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Health Assessment Pre-Test

Health Assessment Pre-Test: Subjective Data

For questions 1-3, refer to the following scenario:

A 47-year-old man is hospitalized for mild chest pain. You are assigned to be his admitting nurse.
1. After going into the room and introducing yourself, how do you begin the admission process?
2. The client tells you that he’s been having some mild chest pain and so he decided to come to the hospital. 

What is the best way for the nurse to qualify his symptom?
3. When you are taking a medical history, you ask if the client has any allergies. The client replies that yes, he is allergic to penicillin. It causes him to break out into hives.

What should your next response be?
4. You are admitting a 53-year-old client with intermittent chest pain to the hospital.
Read through the below subjective assessment and determine which parts of the client's history of present illness were obtained.
Nurse:  Hi, can you tell me when your chest pain started?
Client:  I started to feel every now and then maybe a month or so ago.
Nurse:  How long does the chest pain last when you get it?
Client:  Maybe 10 minutes or so.
Nurse:  Can you rate your pain for me on a scale of 0 to 10?
Client:  Sure, probably a 6.
Nurse:  Can you show me where the pain is?
Client:  It is right here in the center of my chest.
Nurse:  What causes your pain?
Client:  It is mainly after I exercise.

Choose all that apply:
5. You are qualifying a new symptom for a client being seen in your outpatient clinic. 

Read through the subjective assessment and determine which parts of the assessment were accomplished.
Nurse:  You look uncomfortable, are you in pain?
Client:  Yes, my ear is really starting to hurt.
Nurse:  When did that start to bother you?
Client:  About an hour ago.
Nurse:  Is there anything that makes it better?
Client:  Well I haven’t had much time to think about it, but I guess when I blow my nose and it’s not stuffy everything feels better.
Nurse:  Is there anything that makes it worse?
Client:  When I swallow it really, really hurts!
Nurse:  Can you rate your pain after you blow your nose?
Client:  It’s probably a 3 or 4.
Nurse:  Can you rate your pain when you swallow?
Client: Probably a 7!
Nurse:  When your pain is at its worst, does it stay in your ear, or does it travel down your neck or anywhere else?
Client: No, it’s really just in my ear.

Choose all that apply: