high blood pressure and cholesterol. And diabetes -- we have diabetes in common. 102. Student: I can't even imagine how you feel about losing your father - Correct answer Tina Jones: Thanks. 103. Student: Tell me about your father. - Correct answer Tina 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 pain. - Correct answer Example Question: Can you please describe the pain? 115. 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 answer Example Question: What is the pain like when you stand on your foot? 116. 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 answer Example Question: How has the pain changed over time? 117. 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 answer Example Question: Does the pain radiate anywhere else? 118. 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 answer Example Question: Can you bear weight on your foot? 119. Finding: Asked location of wound - Correct answer 120. 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 answer Example Question: Which foot is in pain? 121. 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 answer Example Question: Where is the wound? 122. Finding: Asked details of the injury - Correct answer 123. 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 answer Example Question: How did your injury happen? 124. 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 answer Example Question: When did your injury occur? 125. 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 answer Example Question: Did you injure anything besides your foot? 126. 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 answer Example Question: Were you wearing shoes when you fell? uncontrolled blood sugar. - Correct answer Example Question: How often do you change your bandage? 137. 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 answer Example Question: How often did you clean the wound? 138. 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 answer Example Question: Did you use any ointment on the wound? 139. Finding: Followed up on effectiveness of ointment - Correct answer 140. 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 answer Example Question: Did the ointment help? 141. Finding: Asked about other foot wound symptoms - Correct answer 142. 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 answer Example Question: Is there swelling around the wound? 143. 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 answer Example Question: How long have you noticed swelling around the wound? 144. Finding: Reports redness around the wound (Found)Pro Tip: Asking about redness will help you understand the timeline for the infection progression. - Correct answer Example Question: Did you notice any redness around the wound? 145. Finding: Reports that the wound feels warm (Found)Pro Tip: Asking about warmth will help you understand the timeline for the infection progression. - Correct answer Example Question: Does the wound feel warm? 146. Finding: Explored impact of patient's foot injury on activities of daily living - Correct answer 147. 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 answer Example Question: Does your injury impact your ability to walk? 148. 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 drastically affect how you care for her. - Correct answer Example Question: Do you know what type of diabetes you have? 157. Finding: Asked about diabetes management through lifestyle changes - Correct answer 158. 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 well as her health literacy. - Correct answer Example Question: Tell me more about any sugars you consume. 159. 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 answer Example Question: Do you drink sugary drinks? 160. Finding: Asked about current diabetes medication use - Correct answer 161. 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 answer Example Question: Do you take prescribed medication for your diabetes? 162. Finding: Asked about past diabetes medication use - Correct answer 163. 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 answer Example Question: Have you ever taken medication for your diabetes? 164. 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 answer Example Question: Do you remember what you were prescribed for diabetes? 165. 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 answer Example Question: When was the last time you took your diabetes medication on a regular basis? 166. Finding: Followed up on stopping diabetes regimen - Correct answer 167. Finding: Reports disliking diabetes medication side effects (Found)Pro Tip: Asking about side effects from medication can provide information about your patient's you will want to explore this classic symptom of the condition. - Correct answer Example Question: Are you drinking more water than normal? 176. Finding: Asked about frequency of urination - Correct answer 177. 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 answer Example Question: Have you been urinating more often than usual? 178. 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 answer Example Question: How often do you urinate during the day? 179. 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 answer Example Question: How often do you wake up at night to urinate? 180. Finding: Asked about diet - Correct answer 181. 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 answer Example Question: What did you eat for breakfast yesterday? 182. 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 answer Example Question: What did you eat for lunch yesterday? 