Chapter 2: Collecting Subjective Data: The Interview and Health History PrepU
When interviewing, the nurse should logically move from specific to open-ended questions. a. True b. False
b. False
During the interview of an adult client, the nurse should: a. use leading questions for valid responses. b. provide the client with information as questions arise. c. read each question carefully from the history form. d. complete the interview as quickly as possible.
b. provide the client with information as questions arise. Another important thing to do throughout the interview is to provide the client with information as questions and concerns arise. Make sure that you answer every question as thoroughly as you can. If you do not know the answer, explain that you will find out for the client. The more clients know about their own health, the more likely they are to become equal participants in caring for their health.
For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have a. advanced preparation in this area. b. experience in dealing with these types of clients. c. knowledge of his or her own thoughts and feelings about these issues. d. personal experiences with death, dying, and sexuality.
c. knowledge of his or her own thoughts and feelings about these issues. Be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then recognize that these factors may affect the client's health and may need to be discussed with someone.
Nurses weave the individualization of the client interview through all aspects of the encounter. The nurse should avoid assuming that clients follow cultural beliefs. In place of making this assumption, what should a nurse do? a. Assess the degree to which the client perceives the cultural beliefs b. Assess how acculturated the client is c. Know the mores of the culture d. Know his or her own cultural beliefs
a. Assess the degree to which the client perceives the cultural beliefs The nurse should avoid assuming clients follow cultural beliefs and assess the degree to which each individual perceives those beliefs. Knowing the mores of the culture and the nurse's own cultural beliefs are important, but do not answer the question at hand. The nurse would have difficulty assessing how acculturated the client is within the client's cultural beliefs.
A client states, "I feel worse since the nurse gave me that medication." What is the nurse's best action? a. Record the information as subjective data. b. Report the client's complaints to quality control. c. Note the statement as objective data in the nurse's notes. d. Do not document any direct client statements.
a. Record the information as subjective data. Both subjective data, what the client says, and objective data can be recorded in the client's medical record. Clients' complaints do not have to be reported to quality control.
A nurse collects data about a client's family health history. Which family members' health problems should the nurse include when documenting this information in the database? a. Only the members with health problems that relate to the client's gender b. As many genetic relatives as the client can recall c. Those with diseases that are known to have a genetic link d. Those with illnesses that resulted in death or disablement
b. As many genetic relatives as the client can recall Both maternal and paternal genetic relatives are included in the family health history. Problems can arise in families that are not genetically based but are manifest by virtue of exposure to lifestyle practices. Parents, grandparents, aunts, uncles, and children are all included in this history. If the relative is deceased, the cause of death and age of death of the relative is recorded.
How would the nursing instructor explain the goal of guided questioning to his or her students? a. Providing the most plausible answer to the client b. Facilitating the client's fullest communication c. Developing a basis for accurate health promotion activities d. Creating an opportunity for the early generation of a plan
b. Facilitating the client's fullest communication The main goal of guided questioning is to facilitate the client's fullest communication. The early generation of a plan is not a paramount goal and it is incorrect to suggest particular answers to the client.
A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information? a. physical examination b. health maintenance c. personal and social history d. review of systems
b. health maintenance Health maintenance includes any preventative diagnostics or health-promoting activities the client completed in the past. This is a subsection of the past history in the health assessment. The physical examination and review of systems capture the objective data that arises from the health assessment conducted by the nurse. Personal and social history capture client lifestyle factors such as family, employment, and habits.
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 a. allow the client time to calm down. b. avoid discussing sensitive issues. c. set time limits with the client. d. explain the role and purpose of the nurse.
d. explain the role and purpose of the nurse. When interacting with an anxious client provide the client with simple, organized information in a structured format and explain who you are, along with your role and purpose.
A client has a 10-year history of being treated for hypertension. Where should the nurse document this information? a. health patterns b. review of systems c. health maintenance d. past medical history
d. past medical history An adult medical illness is documented as part of the past medical history. Health patterns identify the client's personal/social history and daily living routines that may influence health and illness. The review of systems focuses on the presence or absence of common symptoms related to each major body system. Health maintenance is a part of the past medical history and identifies actions taken to improve or maintain health.
