Chapter 02: Health History and Interview
A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?
"Can you tell me about your sleep problem from when it started until now?"
The nurse is preparing to assess a female client's activities related to health promotion and maintenance. Which question would provide the most objective and thorough data?
"Could you describe how you perform self-breast exams?"
The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data?
"Could you describe how you perform self-breast exams?"
During a health history, a client asks why family information is requested. Which response should the nurse make to the client?
"It can help identify any illnesses that you might be at risk for developing."
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?
"What is your major health concern at this time?"
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?
"You must quit smoking because it affects others, not only you."
Upon entering an exam room, the client states, "Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!" Which response by the nurse would be most appropriate?
"You're certainly justified in being upset, but I am ready to begin your exam now."
Which statements provide information about a client's health maintenance? Select all that apply.
A child received immunizations based on the recommended schedule. A female client had a mammogram 2 weeks ago. A client recently a had lab test for liver function.
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?
Active listening
The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use?
After assessing for cigarette use
During the nurse's assessment of the client's exercise and activity habits, the client laughs and then states, "Unless you're including channel surfing, I don't really do much of anything." What would the nurse do next?
Briefly describe some of the potential benefits of regular exercise.
A client reports pain as being 7 on a scale from 1 to 10. In which area of the symptom should the nurse document this information?
Characteristic
A nurse, conducting a functional assessment on an adult client, assesses overall psychosocial well-being by assessing what?
Coping/stress tolerance
While gathering data for the family history portion of the health history, what would you ask about?
Coronary artery disease
While assessing a patient, the nurse is asking questions that help the nurse perceive and communicate an understanding of what the patient is feeling. What is this called?
Empathy
When beginning the collection of the client data base, which of the following would be most important for the nurse to do?
Establish a trusting relationship
Learning about the effects of the illness does what for the nurse and the patient?
Gives them the opportunity to create a complete and congruent picture of the problem
The nurse is teaching the patient how to self-administer insulin. Which functional health pattern does this nursing intervention address?
Health perception-health management
The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?
History of present illness
A group of students is reviewing for a quiz on verbal and nonverbal communication. The students demonstrate a need for additional studying when they identify which of the following as an example of nonverbal communication?
Laundry list
Which action should a nurse implement when assessing a non-native client to facilitate collection of subjective data?
Maintain a professional distance during assessment
During the review of systems, a client reports dizziness, tingling, and mood changes. In which area should the nurse document this information?
Neurologic
Which should the nurse assess when conducting a health history of the pregnant woman? Select all that apply.
Obstetrical history Gynecological history Genetically inherited diseases Lifestyle behaviors History of abuse
During a comprehensive health history, a client reports smoking cigarettes for 20 years. The nurse will document this information in which of the following sections?
Past history
The nurse would document driving with car seatbelt fastened, bicycling with properly-fitted helmet, and installing a smoke detector in a vacation home in the client's health history under which of the following?
Personal and social history
A comprehensive health history includes which components? Select all that apply.
Reason for seeking care History of present illness Past health history
A patient has come to the physician's office several times in the last month with a black eye, bruises, and lacerations on the lower extremities. The patient always explains having fallen and tripped. The nurse suspects abuse. The next step should be to:
Report the findings to a supervisor.
During an interview, the patient begins to talk about the frequency of being abused by a spouse. What can the nurse do at this time to acknowledge the sensitivity of the information the patient is providing?
Stop documenting in order to maintain eye contact with the patient.
A nurse is obtaining subjective data from an adult client who is new to the clinic. The nurse has asked the client, "Where do you usually turn for help in a time of crisis?" What domain is this nurse assessing?
The client's stress management and coping strategies
A nurse is interviewing a client with a different cultural background. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?
Using a moderate amount of eye contact
A nurse assesses a client who reports the onset of a severe headache. During which phase of the nursing interview should the nurse ask the client about the history of the present health concern and the reasons for seeking care?
Working
During a health history, a client states "I want to know why my feet are swelling" whereas the primary diagnosis is arthritis. What should the nurse do with the client's statement?
Write is as the chief complaint
During the working phase of an interview the nurse encourages the client to continue and expand on the health issues. What technique is the nurse using?
active listening
When the nurse is conducting the health history, when would be the most natural time to ask the client about alcohol use?
after asking about cigarette smoking
The nurse is beginning a health history interview with an adult client who expresses anger at the nurse. The best approach for dealing with an angry client is for the nurse to
allow the client to verbalize his or her feelings.
The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus?
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
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
The nurse is reviewing the medical record before meeting a new client. In which phase of the interview process is the nurse working?
pre-interview
A woman brings her newborn to the clinic for a well-baby visit. The nurse knows that the focus of this health history should be on which of the following:
pregnancy, birth, and perinatal histories
The nurse is completing a comprehensive assessment with a client experiencing a lung infection. Which information is essential to document within risk factors?
tobacco use
The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document?
unable to go to the gym since having back surgery
A male older adult client reports a 2-week history of sleep disruption due to frequently waking up to void in the middle of the night. Where in the review of systems should the nurse document this symptom?
urinary
A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?
value-belief
The nurse suspects that a client is experiencing alcohol abuse. When completing the CAGE questionnaire, the nurse can confirm the client is having guilty feelings when she makes which statement?
"My family doesn't deserve my bad behavior."
Which statements demonstrate the nurse's attempt to empower the client during an assessment interview? Select all that apply.
"Please tell about what brought you here today." "I'm not sure when the test will be scheduled, but I will find that out before you leave." "Falling as you did must be a very frightening experience."
The review of systems component of the health history is best described as a:
Focus on common questions and issues related to each of the different body systems
A client with a foot wound returns to the outpatient wound clinic for a weekly appointment and treatment. Which type of assessment should the nurse complete with this client?
Follow-up
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.
The nurse is interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of guided questioning?
Reassure the client that the urinary symptoms are most often treated successfully.
An older adult client is brought to the ED. The client tells the nurse, "I feel like something really heavy is sitting on my chest." The nurse then says to the client, "You feel as if something heavy is sitting on your chest?" Of what type of nurse-client communication is this an example?
Restatement
A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask the patient next. What is a useful interview technique for the student to use at this point?
Summarization
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
A nursing instructor is teaching the student during clinical how to take a health history and perform a complete assessment on a patient. The student shows understanding of the difference between subjective and objetive data by identifying the following as objective data.
decubitus on left heel
During an interview with an adult client, the nurse can keep the interview from going off course by
using closed-ended questions.