183. 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 answer Example Question: What did you eat for your last meal? 184. Finding: Asked about change in appetite - Correct answer 185. 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 answer Example Question: Have you noticed an increase in appetite? 186. 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 answer Example Question: When did you notice the increase in your appetite? 196. 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 answer Example Question: What do your asthma symptoms feel like? 197. 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 answer Example Question: Do you have trouble breathing? 198. 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 by asking about symptoms during an exacerbation, such as wheezing. - Correct answer Example Question: Do you ever wheeze? 199. Finding: Asked about prior hospitalizations - Correct answer 200. 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 answer Example Question: Have you been hospitalized in the past? 201. 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 answer Example Question: Why were you hospitalized last time? 202. 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 answer Example Question: When was your last hospitalization? 203. 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 answer Example Question: How many times have you been hospitalized? 204. 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 answer Example Question: Have you ever used a nebulizer? 205. Finding: Asked about asthma diagnosis - Correct answer 206. 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 answer Example Question: At what age were you diagnosed with asthma? 215. 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 answer Example Question: What's the most puffs you ever take? 216. Finding: Asked about asthma triggers - Correct answer 217. 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 answer Example Question: What triggers your asthma problems? 218. 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 answer Example Question: Does dust trigger your asthma? 219. 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 answer Example Question: Do you have seasonal asthma triggers? 220. Finding: Asked about general allergies - Correct answer 221. 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 answer Example Question: What allergies do you have? 222. Finding: Followed up on cat allergy symptoms - Correct answer 223. 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 answer Example Question: What is your reaction to cats? 224. Finding: Asked about latex allergy - Correct answer 225. 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 answer Example Question: Are you allergic to latex? 226. Finding: Asked about medication allergies - Correct answer 227. 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 answer Example Question: What medication allergies do you have? 228. Finding: Asked about penicillin reaction - Correct answer 229. 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. 239. Finding: Asked about childhood immunizations - Correct answer 240. 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 answer Example Question: Did you receive the measles vaccine? 241. 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 answer Example Question: Did you receive the polio vaccine? 242. 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 answer Example Question: Did you receive the chicken pox vaccine? 243. 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 answer Example Question: Did you receive the Hepatitis vaccine? 244. 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 answer Example Question: Did you receive the meningitis vaccine? 245. 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 answer Example Question: Did you receive the HPV vaccine? 246. Finding: Asked if the patient has received a flu vaccine - Correct answer 247. 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 answer Example Question: Did you get a flu shot this year? 248. Finding: Asked if the patient received a tetanus immunization - Correct answer 249. 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 answer Example Question: When was your last tetanus booster? 250. Finding: Asked about use of pain medication - Correct answer 259. 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 answer Example Question: How effective is the pain medication? 260. 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 answer Example Question: How long does the pain medication last? 261. Finding: Asked about prescription medications - Correct answer 262. 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 answer Example Question: What prescription medications do you take? 263. Finding: Asked about use of OTC medication - Correct answer 264. 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 will help you get a complete health history and avoid unwanted drug interactions. - Correct answer Example Question: Do you take any over the counter medications? 265. 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 answer Example Question: Do you take any over the counter medications? 266. 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 answer Example Question: Do you take any supplements? 267. 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 answer Example Question: Do you take any herbal supplements? 268. Social History - Correct answer 269. Finding: Asked about patient's level of education - Correct answer 270. 