The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to a. use very basic lay terminology. b. have a family member present during the interview. c. use standard medical terminology. d. show the client pictures of different symptoms, such as the "faces pain chart."
a. use very basic lay terminology. If the client appears to have a limited vocabulary, the nurse may need to ask questions in several different ways and use very basic lay terminology.
When considering the attributes of a symptom and the OLD CART mnemonic, which questions will the nurse ask a client who is reporting pain in the left knee? Select all that apply. a. "Is there a particular action that causes the knee pain?" b. "Can you point to where you feel the greatest amount of knee pain?" c. "What do you think is causing your knee pain?" d. "Do you feel the pain in places other than just your left knee?" e. "What do you do to make the knee pain less severe?"
a. "Is there a particular action that causes the knee pain?" b. "Can you point to where you feel the greatest amount of knee pain?" d. "Do you feel the pain in places other than just your left knee?" e. "What do you do to make the knee pain less severe?" The OLD CART mnemonic includes questions concerning the symptom's Onset, Location, Associated manifestations, and Relieving factors. While it may not be inappropriate to ask the client his or her opinion of the cause of the symptom, such a question is not associated with OLD CART or the assessment of the attributes of a symptom.
What occurs during the termination phase of an interview? a. Planning for follow-up care b. Addressing topics that have not yet been addressed c. Assessing the client's mental status d. Letting the client know you understood all he or she has told you
a. Planning for follow-up care The main activity that takes place during the termination phase is planning for follow-up and closing the interview.
During a health history a client recalls the date when being first diagnosed with hypertension. Which term should the nurse use to categorize the quality of the client's data? a. reliable b. puzzling c. concerning d. questionable
a. reliable The client's memory is intact and would be considered reliable. The terms puzzling, concerning, and questionable would not apply because the client was able to provide an exact date.
A nurse collects data about a client's family health history. Which family member's health problems should the nurse include when documenting this information in the database? a. Only the members with health problems that relate to the client's gender b. As many maternal and paternal relatives as the client can recall c. Disease processes that are known to have a genetic link d. Illnesses that resulted in death or disablement
b. As many maternal and paternal relatives as the client can recall Both maternal and paternal relatives are included in the family health history. Problems can arise in families that are not genetically based but are manifest by virtue of exposure to lifestyle practices. Parents, grandparents, aunts, uncles, and children are all included in this history. If the relative is deceased, the cause and age of the relative is recorded.
A nurse is collecting data on a client's chief complaint, which is pain in the heel of his foot. The nurse asks the client, "When did this pain start?" Which component of symptom analysis does this question represent? a. Character b. Onset c. Duration d. Pattern
b. Onset The onset of a symptom is when it began. The character of a symptom is a description of the quality of the symptom. Duration is how long the symptom lasts when it occurs. Pattern refers to factors that make the symptom better or worse.
During an interview with an adult client for the first time, the nurse can clarify the client's statements by a. offering a "laundry list" of descriptors. b. rephrasing the client's statements. c. repeating verbatim what the client has said. d. inferring what the client's statements mean.
b. rephrasing the client's statements. Rephrasing information the client has provided is an effective way to communicate during the interview. This technique helps you to clarify information the client has stated; it also enables you and the client to reflect on what was said.
While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is: a. "Do you feel stress at work?" b. "How often do you feel stressed?" c. "Is stress a problem in your life?" d. "How do you manage your stress?"
d. "How do you manage your stress?" To investigate the amount of stress clients perceive they are under and how they cope with it, ask questions that address what events cause stress for the client and how they usually respond. In addition, find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive.
A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information? a. History of present illness b. Review of systems c. Chief complaint d. Personal health history
d. Personal health history The chief complaint is the abdominal pain. Any associated symptoms would be a part of the history of present illness. The information provided by the client about a past illness would be part of the personal health history. Review of systems provides specific questions about past illnesses that might still be impacting the client.
One technique of therapeutic communication is silence. What does silence allow the client to do? a. Learn to trust the nurse b. Change topics if he or she wants c. Communicate concerns nonverbally d. Decide how much information to disclose
d. Decide how much information to disclose Silence may give clients a chance to decide how much information to disclose.
