Question

A nurse is reviewing with a group of newly licensed nurses the essential components of an admission assessment.

Nursing Interventions:
List at least three aspects of the health history the nurse must gather and document, as well as at least three aspects of the psychosocial evaluation the nurse must gather and document

Answer 1

A nurse must gather and document aspects of the health history and psychosocial evaluation during an admission assessment.

Step-by-step explanation:

When conducting an admission assessment, a nurse must gather and document several aspects of the health history and psychosocial evaluation of a patient.

Health History:

1. Chief complaint: The primary reason the patient is seeking healthcare.
2. Medical history: This includes information about past and current medical conditions, surgeries, allergies, and medications.
3. Family history: Information about the health conditions and diseases that run in the patient's family.

Psychosocial Evaluation:

1. Social support: Information about the patient's living situation, relationships, and support systems.
2. Mental health history: A review of any past or present mental health conditions or treatments, such as depression, anxiety, or substance abuse.
3. Psychosocial stressors: Identifying any stressors, such as recent life events, that may impact the patient's mental well-being.