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 answer Example Question: What is your highest level of education? 271. Finding: Reports her major is accounting (Available)Pro Tip: Asking about a patient's course of study is a good beliefs will allow you to provide the appropriate support and resources. - Correct answer Example Question: What is your religious affiliation? 281. Finding: Asked if patient has experienced abuse - Correct answer 282. Finding: Denies experiencing abuse (Found)Pro Tip: Determining if a patient has experienced abuse, whether it be emotional, physical, or financial, is important for understanding the patient's needs. It is necessary to approach this subject with the utmost respect and sensitivity. - Correct answer Example Question: Have you experienced any type of abuse? 283. Finding: Asked about illicit drug use - Correct answer 284. Finding: Reports history of recreational marijuana smoking (Found)Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted. - Correct answer Example Question: Have you ever smoked marijuana? 285. Finding: Followed up on drug use - Correct answer 286. Finding: Reports last use was at age 20 or 21 (Found)Pro Tip: When a patient reports drug use, it's important to determine the reason for drug use, as well as the timeline. Depending on when the drug was most recently taken, it could interfere with medications. You also want to identify any potential issues with substance abuse. - Correct answer Example Question: When did you last smoke marijuana? 287. Finding: Reports she stopped because of health reasons and waning interest (Available)Pro Tip: Communicating about why a patient stopped or started drug use gives insight into their attitudes and dependencies on a substance. Example Question: What happened to cause you to stop smoking pot? - Correct answer 288. Finding: Asked about alcoholic intake - Correct answer 289. Finding: Reports last alcoholic drink was 3 weeks ago (Available)Pro Tip: Confirming when a patient had her last alcohol intake is important, because she will receive medications while admitted, and alcohol is often contraindicated. - Correct answer Example Question: When was your last alcoholic drink? 290. Finding: Reports no more than 2 or 3 alcoholic drinks in one sitting (Available)Pro Tip: Finding out how many alcoholic drinks a patient has in a single day or sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient. - Correct answer Example Question: How many alcoholic drinks do you have in one sitting? 291. Finding: Reports no more than 1 or 2 nights a week drinking alcohol (Available)Pro Tip: Finding out how many nights a week your patient has alcohol gives insight into potential habits or abuse. - Correct answer Example Question: How many nights a week do you drink alcohol? 292. Finding: Asked about tobacco use - Correct answer 293. Finding: Denies smoking tobacco (Found)Pro Tip: Finding out if a patient uses tobacco products is important to 303. Finding: Reports father was diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had high blood pressure can reveal generational patterns. - Correct answer Example Question: Does your father have health conditions? 304. Finding: Reports father was diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had high cholesterol can reveal generational patterns. - Correct answer Example Question: Does your father have health conditions? 305. Finding: Followed up on father's death - Correct answer 306. Finding: Reports father died at age 58 (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient's case. Uncovering the age of death can help you assess the patient's current risks. - Correct answer Example Question: How old was your father when he died? 307. Finding: Reports cause of death was a car accident (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient's case. Uncovering the cause of death can help you assess the patient's current risks. - Correct answer Example Question: What caused your father's death? 308. Finding: Followed up on coping with father's death - Correct answer 309. Finding: Reports past grief (Found)Pro Tip: Asking about Tina's reaction to her father's death is a vital part of patient-centered care. You may discover that a patient experiencing grief needs additional resources and support. - Correct answer Example Question: How are you coping with your father's death? 310. Finding: Reports feeling at peace now (Found)Pro Tip: Asking about Tina's reaction to her father's death is a vital part of patient-centered care. You should assess her needs to determine if providing any addition resources or support is appropriate. - Correct answer Example Question: How are you coping now? 311. Finding: Asked about paternal grandfather's health - Correct answer 312. Finding: Reports paternal grandfather diagnosed with Type 2 diabetes (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had diabetes can reveal generational patterns. - Correct answer Example Question: Does your paternal grandfather have health conditions? 313. Finding: Reports paternal grandfather diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had high blood pressure can reveal generational patterns. - Correct answer Example Question: Does your paternal grandfather have health conditions? 314. Finding: Reports paternal grandfather diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal generational patterns. - Correct answer Example Question: Does your maternal grandmother have health conditions? 