The nurse is preparing to interview a client with a history of sexual abuse. What technique should the nurse use when conducting this interview? a. avoid eye contact b. be nonjudgmental c. ask direct questions d. skip the sexual history
b. be nonjudgmental The most important thing for the nurse to do when broaching a sensitive topic is to be nonjudgmental. Avoiding eye contact may communicate something different to the client. Asking direct questions may be intimidating. Skipping the sexual history would not ensure that a thorough comprehensive interview was conducted.
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? a. Active listening b. Restatement c. Reflection d. Encouraging elaboration (facilitation)
a. Active listening Active listening is the ability to focus on the client and their perspectives. It requires the nurse to constantly decode messages including thoughts, words, opinions, and emotions. For example, if a client is sad, it is appropriate for a nurse to place a hand over the client's and to show a facial expression of compassion. The purpose of restatement is to have the client elaborate on what was originally stated by the client. Reflection uses summarizing by the nurse to find the true meaning of a client's words. Encouraging elaboration encourages the client to explain or go into more detail in the client's responses.
When using an interpreter to facilitate an interview, where should the interpreter be positioned? a. Behind the examiner, so the interpreter can pick up the movements of the lips of the client and the client's nonverbal cues b. Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client c. Between the examiner and the client, so all parties can make the necessary observations d. In a corner of the room, so as to provide minimal distraction to the interview
b. Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client A priority is for the examiner is to have a good view of the client and to avoid having to look back and forth between client and interpreter. The nurse should remember to use short simple phrases while speaking directly to the client and ask the client to repeat back what he or she understands.
The nurse asks a client "is there any time when you feel unsafe?" On which part of the comprehensive health history is the nurse focusing with this question? a. self-concept b. mental health c. family violence d. role-relationship
c. family violence The family violence portion of the comprehensive health history focuses on personal safety. Self-concept and role-relationship are health patterns. The mental health portion of the comprehensive health history focuses on emotional and mental health.
The nurse is interviewing a 78-year-old client for the first time. The nurse should first a. assess the client's hearing acuity. b. establish rapport with the client. c. obtain biographic data. d. use medical terminology appropriately.
a. assess the client's hearing acuity. When interviewing an older client, you must first assess hearing acuity. Hearing loss occurs normally with age, and undetected hearing loss is often misinterpreted as mental slowness or confusion.
While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should: a. maintain eye contact while asking the questions from the form. b. read the questions verbatim from the form. c. ask the client to complete the form. d. ask leading questions throughout the interview.
a. maintain eye contact while asking the questions from the form. Establish eye contact when the client is speaking to you but look down at your notes from time to time.
A nurse has completed assessment of a client and is now validating the information gathered and reviewing goals with the client. Which phase of the interview process is this? a. Introductory b. Summary c. Analysis d. Working
b. Summary During the summary and closing, the nurse summarizes information obtained during the working phase and validates problems and goals with the client. In the introductory phase, the nurse meets the client and explains the purpose of the interview, discusses what type of questions will be asked, explains reasons for taking notes, and assures the client that confidential information will remain confidential. Analysis is not a phase of the interview process. The working phase is when data collection occurs.
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? a. History of present health concern b. Personal health history c. Family health history d. Lifestyle and health practices profile
d. Lifestyle and health practices profile By assessing the client with regard to nutritional habits, use of substances, education, and work and stress levels, the nurse expects to obtain a lifestyle and health practices profile. To determine the history of present health concerns, the nurse should ask questions relating to the onset, duration, and treatments, if any have been conducted on the client, for the present health concern. The questions related to personal health history assist the nurse in identifying risk factors that stem from previous health problems. Family health history helps the nurse to identify potential risk factors for the client.
The nurse is focusing an interview on a client's respiratory status. Which question should the nurse ask first to begin this interview? a. Do you currently have a cough? b. Do you have any difficulty producing sputum? c. Describe how you breathe for me? d. Do you experience any pain when you breathe?
c. Describe how you breathe for me? During an interview, questions should proceed from general to specific. The question that is the most general is "describe your breathing." This provides the client with an opportunity to discuss the current breathing pattern with the nurse. The other questions are specific and will elicit a yes-no response.
Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms and to generate and test diagnostic hypotheses? a. yes-or-no questions to determine relevant areas of the physical examination b. specific questions to secure a description of every symptom c. pertinent positive and negative questions to determine relevant details d. open-ended questions to encourage the client to tell his or her story
d. open-ended questions to encourage the client to tell his or her story Using the visualization of "the cone," the process begins with open-ended questions to hear "the story of the symptom," ideally in the client's own words. Specific questions are then used to get the features of every symptom. Yes-or-no questions, also referred to as pertinent positives and negatives, are used to retrieve information from the review of systems assessment.
During an interview with an adult client, the nurse can keep the interview from going off course by: a. using open-ended questions. b. rephrasing the client's statements. c. inferring information. d. using closed-ended questions.
d. using closed-ended questions. Use closed-ended questions to obtain facts and to focus on specific information. Closed-ended questions are useful in keeping the interview on course.
During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information? a. neurologic b. cardiovascular c. musculoskeletal d. peripheral vascular
a. neurologic Because the client states numbness of the hands, this information should be included under the neurologic system. Even though the symptom affects the hands, it should not be documented under musculoskeletal. This symptom is not a cardiovascular problem. Peripheral vascular is not a category within the review of systems.
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? a. Provide simple and organized information. b. Approach the client in an in-control manner. c. Refer the client to a spiritual guide. d. Mirror the client's feelings.
a. Provide simple and organized information. The nurse should provide simple and organized information to reassure the client about the procedure and its expected outcomes. The nurse approaches the aggressive, not anxious, client in an in-control manner. The nurse refers the dying client or client with spiritual concerns to a spiritual guide. The nurse should avoid expressing anxiety or becoming anxious like the client, as it would make the client more anxious.
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? a. Working b. Beginning c. Closing d. Pre-interaction
a. Working During the working phase, the nurse collects data by asking specific questions. Two types of questions are closed-ended and open-ended. Each type has a purpose; the nurse chooses which type will help solicit the appropriate information. The pre-interaction phase is prior to meeting with the client. The nurse review the client's medical records to collect important data. The beginning phase is the phase when introductions are exchanged and the purpose of the interaction is explained to the client. The closing phase is a time for summarizing information shared with the client and assessing any learning deficits.
Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data? a. Speak to the client using local slang. b. Maintain a professional distance during assessment. c. Avoid any eye contact with the client. d. Ask one of the client's children to interpret.
b. Maintain a professional distance during assessment. When assessing a nonnative client, the nurse should maintain a professional distance during assessment; the size of personal space affects one's comfortable interpersonal distance. The nurse should not speak to the client using local slang; if the client finds it difficult to learn the proper language, slang would be much more difficult to understand. The nurse need not avoid any eye contact with the client, but should maintain eye contact with the client as required, without giving the client reason to think that the nurse is being rude. Asking one of the client's children to interpret during the interview may actually impair the assessment process. In addition, health care institutions often have specific policies regarding interpreters that you must be aware of prior to using an interpreter.
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? a. "Are both of your parents still living?" b. "What do you usually eat in a typical day?" c. "What diseases did you have as a child?" d. "How do you feel about having to seek health care?"
c. "What diseases did you have as a child?" Information covered in the personal health history section includes questions about birth, growth, development, childhood diseases, immunizations, allergies, medication use, previous health problems, hospitalizations, surgeries, pregnancies, births, previous accidents, injuries, pain experiences, and emotional or psychiatric problems. The question, "How do you feel about having to seek health care?" would be asked during the reason for seeking health care section of the interview. The question regarding the status of the client's parents would be posed in the family health history section. The question regarding what the client usually eats in a typical day would be included in the lifestyle and health practices profile section.
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? a. "What medication do you take for your depression?" b. "When was the last time you talked with a psychiatrist?" c. "Have you considered counseling for your mental problems? d. "Have you ever had a problem with mental or emotional illness?"
d. "Have you ever had a problem with mental or emotional illness?" The nurse should begin by asking a non-threatening open-ended question such as "have you ever had a problem with mental or emotional illness?" Asking specifically about medication for depression assumes the client has a history of depression. Asking about talking with a psychiatrist or counseling may cause the client to become defensive.
