Ch. 2: Collecting Subjective Data: The Interview and Health History

A nurse is interviewing a man complaining of a pain in his shoulder. The nurse asks him where exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen similar cases in other clients and recognizes that is likely from prolonged work at a computer, particularly using a mouse. Which of the following is the most effective use of inferring that the nurse might implement in this situation? -"You work at a computer a lot, don't you?" -"I recommend that you change your posture while working at the computer." -"When did the pain start?" -"Do you perform any sustained or continually repetitive motions with that arm?"

"Do you perform any sustained or continually repetitive motions with that arm?"

The nurse is performing a follow-up assessment and interview of a 72-year-old woman with a history of congestive heart failure. The nurse asks the client, "Have you been experiencing any activity intolerance since I last saw you?" What would be a more appropriate way for the nurse to elicit this information? -"Has this been having an effect on your ability to carry out your routines and get around your home?" -"Do you ever find yourself SOB when you're carrying out your daily routines?" -"Has your congestive heart failure been affecting your activities of daily living recently?" -"Has your heart failure been causing you any dyspnea lately?"

"Has this been having an effect on your ability to carry out your routines and get around your home?"

The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview? -"Have you considered counseling for your mental problems? -"Have you ever had a problem with mental or emotional illness?" -"When was the last time you talked with a psychiatrist?" -"What medication do you take for your depression?"

"Have you ever had a problem with mental or emotional illness?"

The nurse is preparing to meet Mr. James Smith, a 70-year-old client. How should the nurse greet this client? -"Hello Mr. Smith." -"How are you doing today Mr. Jim?" -"So nice to meet you Jim!" -"Hi dear! Have a seat!"

"Hello Mr. Smith."

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is -"Is stress a problem in your life?" -"How do you manage your stress?" -"Do you feel stress at work?" -"How often do you feel stressed?"

"How do you manage your stress?"

During a health history, the nurse recommends using a genogram. The client asks the nurse to explain the purpose of a genogram. How should the nurse respond? -"It helps the nurse organize data on the client's family history." -"It helps the nurse cluster client cues." -"It is used to collect data about a client's health." -"It is a short questionnaire."

"It helps the nurse organize data on the client's family history."

A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time? -"Are both of your parents still living?" -"What do you usually eat in a typical day?" -"What diseases did you have as a child?" -"How do you feel about having to seek health care?"

"What diseases did you have as a child?"

A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history? -"Are you generally fairly healthy?" -"Do you have adequate health insurance coverage?" -"What is your major health concern at this time?" -"Did you bring all your medications with you?"

"What is your major health concern at this time?"

Which of the following questions is most useful in the assessment of a client's diabetes management? -"Are you still using your glucometer 4 times a day?" -"You check your sugars before each meal, don't you?" -"What is your routine for checking your blood sugar these days?" -"Are you staying vigilant with your blood sugar monitoring?"

"What is your routine for checking your blood sugar these days?"

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors? -"Where did the numbness and tingling occur?" -"How long did the spell last?" -"How bad was the tingling and numbness?" -"What other symptoms occurred during the spell?"

"What other symptoms occurred during the spell?"

A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental? -"Your husband's death must have been very difficult for you." -"You must quit smoking because it affects others, not only you." -"How often do your adult children typically visit you?" -"How would you describe your feelings about getting older?"

"You must quit smoking because it affects others, not only you."

A client will require an extended period of intense physical therapy after having a compound fracture of the femur surgically repaired. What question should the nurse ask when assessing the client's perception of the injury and recovery plan? (Select all that apply.) -"What frustrations are you experiencing since your accident?" -"How do you plan to support yourself financially while you recover?" -"How does experiencing such a trauma make you feel?" -"What do you expect from the physical therapy you will have?" -"What did the pain feel like when you broke your femur?"

-"What frustrations are you experiencing since your accident?" -"How do you plan to support yourself financially while you recover?" -"How does experiencing such a trauma make you feel?" -"What do you expect from the physical therapy you will have?"