323. Finding: Reports maternal grandmother diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her maternal grandmother had high cholesterol can reveal generational patterns. - Correct answer Example Question: Does your maternal grandmother have health conditions? 324. Finding: Asked about brother's health - Correct answer 325. Finding: Denies brother having diagnosed health problems (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her brother has any health problems can reveal potential risks. - Correct answer Example Question: Does your brother have health conditions? 326. Finding: Asked about sister's health - Correct answer 327. Finding: Reports sister diagnosed with asthma (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her asthma can help you develop a sense of health patterns within her family. - Correct answer Example Question: Does your sister have health conditions? 328. Finding: Asked about family history of obesity - Correct answer 329. Finding: Reports that family members are overweight (Found)Pro Tip: Asking about trends such as obesity can help you fill in holes in the history that your patient may have missed and can allow you insight into other inherited diseases that affect relatives outside of immediate family. - Correct answer Example Question: Does obesity run in your family? 330. Finding: Asked about family history of thyroid issues - Correct answer 331. Finding: Denies family history of thyroid issues (Found)Pro Tip: Asking about trends such as thyroid issues can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family. - Correct answer Example Question: Do you have a family history of thyroid problems? 332. Finding: Asked about family history of substance abuse - Correct answer 333. Finding: Reports 1 uncle has alcoholism (Found)Pro Tip: Asking about trends in substance abuse can help you understand your patient's risk for inherited diseases linked to addiction. - Correct answer Example Question: Do you have relatives with addiction problems? 334. Finding: Asked about family history of headaches - Correct answer 335. Finding: Denies family history of headaches (Found)Pro Tip: Asking about trends such as headaches can help you fill in holes in the history that your patient may have missed and can allow you insight into other inherited diseases that affect relatives outside of immediate family. - Correct answer Example Question: Do you have a family history of headaches? 343. Finding: Asked about review of systems for mental health - Correct answer 344. Finding: Denies depression (Available)Pro Tip: Asking about the patient's history with depression is one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Correct answer Example Question: Do you have a history of depression? 345. Finding: Denies suicidal ideation or attempts (Available)Pro Tip: Asking about the patient's suicidal ideation one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. Higher levels of pain have been associated with thoughts of self-harm. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Correct answer Example Question: Do you have a history of suicidal thinking? 346. Finding: Asked about review of systems for head - Correct answer 347. Finding: Reports occasional headaches (Available)Pro Tip: Asking about headache frequency is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Correct answer Example Question: Do you ever get headaches? 348. Finding: Denies current headache (Available)Pro Tip: Asking Tina is she currently has a headache is important because it might be contributing to her current discomfort and should be treated promptly. - Correct answer Example Question: Do you have a headache? 349. Finding: Denies head injury (Available)Pro Tip: Asking about the patient's history of physical trauma, including head injury, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Correct answer Example Question: Have you had any head injuries? 350. Finding: Asked about review of systems for ears - Correct answer 351. Finding: Denies change in hearing (Available)Pro Tip: Asking about changes in hearing is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems, such as hearing loss, not discovered during the discussion of the patient's chief complaint. - Correct answer Example Question: Has your hearing changed? 352. Finding: Denies ringing or tinnitus (Available)Pro Tip: Ringing in the ears can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing, or hearing loss. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. - Correct the patient's chief complaint, such as allergic reactions or infection. - Correct answer Example Question: Have you had itchy eyes? 359. Finding: Reports infrequent eye redness (Available)Pro Tip: Asking about symptoms, such as eye redness, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as allergic reactions or infection. - Correct answer Example Question: Have you had red eyes? 360. Finding: Reports infrequent discharge, crusting or wateriness (Available)Pro Tip: Asking about symptoms, such as eye discharge, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as allergic reactions or infection. Example Question: Have you had watery eyes? - Correct answer 361. Finding: Denies eye pain (Available)Pro Tip: Asking about symptoms, such as eye pain, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as allergic reactions, infection, or physical trauma. - Correct answer Example Question: Have you had eye pain? 362. Finding: Denies dry eyes (Available)Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Asking Tina if she has dry eyes solicits information about one particular