Learning about the effects of the illness does what for the nurse and the client? a. Gives them the basis to establish a trusting relationship b. Gives them each a better understanding of the other c. Gives them the ability to communicate better d. Gives them the opportunity to create a complete and congruent picture of the problem
d. Gives them the opportunity to create a complete and congruent picture of the problem Learning about the effects of the illness gives the nurse and the client the opportunity to create a complete and congruent picture of the problem.
What is the best action by a nurse when a client has difficulty describing the chief complaint? a. Restate the question using simple terms b. Wait in silence until the client can find the correct words c. Ignore the complaint & return to it at a later time in the interview d. Provide the client with a laundry list of words to choose from
d. Provide the client with a laundry list of words to choose from A laundry list of descriptive terms can assist the client to describe symptoms, conditions, or feelings. The laundry list will assist the nurse to obtain specific answers & reduce the likelihood of the client perceiving or providing an expected answer. Restating the question would be useful if the client does not understand the questions being asked. Silence will not assist the client in describing symptoms but may make the situation even more uncomfortable. Ignoring the problem send the client a message that his concerns are not important to the nurse.
A client with abdominal pain says that the last time it the pain occurred, over-the-counter laxatives helped. In which part of the assessment should the nurse document this information? a. chief complaint b. past health history c. review of symptoms d. history of present illness
d. history of present illness The history of present illness describes how each symptom developed. It includes the client's thoughts and feelings about the illness, relevant parts of the review of systems, and medications, allergies, and lifestyle habits that impact the present illness. The history of present illness includes any attempts at self-treatment for the problem. The chief complaint is the reason for the person seeking care. The past history lists childhood illnesses, adult illnesses with dates, health maintenance practices, and risk factors. The review of systems is where the presence or absence of common symptoms related to each major body system are reviewed and documented.
A nurse is gathering biographic data from a new client who is visiting the office for the first time. Which of the following pieces of data would likely be included in the biographic section of the client's health history? Select all that apply. a. Lamar P. Thompson b. 1212 South Maple St., Sylvan, VA 23236 c. Caucasian d. Occupation: Brick mason e. Mother: Sugar L. Thompson, died 7/14/2006 from heart attack f. Head and neck: sore throat and enlarged lymph nodes
a. Lamar P. Thompson b. 1212 South Maple St., Sylvan, VA 23236 c. Caucasian d. Occupation: Brick mason Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client's birth date, Social Security Number, medical record number, or similar identifying data may be included in the biographic data section. The client's culture, ethnicity, and subculture may begin to be determined by collecting data about date and place of birth; nationality or ethnicity; marital status; religious or spiritual practices; and primary and secondary languages spoken, written, and read. Gathering information about the client's educational level, occupation, and working status at this point in the health history assists the examiner to tailor questions to the client's level of understanding. The information regarding the client's mother, including the date and cause of death, would appear in the family health history section. The information on the head and neck would appear in the review of systems section.
Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients? Select all that apply. a. Make sure that dress and appearance are professional b. Do not use facial expressions such as rolling the eyes or looking bored or disgusted c. Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally d. Laugh a lot, which puts the client at ease e. Do not look the client in the eye
a. Make sure that dress and appearance are professional b. Do not use facial expressions such as rolling the eyes or looking bored or disgusted c. Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally The physical appearance of the nurse sends a message to the client. Thus, it is important for nurses to ensure that their dress and appearance are professional. Facial expressions should be relaxed, caring, and interested. Facial expressions common in social situations (e.g., rolling the eyes, looking bored or disgusted) reduce trust. The nurse uses gestures intentionally to illustrate points, especially for clients who cannot communicate verbally. The nurse may point with a finger or gesture an action, such as pretending to drink or pointing to the bathroom. Gestures are purposeful rather than distracting from the communication. Therefore, laughing a lot and not making eye contact are incorrect answers.