During one of your clinical placements you encounter a client who becomes silent during the nursing interview. What would be appropriate for you to do? (Mark all that apply.) -Ask your question again -Change the subject you are asking about -Appear attentive -Watch the client closely for nonverbal cues -Give brief encouragement to the client

-Appear attentive -Watch the client closely for nonverbal cues -Give brief encouragement to the client

When interacting with a client, what conveys the extent of interest, attention, acceptance, and understanding of the nurse? (Select all that apply.) -Posture -Eye contact -Tone of voice -Gestures -Cultural reassurance

-Posture -Eye contact -Tone of voice -Gestures

A nurse in a clinic is preparing to meet with a new, 35-year-old male client. Complete the following sentence by choosing from the lists of options. Prior to meeting the new client, the nurse should first ___________________ (review the client's medical record, conduct a comprehensive phone interview, request blood tests be performed) and then ______________________ (speak to family members, ask the client about their past medical history, explain the purpose of the interview)

-review the client's medical record and then -explain the purpose of the interview

A nurse in a community clinic is attempting to collect a health history on a 26-year-old female new client who appears anxious. Drag words from the choices below to fill in each blank in the following sentence. To help reduce the client's anxiety, the nurse should ______________, _____________, ______________, and _______________. -perform the health history at a fast pace -only ask open-ended questions -introduce oneself -explain the nurse's role -ask simple, concise questions -decrease environmental stimuli

1. introduce oneself 2. explain the nurse's role 3. decrease environmental stimuli 4. ask simple, concise questions

A nurse is interviewing an adult client who had a miscarriage 3 weeks ago. The woman is crying and is having difficulty talking. The nurse moves closer and places a hand on the woman's hand. What type of communication is this? -Restatement -Active listening -Reflection -Encouraging elaboration (facilitation)

Active listening

During a health history interview the client states, "I have been short of breath." What is the priority action of the nurse? -Ask the client if they currently feel short of breath. -Move to the next system. -Document the finding. -Ask the client what exacerbates their shortness of breath.

Ask the client if they currently feel short of breath.

The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action? -Change the subject to put the client at ease. -Refer all questions to the client's family member in room. -Turn the television on for distraction. -Ask the client to repeat the statement or question.

Ask the client to repeat the statement or question.

During an interview, how can the nurse best assist the client as the client tells their story? -Avoid interrupting the client. -Correct the client when the client makes erroneous statements. -Use a focused questioning format. -Suggest information the client has appeared to have forgotten.

Avoid interrupting the client.

Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client did not want to wait. The nurse has heard about this client many times from colleagues and is aware that she is very talkative. Which of the following is a helpful technique to improve the quality of the interview for both provider and client? -Allow the client to speak uninterrupted for the duration of the appointment. -Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed. -Allow impatience to show so that the client picks up on nonverbal cues that the appointment needs to end. -Set the time limit at the beginning of the interview and stick with it, no matter what occurs in the course of the interview.

Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed.

A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format of representing a deceased female relative? -Circle with a cross -Square with a cross -Simple circle -Simple square

Circle with a cross

What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"? -Asking the client if they are wearing a hearing aide -Introducing hand gestures whenever it is appropriate -Using pre-written cards that state the interview questions -Closing the door may help to limit background noise.

Closing the door may help to limit background noise.

The nurse has been assigned to a group of clients on a medical surgical unit. What is the best action of the nurse prior to receiving a report on these clients? -Conduct a brief review of the client's charts. -Provide a brief introduction to the clients. -Validate problems and goals with the clients. -Perform a quick assessment on all the clients.

Conduct a brief review of the client's charts.

The nurse is focusing an interview on a client's respiratory status. Which question should the nurse ask first to begin this interview? -Do you currently have a cough? -Describe how you breathe for me? -Do you have any difficulty producing sputum? -Do you experience any pain when you breathe?

Describe how you breathe for me?

A nurse completes an initial assessment and discusses findings with the client. What is the next best action of the nurse? -Validate the client's biographical data. -Develop a plan of care with the client. -Discuss lifestyle and health practices with the client. -Perform a review of systems.

Develop a plan of care with the client.

A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client's data, which of the following actions should the nurse prioritize? -Identifying potential health problems -Making clinical inferences -Establishing a trusting relationship -Determining the client's strengths

Establishing a trusting relationship

A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first? -Obtain family health history data. -Determine the client's vital signs. -Collaborate with the client to identify problems. -Explain the purpose of the interview.

Explain the purpose of the interview.

