Health Assessment
Sample Question
The nurse is obtaining a client's complete health history. Which of the following statements by the client should the nurse document as part of the client's family history? Select all that apply.
1. "My sisters are identical twins." | ||
2. "My cousin is a health care provider." | ||
3. "My brother died of colon cancer at age 52." | ||
4. "My grandmother had coronary artery disease." | ||
5. "My father was hospitalized after a fall 1 year ago." |
The complete health history refers to information gathered from the client or others (eg, family members) to form the most accurate clinical picture and help guide the client's care. When documenting the complete health history, the nurse should record the client's statements (in quotations), the chief complaint, biographical data, medical history, social history, and family history.
When obtaining a client's complete health history, the nurse should document the medical history of the client's family, which includes:
- History of twins (ie, twinning) (Option 1)
- Causes of death (eg, leukemia, colon cancer) (Option 3)
- Medical conditions (eg, coronary artery disease) (Option 4)
- Hereditary (ie, genetically transmitted) conditions
- Mental health conditions (eg, schizophrenia)
- Substance use (eg, alcohol dependence)
(Option 2) A cousin's occupation (ie, health care provider) is not part of the client's complete health history. The client's occupation would be documented under biographical data.
(Option 5) A client's family history captures significant hereditary, not acute (ie, a fall), conditions that may increase health risks for the client.
Educational objective:
The family history component of the complete health history includes family health data such as history of twins, causes of death (eg, colon cancer), medical conditions (eg, coronary artery disease), hereditary conditions, mental health conditions, and substance use.