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


A) Review of systems
B) Present health status
C) Past health history
D) Functional ability

E) A) and B)
F) A) and C)

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


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

G) A) and C)
H) C) and D)

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B, E, F

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


A) Chronic diseases
B) Immunizations received
C) Allergies to medications or food
D) Causes of death of the patient's parents

E) All of the above
F) A) and B)

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B

What data do nurses document under the category general survey?


A) Mental health
B) Functional ability
C) Diet and nutrition
D) Orientation

E) None of the above
F) C) and D)

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D

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


A) Counts on her friends in stressful times
B) "I only sleep for 2 to 3 hours a night and use diphenhydramine for sleep."
C) Has a physical examination and flu vaccination annually
D) "I feel good about myself most of the time."

E) All of the above
F) C) and D)

Correct Answer

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Which documentation by a nurse is most descriptive?


A) Heart sounds normal.
B) Few ectopic beats heard during auscultation.
C) S1 murmur is heard at second right sternal border.
D) Pulse within normal limits.

E) C) and D)
F) B) and C)

Correct Answer

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