During the admission history, the client states that he has trouble br

During the admission history, the client states that he has trouble breathing at night. In obtaining data for a problem-oriented database, the nurse should first question the client about:

1. The onset and duration of his present breathing problem
2. His personal smoking, alcohol use, and exercise practices
3. Any extended family members who have diagnosed heart disease
4. Changes in other body systems that the client perceives as problematic

ANSWER

ANS: 1
A client’s database originates with the client’s perception of a symptom or health problem. If an illness is present, the nurse gathers essential and relevant data about the nature and onset of symptoms. The problem-seeking technique takes the information provided in the client’s story to more fully describe and identify the client’s specific problems. Habits and lifestyle patterns such as smoking, alcohol use, and exercise may be assessed in an admission history. However, it is not the first question the nurse should ask when obtaining data for a problem-oriented database after the client reports having a health problem. Information regarding family history, such as members who had heart disease, may be obtained in an admission history. However, if a client reports a problem, the nurse should first follow-up with questions relevant to the nature and onset of symptoms. The nurse may inquire about changes in other body systems during an admission his-tory; however, if the client reports a problem, the nurse should first follow-up using a prob-lem-oriented approach. This would include asking specific questions about the client’s health problem, such as the nature and onset of symptoms.