Documenting The Comprehensive Health Assessment

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Question 1
Free
Multiple Choice

Which documentation by a nurse is most descriptive?

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A

Heart sounds normal.

B

Few ectopic beats heard during auscultation.

C

S1 murmur is heard at second right sternal border.

D

Pulse within normal limits.

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Question 2
Free
Multiple Choice

The nurse documents which data under the category of present health status?

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A

Counts on her friends in stressful times

B

"I only sleep for 2 to 3 hours a night and use diphenhydramine for sleep."

C

Has a physical examination and flu vaccination annually

D

"I feel good about myself most of the time."

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Question 3
Free
Multiple Choice

Which data do nurses document under the category of past health history?

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A

Chronic diseases

B

Immunizations received

C

Allergies to medications or food

D

Causes of death of the patient's parents

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Question 4
Free
Multiple Choice

A patient reports she has shortness of breath and peripheral edema. Under which category does the nurse document these data?

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A

Review of systems

B

Present health status

C

Past health history

D

Functional ability

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Question 5
Free
Multiple Choice

What data do nurses document under the category general survey?

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A

Mental health

B

Functional ability

C

Diet and nutrition

D

Orientation

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Question 6
Multiple Choice

Which data do nurses document under the category of personal and psychosocial health history? (Select all that apply.)

Choose correct answer/s
A
Allergies to medications or food
B
Diet and foods eaten on a regular basis
C
Type of employment
D
Address and date of birth
E
Activities that promote health
F
Use of tobacco and alcohol
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