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? a. The client b. The client's wife c. The physician d. The client's medical record
a. The client Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client is considered the primary source and all others (including the client's medical record) are secondary sources. In some cases, the client's immediate family or caregiver may be a more accurate source of information than the client. An example would be an older adult client's wife who has kept the client's medical records for years or the legal guardian of a mentally compromised client. In any event, validation of the information by a secondary source may be helpful.
A client is experiencing a relapse of a urinary tract infection. Which additional information should the nurse collect when discussing this client's present health problem? a. sexual history b. family history c. past medical history d. health maintenance
a. sexual history Although questions about sexual behavior can be used at multiple points in an interview, if the chief complaint involves genitourinary symptoms, questions about sexual health can be included as part of expanding and clarifying the client's story. The issue of repeated urinary tract infections is not appropriate when collecting data about the client's family history, past medical history, or health maintenance.
A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing? a. value-belief b. self-perception c. role-relationship d. coping-stress-tolerance
a. value-belief The value-belief health pattern describes patterns of values, beliefs or goals that guide choices or decisions. The self-perception-self-concept pattern describes body image, feeling state, self-esteem, personal identity, and social identity. The role-relationship pattern describes patterns of role interactions and relationships including family functioning and problems, and work and neighborhood environment. The coping-stress-tolerance pattern describes general coping pattern and its effectiveness in terms of stress tolerance.
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? a. Allow the client to speak uninterrupted for the duration of the appointment. b. 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. c. Set the time limit at the beginning of the interview and stick with it, no matter what occurs in the course of the interview. d. Allow impatience to show so that the client picks up on nonverbal cues that the appointment needs to end.
b. 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. The nurse can also say, "I want to make sure I take good care of this problem because it is very important. We may need to talk about the others at the next appointment. Is that OK with you?" This is a helpful technique that can help the nurse to change the subject, but at the same time, validate the client's concerns; this can provide more structure to the interview.
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? a. Introductory b. Working c. Summary d. Closing
b. Working During the working phase, the nurse asks the client about the history of the present health concern and the reasons for seeking care. In the introductory phase the nurse explains the purpose of the interview and assures the client that confidential information will remain confidential. During the summary phase or the closing phase, the nurse summarizes information obtained during the working phase and validates problems and goals with the client.
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? a. health patterns b. chief complaint c. review of systems d. history of present illness
b. chief complaint The chief complaint is the reason for the person seeking care. Health patterns focuses on the client's social history. The review of systems is where the presence or absence of common symptoms related to each major body system are reviewed and documented. The history of present illness describes how each symptom developed. It includes the client's thoughts and feelings about the illness, relevant parts of the review of systems, and medications, allergies, and lifestyle habits that impact the present illness.
The nurse is preparing to interview a newly admitted client. What should be done prior to hearing the client's story? a. review the attributes of a symptom b. establish the agenda for the interview c. review the client's issues in a chronologic order d. ask specific questions about the reason for admission
b. establish the agenda for the interview Prior to hearing the client's story during the working phase of the interview, the nurse should establish the agenda for the interview. Attributes of a symptom are examined during the working phase. Reviewing the client's issues in chronologic order is completed during the working phase. Asking questions about the reason for admission is the first action completed during the working phase of the interview.
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? a. risk factors b. health maintenance c. screening test completion d. compliance with treatment
b. health maintenance One area within health maintenance is completion of vaccinations. If the client cannot recall when the last immunizations were received, this would impact health maintenance. Risk factors focus on tobacco use, environment, safety, and substance use. Screening tests are a subcategory within health maintenance. It is possible that the client is unaware of which vaccinations should be obtained. If this is the case, the client should not be labeled as not being compliant with treatment.
