Which assessment data should the nurse include when obtaining a review of body systems?
A. Brief statement about what brought the client to the health care provider.
B. Client complaints of chest pain, dyspnea, or abdominal pain.
C. Information about the client’s sexual performance and preference.
D. The client’s name, address, age, and phone number.
Correct Answer: B. Client complaints of chest pain, dyspnea, or abdominal pain.
Client complaints about chest pain, dyspnea, or abdominal pain are considered part of the review of body systems. This portion of the assessment elicits subjective information on the client’s perceptions of major body system functions, including cardiac, respiratory, and abdominal. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts.
Option A: A brief statement about what brought the client to the health care provider is the chief complaint. The CC is the reason for the visit as stated in the patient’s own words. This must be present for each encounter, and should reference a specific condition or complaint (e.g., patient complains of abdominal pain).
Option C: Information about the client’s sexual performance and preference addresses past health status. Understanding the client’s current and past health is important and may provide an explanation or rationale for the client’s current health status. Furthermore, these data can provide insight into health promotion needs and co-morbidities. It is helpful to understand the current and past health profiles before assessing other aspects of health, as the information will inform subsequent questions.
Option D: The client’s name, address, age, and phone number are biographical data. “Introductory Information” refers to the demographic and biographic data that you collect from the client. This data provides you with basic characteristics about the client, such as their name, contact information, birth date and age, gender and preferred pronouns, allergies, languages spoken and preferred language, relationship status, occupation, and resuscitation status.