Shadow Health - Tina Jones, Health History Test with Verified Answers
Diana Shadow: Your patient is Tina Jones:, a 28-year-old
African American woman who has just been admitted to
Shadow General Hospital for a painful foot wound. Your
Student: What is the situation?
role in this simulation is that of a healthcare provider who
will take Ms. Jones' health history, a key component of her
admission process.
Diana Shadow: A health history requires you to ask ques-
tions related to Ms. Jones' past and present health, from
her current foot wound to her pre-existing conditions. You
will also want to review Ms. Jones' systems, psychosocial
history, and family medical history. These assessments to-
gether will give you a comprehensive picture of Ms. Jones'
overall health. If you discover any disease states, ask about
symptoms and the patient's experiences of them. Your
questioning should cover a broad array of the symptoms'
characteristics. Throughout the conversation, you should
educate and empathize with Ms. Jones when appropriate
to increase her health literacy and sense of well-being.
Student: What are my objectives in this assessment?
Regardless of whether you have assessed Ms. Jones previ-
ously, ask all questions that are necessary for obtaining a
complete health history. While you should communicate
with patients using accessible, everyday language, it is
standard practice to use professional medical terminology
everywhere else, such as in documenting physical findings
and nursing notes. You may complete the exam activities
in any order and move between them as needed. After
obtaining Ms. Jones' health history, you will complete
an information processing activity. You will identify and
prioritize diagnoses, then create a plan to address the
identified diagnoses.
Student: How does this assignment prepare me for the
real world?
,Diana Shadow: In this assessment, you will become famil-
iarized with the structure and content of a health history
exam so that with real-life patients, you can: º ask ettective
and comprehensive questions º obtain a thorough health
history º evaluate the patient's risk of disease, infection,
injury, and complications º educate and empathize º reflect
on your experience and identify areas to improve º identify
and prioritize nursing diagnoses º and develop a plan to
address nursing diagnoses.
Diana Shadow: In 1 or 2 sentences, answer this question Student: So that you understand if there are any problems
to help prepare for the upcoming exam: Why is it impor- related to their chief complaint. Also, to help treat their
tant to obtain a patient's complete health history? current condition.
Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood
glucose: 238, Temperature: 102.4° F, Blood pressure:
Patient Exam - Vital Signs:
138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat:
98%
Patient Exam - Interview:
Student: Hello, my name is Catlain, I am your nurse today. Tina Jones: Hey.
Student: Can you confirm your name? Tina Jones: Tina Jones:.
Tina Jones: I got this scrape on my foot a while ago, and it
Student: Why did you come in today?
got really infected. It's killing me.
Student: What additional symptoms have you experi- Tina Jones: I mean, it's all red and swollen, and there's pus,
enced? it feels hot, it hurts like hell... It's got all that going on.
Student: Can you rate your current pain level on a scale of Tina Jones: ...Like a 7. It hurts a lot, but whatever pain med
0 to 10? the ER gave me is helping a little bit.
Tina Jones: It's throbbing and like, sharp if I try to put
Student: Please describe the pain.
weight on it.
, Tina Jones: I was changing a light bulb, and I had to use
our little stepstool to reach it. My foot slid ott the bottom
Student: How did you hurt your foot?
step and it got all scraped up. I didn't realize how sharp
the edge was!
Student: Has your foot been draining any liquids? Tina Jones: Yeah, there's definitely pus.
Student: What color was the pus? Tina Jones: It's... white or maybe ott-white.
Student: How have you treated the wound? Tina Jones: I've been taking Advil for my foot for a few days.
Student: What did you do to treat your foot after your Tina Jones: I made sure to clean it and keep it bandaged.
accident? And I put Neosporin on it.
Student: How ettective was the Neosporin? Tina Jones: Well, I'm here, so I guess it didn't do its job.
Tina Jones: No, I can't. I can't put any weight on it without
Student: Can you walk with your foot being injured?
like, shooting pain.
Student: What preexisting medical conditions do you Tina Jones: I mean, I have asthma and diabetes, but right
have? I now I just care about my foot!
Student: I understand your foot hurts, but I need to know
this information to make sure I take care of the problem Tina Jones: Thanks.
correctly.
Student: When were you diagnosed with diabetes? Tina Jones: I was diagnosed when I was 24.