A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information? -Personal health history -Family health history -History of present health concern -Lifestyle and health practices profile

Lifestyle and health practices profile

How would the nursing instructor explain the goal of guided questioning to his or her students? -Facilitating the client's fullest communication -Providing the most plausible answer to the client -Creating an opportunity for the early generation of a plan -Developing a basis for accurate health promotion activities

Facilitating the client's fullest communication

When interviewing, the nurse should logically move from specific to open-ended questions. -False -True

False

A graduate nurse working on a medical-surgical unit is admitting a client who does not speak English. No interpreters are available. The client's spouse is present and speaks English. What should the nurse remember about the use of interpreters when communicating with clients? -Interpreters do not understand cultural health beliefs and practices, so they are unable to help bridge the gap -Hospital interpreters may not always be the best choice because they are unfamiliar with the client -Using children in the family, other relatives, or close friends as interpreters does not violate privacy laws -Friends and family who are unfamiliar with medical terminology may misinterpret information

Friends and family who are unfamiliar with medical terminology may misinterpret information

The nurse is reviewing a new client's chart prior to the initial interview. The chart reveals the client has a visual impairment. What actions should the nurse take to ensure a successful interview? -Turn lights on when entering the room and announce self. -Approach the client on the unaffected side and announce self. -Knock and announce self before entering the client's room. -Loudly announce self when approaching the client.

Knock and announce self before entering the client's room.

When gathering information about medication use, a nurse should ask a client about which types of drugs? -Prescription and OTC medications -Vitamins and herbal supplements -Prescription medications only -Over the counter (OTC) medications

Prescription and OTC medications

A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client? -Provide simple and organized information. -Mirror the client's feelings. -Approach the client in an in-control manner. -Refer the client to a spiritual guide.

Provide simple and organized information

An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary? -The client's medical record -The physician -The client's wife -The client

The client

A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client? -The client may not want the sister to know their private information -The sister may not tell the client exactly what the nurse says -The sister may not be there every time the nurse needs to talk to the client -The client's sister may not understand medical terminology

The client may not want the sister to know their private information

While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose? -To promote objectivity -To restate what the client has said -To clarify -To summarize the conversation

To clarify

During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved? -Working -Beginning -Closing -Pre-interaction

Working

During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions? -Pre-interaction -Beginning -Closing -Working

Working

The nurse is caring for a client in the health care provider's office. In reviewing the client's chart, the nurse recognizes the need for providing the client with additional education related to COVID-19 when noting which of the following about the client? -Has a history of low blood pressure -Lives in a high-income household -Works in the service industry -Eats a diet low in carbohydrates

Works in the service industry

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information? -review of systems -chief complaint -history of present illness -health patterns

chief complaint

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus? -activity-exercise -sleep-rest -coping-stress-tolerance -self-perception/self-concept

coping-stress-tolerance

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information? -create a genogram -include in the past medical history -document it in a narrative note -consider using it when planning care

create a genogram

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should -maintain eye contact while asking the questions from the form. -ask the client to complete the form. -read the questions verbatim from the form. -ask leading questions throughout the interview.

maintain eye contact while asking the questions from the form.

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should -avoid discussing sensitive issues. -explain the role and purpose of the nurse. -set time limits with the client. -allow the client time to calm down.

explain the role and purpose of the nurse.

A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice? -screening test completion -risk factors -compliance with treatment -health maintenance

health maintenance

A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information? -personal and social history -health maintenance -physical examination -review of systems

health maintenance

A client's spouse answers the interview questions and will not leave the examination room. What should the nurse suspect may be occurring with the client? -intimate partner violence -cognitive disorder -low self-esteem -mental health disorder

intimate partner violence

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have -advanced preparation in this area. -personal experiences with death, dying, and sexuality. -experience in dealing with these types of clients. -knowledge of his or her own thoughts and feelings about these issues.

knowledge of his or her own thoughts and feelings about these issues.

An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information? -last surgery date validated by adult daughter -unable to recall exact date of last surgery -adult daughter controlling the interview -confused regarding dates of surgical procedures

last surgery date validated by adult daughter

Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms? -open-ended questions to allow full freedom of response -specific questions to secure a description of every symptom -yes-or-no questions to determine relevant areas of the physical examination -pertinent positive and negative questions to determine relevant details

open-ended questions to allow full freedom of response

During an initial health history, a client states, "I haven't slept in weeks." The nurse asks, "You are saying that you have not had any sleep in weeks?" What communication technique is the nurse using to obtain accurate subjective data from the client? -close-ended questioning -rephrasing -active listening -well-placed phrasing

rephrasing

During an interview with an adult client for the first time, the nurse can clarify the client's statements by -rephrasing the client's statements. -offering a "laundry list" of descriptors. -inferring what the client's statements mean. -repeating verbatim what the client has said.

rephrasing the client's statements.

The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document? -misses seeing friends who used to go for walks together -gained 15 lbs. over the last 6 months -experiences panic attacks several times a week -unable to go to the gym since having back surgery

unable to go to the gym since having back surgery

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing? -self-perception -coping-stress-tolerance -role-relationship -value-belief

value-belief

During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed -working. -introductory. -ongoing. -closure.

working.