A nurse is conducting a review of systems with a client and is asking about his ears. The nurse asks, "Do you have any problems with your ears or your hearing?" The client stares blankly at the nurse a moment and then says, "I'm sorry—could you repeat that?" The nurse repeats the question, to which the client replies, "No." The nurse then asks, "Do you ever experience any trouble hearing or any ringing, buzzing, or earaches?" The client responds, "No." What should the nurse record under "Ears" in the review of systems section of the client's health history? a. "No problems." b. Nothing—it should be left blank c. "Denies any trouble hearing or any ringing, buzzing, or earaches." d. "Client denies any problems but had trouble hearing me when I asked him a question."
c. "Denies any trouble hearing or any ringing, buzzing, or earaches." During the review of body systems, document the client's descriptions of her health status for each body system and note the client's denial of signs, symptoms, diseases, or problems that the nurse asks about but are not experienced by the client. If the lone entry "no problems" is entered on the health history form, other health care professionals reviewing the history cannot ascertain what specific questions had been asked, if any. Care must be taken in this section to include only the client's subjective information and not the examiner's observations. Thus, the nurse should not include the observation about the client having trouble hearing the nurse, especially because the client may have simply misunderstood the question when the nurse posed it the first time.
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? a. Simple circle b. Simple square c. Circle with a cross d. Square with a cross
c. Circle with a cross The standard format of representing a deceased female relative in a genogram is using a circle with a cross. A simple circle indicates a living female relative. A simple square indicates a living male relative. A square with a cross indicates a deceased male relative.
What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"? a. Asking the client if they are wearing a hearing aide b. Using pre-written cards that state the interview questions c. Closing the door may help to limit background noise. d. Introducing hand gestures whenever it is appropriate
c. Closing the door may help to limit background noise. Closing the door may help to limit background noise, making it easier for the client to hear. Not all clients with minimal hearing loss wear hearing aids. Pre-written questions and hand gestures are interventions reserved for those diagnosed with severe hearing limitations.
The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus? a. sleep-rest b. activity-exercise c. coping-stress-tolerance d. self-perception/self-concept
c. coping-stress-tolerance The client's inability to sleep is being caused by anxiety which would be addressed within the coping-stress-tolerance category of the health pattern review. The client's anxiety is causing an issue within the category of sleep-rest. The client's anxiety would not be addressed within the activity-exercise or self-perception/self-concept categories within the health pattern review.
A client reports experiencing chest pain after eating. Which category within the review of systems should the nurse document this information? a. neurologic b. cardiovascular c. gastrointestinal d. musculoskeletal
c. gastrointestinal Because the client reports "chest pain" after eating, this information is most appropriate for the gastrointestinal system. This pain should not be documented under neurologic or musculoskeletal system. If the chest pain was not associated with eating, then it would be appropriate to document it under cardiovascular.
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? a. adult daughter controlling the interview b. unable to recall exact date of last surgery c. last surgery date validated by adult daughter d. confused regarding dates of surgical procedures
c. last surgery date validated by adult daughter The client's memory was cloudy but the adult daughter was able to provide the exact date based upon a life event that can be validated. This interaction does not indicate that the adult daughter is controlling the interview. The client was unable to recall the exact date of the surgery but with the daughter's help, the date was provided. The exact information about the surgical date and the person who provided the information should be documented. The client may have been confused, but that is not what needs to be documented.
The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document? a. gained 15 lbs. over the last 6 months b. experiences panic attacks several times a week c. unable to go to the gym since having back surgery d. misses seeing friends who used to go for walks together
c. unable to go to the gym since having back surgery The client's inability to go to the gym after having back surgery is affecting the activity-exercise health pattern. Gaining weight affects the nutrition health pattern. Panic attacks affects coping-stress-tolerance health pattern. Missing friends affects the role-relationship health pattern.
During an interview, the client 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 client is providing? a. Write down the information as the client is speaking. b. Key the information into the electronic medical record as the client is speaking. c. Avoid maintaining eye contact while the client is discussing spouse abuse. d. Stop documenting in order to maintain eye contact with the client.
d. Stop documenting in order to maintain eye contact with the client. Whenever the client is talking about sensitive or disturbing information, the nurse should stop documenting or move away from the keyboard and maintain eye contact with the client. The nurse should not write down the information as the client is speaking and should not continue keying the information into the electronic medical record while the client is speaking. Avoiding eye contact minimizes the importance of the information that the client is providing and should not be done.
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? a. To summarize the conversation b. To restate what the client has said c. To promote objectivity d. To clarify
d. To clarify Another way to clarify is to ask, "What happens when you get low blood sugar?" Such questions prompt clients to identify other symptoms or give more information so that you can better understand the situation.
