During a health history assessment, where is the symptoms description/narrative typically documented?

Review of Systems

Chief Complaint

History of Present Illness

Past Medical History

Answer and Explanation

The Correct Answer is C

Choice A Reason:
The Review of Systems (ROS) is a systematic approach for collecting the patient's self-reported data on all body systems. It is not typically where the narrative of symptoms is documented. Instead, the ROS is used to uncover symptoms the patient may not have mentioned during the initial recounting of their history.

Choice B Reason:
The Chief Complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, or other factors that are the reason for the encounter, usually stated in the patient's words¹. While it does include the symptom prompting the visit, it is not the section where a detailed narrative or description of symptoms is provided.

Choice C Reason:
The History of Present Illness (HPI) is indeed where the detailed narrative of the patient's symptoms is documented. It includes the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date. The HPI tells the story of the patient's chief complaint and provides context for the clinical reasoning process.

Choice D Reason:
The Past Medical History (PMH) includes information about the patient's past experiences with illnesses, operations, injuries, and treatments. It does not contain the current symptoms' narrative but rather the patient's health status before the present illness or concern.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice a reason:
Resonance is the expected percussion note when percussing over normal, healthy lung tissue. This sound is produced due to the presence of air in the lung parenchyma, which allows for the transmission of sound waves through the air-filled spaces. In a healthy individual, the resonance indicates that the lungs are free from any significant abnormalities that could alter the sound, such as fluid or solid masses.
Choice b reason:
Tympanic notes are typically heard over hollow, air-containing structures like the stomach. This sound is not expected in lung percussion unless there is a large, air-filled cavity within the lung tissue, which would be abnormal and indicative of a pathological condition such as a pneumothorax.
Choice c reason:
A flat percussion note is usually heard over dense tissues where air is not present, such as over the thigh muscles or areas of the chest where lung tissue has been replaced by something more solid, like in the case of a pleural effusion or a lung mass.
Choice d reason:
Dullness on percussion usually indicates that the lung is not air-filled and may be suggestive of underlying conditions such as pneumonia, tumor, or atelectasis. It is a higher-pitched sound compared to flatness and is typically found in areas of the lung that are filled with fluid or solid tissue rather than air.

A. A client who has recently been diagnosed with a chronic illness. B. A client with hypotension, tachycardia, SpO2 85%, and a recent gunshot wound. C. A client who just confirmed she is pregnant. D. A client who makes frequent hospital visits reporting the same symptom.

Correct Answer is B

Explanation

Choice a reason:
A client recently diagnosed with a chronic illness would require a comprehensive health history that includes past medical history, medications, and lifestyle factors. While important, it is not typically categorized as an emergency health history unless the chronic condition has acutely worsened.

Choice b reason:
A client presenting with hypotension (low blood pressure), tachycardia (rapid heart rate), an oxygen saturation of 85% (indicating potential hypoxemia), and a recent gunshot wound is experiencing a life-threatening situation that requires immediate medical attention. An Emergency health history is crucial in this scenario to quickly gather information that will guide urgent treatment decisions.

Choice c reason:
A client who has just confirmed pregnancy would need a detailed health history, including obstetric and gynecological history, but this is not considered an emergency unless there are complications or concerns that require immediate attention.

Choice d reason:
A client who frequently visits the hospital reporting the same symptom may indicate a chronic issue that needs ongoing management rather than an emergency. However, if the symptom suggests an acute exacerbation or a new, serious condition, it could escalate to an emergency.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

During a health history assessment, where is the symptoms description/narrative typically documented?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a respiratory physical examination on a healthy patient. When performing the percussion physical assessment technique, the lung percussion note should be:

Correct Answer is A

Explanation

The student nurse is reviewing different types of health history. Which client situation would require an Emergency health history?

Correct Answer is B

Explanation

A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

A client has arrived at the clinic for a routine physical examination. Prior to assessing the client's blood pressure, what should the nurse do?

A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely?

A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect?

A middle-aged school teacher complains of excessive tearing of the eyes every morning. Which assessment should the nurse perform next?

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?