Tina Jones: I try to avoid things that give me breathing
Student: What do you do to manage your asthma? problems, but when my asthma starts to act up, I just use
my inhaler.
Student: What medications did you take for your diabetes? Tina Jones: It was metformin.
Tina Jones: No, I don't take anything for my diabetes any-
Student: Do you currently take medicine for your diabetes?
more.
Tina Jones: I guess I just got sick of feeling sick and gassy
Student: What made you stop taking medication for your
all the time, and it was overwhelming, remembering to
diabetes?
take pills and check my sugar. I feel a lot better now that
, I'm just eating healthier than I did when I was taking the
pills.
Tina Jones: I have a monitor at home, but to be honest I
Student: Do you monitor your blood glucose?
don't really use it that often.
Tina Jones: I don't know. Every hour or two when I'm
Student: How frequently do you urinate?
awake?
Tina Jones: It's pretty good, I think. I'm not a huge health
Student: What is your current diet?
nut or anything.
Tina Jones: Yeah, lately I've definitely been much hungrier
Student: Have you had any change in appetite?
than usual.
Student: Has your weight changed? Tina Jones: Yeah, I've lost some weight recently.
Student: Do you know why you lost weight? Tina Jones: I don't know what caused it, I just lost weight.
Tina Jones: I haven't had a full attack in years. But my
Student: How often do you have asthma exacerbations? breathing definitely acts up. . .not always. Max twice a
week.
Tina Jones: My chest and throat get tight, and I start to
Student: What asthma symptoms have you experienced? wheeze. It feels like I can't take in air, like I can't get enough
air into my lungs.
Tina Jones: I usually use two putts from my inhaler, but
Student: How many putts do you take when using your
sometimes I need three. [Nurse confirmed with Pharma-
asthma inhaler?
cy: albuterol 90mcg/spray MDI]
Tina Jones: Being around cats is the worst, but dust and
Student: What are some things that trigger your asthma?
running up stairs can make my breathing bad, too.
Student: What allergies do you have? Tina Jones: I'm allergic to cats.
Student: When did you realize you were allergic to cats? Tina Jones: For as long as I've been around.
Tina Jones: Whatever pain medication the ER gave me is
Student: How ettective was your pain medication at home?
helping. Before I came in, I was just taking Advil. For the
Diana Shadow: Your patient is Tina Jones:, a 28-year-old
African American woman who has just been admitted to
Shadow General Hospital for a painful foot wound. Your
Student: What is the situation?
role in this simulation is that of a healthcare provider who
will take Ms. Jones' health history, a key component of her
admission process.
Diana Shadow: A health history requires you to ask ques-
tions related to Ms. Jones' past and present health, from
her current foot wound to her pre-existing conditions. You
will also want to review Ms. Jones' systems, psychosocial
history, and family medical history. These assessments to-
gether will give you a comprehensive picture of Ms. Jones'
overall health. If you discover any disease states, ask about
symptoms and the patient's experiences of them. Your
questioning should cover a broad array of the symptoms'
characteristics. Throughout the conversation, you should
educate and empathize with Ms. Jones when appropriate
to increase her health literacy and sense of well-being.
Student: What are my objectives in this assessment?
Regardless of whether you have assessed Ms. Jones previ-
ously, ask all questions that are necessary for obtaining a
complete health history. While you should communicate
with patients using accessible, everyday language, it is
standard practice to use professional medical terminology
everywhere else, such as in documenting physical findings
and nursing notes. You may complete the exam activities
in any order and move between them as needed. After
obtaining Ms. Jones' health history, you will complete
an information processing activity. You will identify and
prioritize diagnoses, then create a plan to address the
identified diagnoses.
Student: How does this assignment prepare me for the
real world?
,Diana Shadow: In this assessment, you will become famil-
iarized with the structure and content of a health history
exam so that with real-life patients, you can: º ask ettective
and comprehensive questions º obtain a thorough health
history º evaluate the patient's risk of disease, infection,
injury, and complications º educate and empathize º reflect
on your experience and identify areas to improve º identify
and prioritize nursing diagnoses º and develop a plan to
address nursing diagnoses.
Diana Shadow: In 1 or 2 sentences, answer this question Student: So that you understand if there are any problems
to help prepare for the upcoming exam: Why is it impor- related to their chief complaint. Also, to help treat their
tant to obtain a patient's complete health history? current condition.
Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood
glucose: 238, Temperature: 102.4° F, Blood pressure:
Patient Exam - Vital Signs:
138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat:
98%
Patient Exam - Interview:
Student: Hello, my name is Catlain, I am your nurse today. Tina Jones: Hey.
Student: Can you confirm your name? Tina Jones: Tina Jones:.
Tina Jones: I got this scrape on my foot a while ago, and it
Student: Why did you come in today?
got really infected. It's killing me.
Student: What additional symptoms have you experi- Tina Jones: I mean, it's all red and swollen, and there's pus,
enced? it feels hot, it hurts like hell... It's got all that going on.
Student: Can you rate your current pain level on a scale of Tina Jones: ...Like a 7. It hurts a lot, but whatever pain med
0 to 10? the ER gave me is helping a little bit.
Tina Jones: It's throbbing and like, sharp if I try to put
Student: Please describe the pain.
weight on it.
, Tina Jones: I was changing a light bulb, and I had to use
our little stepstool to reach it. My foot slid ott the bottom
Student: How did you hurt your foot?
step and it got all scraped up. I didn't realize how sharp
the edge was!
Student: Has your foot been draining any liquids? Tina Jones: Yeah, there's definitely pus.
Student: What color was the pus? Tina Jones: It's... white or maybe ott-white.
Student: How have you treated the wound? Tina Jones: I've been taking Advil for my foot for a few days.
Student: What did you do to treat your foot after your Tina Jones: I made sure to clean it and keep it bandaged.
accident? And I put Neosporin on it.
Student: How ettective was the Neosporin? Tina Jones: Well, I'm here, so I guess it didn't do its job.
Tina Jones: No, I can't. I can't put any weight on it without
Student: Can you walk with your foot being injured?
like, shooting pain.
Student: What preexisting medical conditions do you Tina Jones: I mean, I have asthma and diabetes, but right
have? I now I just care about my foot!
Student: I understand your foot hurts, but I need to know
this information to make sure I take care of the problem Tina Jones: Thanks.
correctly.
Student: When were you diagnosed with diabetes? Tina Jones: I was diagnosed when I was 24.
Tina Jones: I try to avoid things that give me breathing
Student: What do you do to manage your asthma? problems, but when my asthma starts to act up, I just use
my inhaler.
Student: What medications did you take for your diabetes? Tina Jones: It was metformin.
Tina Jones: No, I don't take anything for my diabetes any-
Student: Do you currently take medicine for your diabetes?
more.
Tina Jones: I guess I just got sick of feeling sick and gassy
Student: What made you stop taking medication for your
all the time, and it was overwhelming, remembering to
diabetes?
take pills and check my sugar. I feel a lot better now that
, I'm just eating healthier than I did when I was taking the
pills.
Tina Jones: I have a monitor at home, but to be honest I
Student: Do you monitor your blood glucose?
don't really use it that often.
Tina Jones: I don't know. Every hour or two when I'm
Student: How frequently do you urinate?
awake?
Tina Jones: It's pretty good, I think. I'm not a huge health
Student: What is your current diet?
nut or anything.
Tina Jones: Yeah, lately I've definitely been much hungrier
Student: Have you had any change in appetite?
than usual.
Student: Has your weight changed? Tina Jones: Yeah, I've lost some weight recently.
Student: Do you know why you lost weight? Tina Jones: I don't know what caused it, I just lost weight.
Tina Jones: I haven't had a full attack in years. But my
Student: How often do you have asthma exacerbations? breathing definitely acts up. . .not always. Max twice a
week.
Tina Jones: My chest and throat get tight, and I start to
Student: What asthma symptoms have you experienced? wheeze. It feels like I can't take in air, like I can't get enough
air into my lungs.
Tina Jones: I usually use two putts from my inhaler, but
Student: How many putts do you take when using your
sometimes I need three. [Nurse confirmed with Pharma-
asthma inhaler?
cy: albuterol 90mcg/spray MDI]
Tina Jones: Being around cats is the worst, but dust and
Student: What are some things that trigger your asthma?
running up stairs can make my breathing bad, too.
Student: What allergies do you have? Tina Jones: I'm allergic to cats.
Student: When did you realize you were allergic to cats? Tina Jones: For as long as I've been around.
Tina Jones: Whatever pain medication the ER gave me is
Student: How ettective was your pain medication at home?
helping. Before I came in, I was just taking Advil. For the
