Question

List at least three (3) aspects of the health history the nurse must gather and document, as well as at least three (3) aspects of the psychosocial evaluation the nurse must gather and document.

A. Health History: Medical conditions, medications, allergies
B. Psychosocial Evaluation: Support system, coping mechanisms, stressors
C. Health History: Family history, surgical history, immunizations
D. Psychosocial Evaluation: Mental health history, substance use, cultural beliefs

Answer 1

When gathering a health history, nurses must document medical conditions, medications, and allergies. In a psychosocial evaluation, they must document the patient's support system, coping mechanisms, and stressors.

Step-by-step explanation:

When gathering and documenting a health history, a nurse must consider the following aspects:

1. Medical conditions: documenting any current or past medical conditions the patient has experienced, as well as any relevant details such as symptoms, treatments, and outcomes.
2. Medications: documenting all medications the patient is currently taking, including dosage and frequency.
3. Allergies: documenting any known allergies the patient has to medications, foods, or other substances.

When gathering and documenting a psychosocial evaluation, a nurse must consider the following aspects:

1. Support system: documenting the patient's social support network, including family, friends, and other sources of support.
2. Coping mechanisms: documenting how the patient manages stress and difficult situations, including any healthy or unhealthy coping mechanisms they may employ.
3. Stressors: documenting any current or ongoing stressors in the patient's life, such as work, relationships, or financial difficulties.