symptom. - Correct answer Example Question: Have you had dry eyes? 363. Finding: Asked about review of systems for nose - Correct answer 364. Finding: Denies current nose problems (Found)Pro Tip: Asking about symptoms, such as nose problems, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as allergic reactions, infection, or physical trauma. - Correct answer Example Question: Do you have any nose problems right now? 365. Finding: Reports infrequent runny nose (Found)Pro Tip: Asking about symptoms, such as runny nose, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as unspecified allergies. - Correct answer Example Question: Have you had a runny nose? 366. Finding: Reports infrequent sinus problems (Available)Pro Tip: Asking about symptoms, such as frequent sinus issues, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as unspecified allergies. - Correct answer Example Question: Have you had problems with your sinuses? 373. Finding: Denies dry mouth (Available)Pro Tip: Asking about symptoms, such as dry mouth, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Correct answer Example Question: Have you had dry mouth? 374. Finding: Denies mouth pain (Available)Pro Tip: Asking about symptoms, such as oral pain, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as oral infection or recent trauma. - Correct answer Example Question: Have you had mouth pain? 375. Finding: Denies mouth sores (Available)Pro Tip: Asking about symptoms, such as mouth sores, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as oral infection or recent trauma. - Correct answer Example Question: Have you had mouth sores? 376. Finding: Denies gum problems (Available)Pro Tip: Asking about symptoms, such as gum problems, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as oral infection or recent trauma. - Correct answer Example Question: Have you had gum problems? 377. Finding: Denies tongue problems (Available)Pro Tip: Asking about symptoms, such as tongue pain, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as oral infection or recent trauma. - Correct answer Example Question: Have you had tongue problems? 378. Finding: Denies jaw problems (Available)Pro Tip: Asking about symptoms, such as jaw problems, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Correct answer Example Question: Have you had jaw problems? 379. Finding: Asked about review of systems for neck, throat and glands - Correct answer 380. Finding: Denies difficulty swallowing (Available)Pro Tip: Asking if a patient has difficulty swallowing is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Correct answer Example Question: Have you had difficulty swallowing? 381. Finding: Denies sore throat (Available)Pro Tip: Asking if a patient has a sore throat is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Correct answer Example Question: Have you had a sore throat? 389. Finding: Denies breast rashes (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as a rash, is one way of assessing overall breast health. - Correct answer Example Question: Do you have a rash on your breasts? 390. Finding: Denies lumps (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as lumps, is one way of assessing overall breast health. Lumps have a range of severity, as they could be the result of breast injury or cancerous growths, but any abnormalities should be handled with the highest level of concern. - Correct answer Example Question: Do you have any lumps in your breasts? 391. Finding: Denies nipple discharge (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as nipple discharge, is one way of assessing overall breast health. - Correct answer Example Question: Have you experienced nipple discharge? 392. Finding: Denies ever having a mammogram (Available)Pro Tip: Inquiring into what breast screenings Tina has had can lead to a discussion about any test results and their implications for her cardiovascular health. If she has not had any screenings, it provides an opportunity for patient education. - Correct answer Example Question: Have you had a mammogram? 393. Finding: Denies history of breast cancer (Available)Pro Tip: If a patient has a history of breast cancer, it is important that you look for signs of recurrence and engage in preventative care, as well as patient education. You may also need to provide further support and resources to the patient. - Correct answer Example Question: Have you had breast cancer? 394. Finding: Asked about review of systems for respiratory - Correct answer 395. Finding: Denies current breathing problems (Available)Pro Tip: Asking about general breathing problems can provide a comparative baseline for assessing Tina's current condition and previous breathing concerns. - Correct answer Example Question: Have you had breathing problems? 396. Finding: Denies current wheezing (Available)Pro Tip: Patients who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Asking Tina if she's been wheezing illustrates how her asthma is presenting. - Correct answer Example Question: Have you been wheezing? 397. Finding: Denies current chest tightness (Available)Pro Tip: Asking about chest tightness is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of chest tightness, it could be a symptom of asthma or another respiratory problem. - Correct answer Example Question: Have you had chest tightness? 398. Finding: Denies pain while breathing (Available)Pro Tip: Asking about pain during breathing is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of pain during breathing, it could be a symptom of asthma or another