EXAMINATION AND HISTORY TAKING EXAM
PREPARATION PACK 2026 KEY CONCEPTS
AND REVISION NOTES
◉ What does a client reporting alcoholic beverages several
mornings a week indicate? Answer: Potential alcohol use that may
need further assessment.
◉ What part of the CAGE questionnaire addresses morning alcohol
consumption before work? Answer: Eye-openers
◉ How should a nurse analyze risk factors during a history of
present illness? Answer: As a contributing factor to the current
problem
◉ What key elements should a nurse document when recording a
client's history of present illness? Answer: Describes how each
symptom developed, includes the client's feelings about the illness,
includes medications contributing to the illness, includes smoking
and alcohol use if they contributed to the illness.
◉ What type of data is considered subjective in a health history
assessment? Answer: Client report of headache, personal health
,history, client verification of allergies to penicillin, and client's flat
affect.
◉ What should a nurse question based on a client's allergy history?
Answer: Penicillin IVPB every 6 hours, due to the client's allergy to
penicillin.
◉ What are the components of a comprehensive adult health
history? Answer: Includes personal health history, family history,
social history, and review of systems.
◉ What is the significance of documenting a client's feelings about
their illness? Answer: It provides insight into the emotional impact
of the illness and aids in holistic care.
◉ Why is it important to include childhood illnesses in a health
history? Answer: They may contribute to the current health issues
the client is experiencing.
◉ What should a nurse focus on when asking about the history of
the present illness? Answer: The onset, duration, and characteristics
of symptoms.
,◉ What is the role of subjective data in health assessments? Answer:
Subjective data reflects the client's personal experiences and
perceptions of their health.
◉ What is the purpose of the CAGE questionnaire in health
assessments? Answer: To screen for potential alcohol use disorders.
◉ What is the importance of documenting medications in a health
history? Answer: To identify potential interactions and
contraindications related to the client's health conditions.
◉ How can a nurse determine if a client's alcohol use is
problematic? Answer: By assessing the frequency and context of use,
such as morning consumption.
◉ What does the term 'PMH' stand for in health history
documentation? Answer: Past Medical History.
◉ What should be included in a client's allergy history? Answer:
Specific allergens and the type of reactions experienced.
◉ What is the relevance of documenting a client's smoking history?
Answer: It can impact their current health status and risk factors for
various diseases.
, ◉ What is the significance of a client's age and sex in health
assessments? Answer: They can influence risk factors and
prevalence of certain health conditions.
◉ What does 'MDI' stand for in the context of medications? Answer:
Metered-Dose Inhaler.
◉ Why is it important to document a client's verification of
allergies? Answer: To prevent administration of allergens during
treatment.
◉ What should a nurse consider when documenting a client's health
history? Answer: Accuracy, completeness, and relevance of the
information provided.
◉ What is the role of the nurse in conducting a health history?
Answer: To gather comprehensive information that informs patient
care and treatment plans.
◉ What is the significance of chronic obstructive pulmonary disease
(COPD) in a health history? Answer: It indicates a history of
respiratory issues that may affect current health status and
treatment.