Jensen Ch. 2: Health History and Interview

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

The review of systems is to be completed next while conducting a comprehensive assessment. Which type of question should the nurse use for this review?

yes or no

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 is preparing to interview a client with a history of sexual abuse. What technique should the nurse use when conducting this interview?

be nonjudgmental

A client's spouse answers the interview questions and will not leave the examination room. What should the nurse suspect be occurring with the client?

physical abuse

After teaching a group of students about verbal communication techniques, the instructor determines that the teaching was successful when the students identify which of the following as an example of a closed-ended question/statement?

"Are you allergic to any medications?"

A nurse is assessing a client who has a sexually transmitted infection. The client tells the nurse he has sexual intercourse with both men and women. Which is the best response to the client's statement?

"Can you tell me more about your sexual health practices?"

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?"

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 ever had a problem with mental or emotional illness?"

A client reports feeling depressed for several months since being fired from a long-term job. Which question should the nurse include when assessing this client?

"Have you thought of hurting yourself?"

The nurse is preparing to meet Mr. James Smith, a 70-year-old client. How should the nurse greet this client?

"Hello Mr. Smith."

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

"How do you manage your stress?"

During the interview, the client states, "Is today the 12th? My wife died 2 months ago today." Which of the following responses would be most appropriate?

"How does that make you feel right now?"

A client states, "My wife died two months ago today." Which of the following responses would be most appropriate?

"How does that make you feel?"

A client's elevated body mass index (BMI) has prompted the nurse to assess the client's activity and exercise level. Which statement would indicate to the nurse that the client is getting the recommended amount of exercise?

"I go to a step class for an hour three times a week."

Which response by the client is appropriate when the nurse asks the client to identify a functional goal related to the client's left hip pain?

"I want to be able to sleep on my left side."

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 60-year-old woman with a bunion will undergo surgery later today. The client tells the nurse in the surgical daycare admitting department, "I'm sure I've been asked these questions before. Can't we just focus on my foot and not all these other topics?" How should the nurse best explain the rationale for obtaining a health history?

"We want to make sure your nursing care matches your needs as closely as possible."

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?

"What diseases did you have as a child?"

Which of the following questions is most useful in the assessment of a client's diabetes management?

"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?

"What other symptoms occurred during the spell?"

The nurse has just asked a client how he feels about his emphysema. He becomes silent, folds his arms across his chest, and leans back in his chair. Then the client replies "It is what it is." How should the nurse respond?

"You seem bothered by this question."

When performing an admission assessment, the nurse knows to ask about both first- and second-order relatives. Why does the nurse do this?

To identify diseases that may be genetic

"Tell me about your pain" is an example of an open-ended question.

True

The nurse recognizes that an example of subjective data would include:

A pain rating of 7

A client angrily tells the nurse that, "It's a shame that you people can't ever be on time. This interview was supposed to start 30 minutes ago." Which technique should the nurse use to diffuse this client's justified anger?

Acknowledge their anger by apologizing for the delay.

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

A nurse is running late after a quarterly quality improvement meeting at the hospital and has just been paged from the nurses' station. A client's relative wants to talk as soon as possible about the client's care. The nurse has clinic duty this afternoon and is about to see the first client. The first appointment time slot is double-booked, and three other clients have arrived, all of whom are sitting in the waiting room. Which of the following demeanors is consistent with skilled interviewing when the nurse walks into the examination room to speak with the first client at the clinic?

Calm

The client presents with complaints of joint stiffness that is interfering with the client's ability to perform activities of daily living. Which of Gordon's functional health patterns should the nurse conduct a focused assessment?

Activity-exercise

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

Which would the nurse include when conducting a mental health history? Select all that apply.

Alcohol consumption Tobacco use Drug use

On a very busy day in the office, Mrs. Donelan, 81 years old, comes for her usual visit to check her blood pressure. She has been on a low-dose diuretic for many years and denies any side effects. Today, her blood pressure is 118/78 today, which is well-controlled. The client mentions that it is hard not having her husband Bill around anymore. What would the nurse do next?

Ask why Bill is not there.

The principle of confidentiality is of paramount importance in the nurse-client relationship. When should you inform the client of with whom his or her information will be shared?

At the beginning of the interview

The nurse plans to assess a client's new symptom. Which characteristics will the nurse assess when using the COLDSPA mnemonic?

Character, onset, location, duration, severity, pattern, associated factors

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 is creating a genogram of a client's family health history. The nurse should use which of the following symbols to denote the client's female relatives?

Circle

A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative?

Circle with a cross

While conducting a comprehensive health history, the nurse asks a client to describe strategies for managing stress. This information is important for the nurse because it assesses the client's:

Coping stress tolerance patterns

While gathering data for the family history portion of the health history, what would you ask about?

Coronary artery disease

Which factor influences the nurse's ability to individualize the health assessment? Select all that apply.

Cultural factors Sensory deficits Age of individual

Prior to a client interview, the nurse collects information from the client's medical record, such as prior surgeries, home medications, allergies, and past treatments. What phase of the interview process is this?

Pre-interaction

A client arrives at the Emergency Department reporting shortness of breath. She is cyanotic with bilateral wheezing. The client begins to gasp for air and cannot speak. The nurse begins to gather information so that interventions can resolve the immediate breathing problem. Her assessment and interventions are concurrent. The nurse is performing what type of health history?

Emergency

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

A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize?

Establishing a trusting relationship

The nurse prepares a genogram after collecting health history information from a client. For which part of the history is this diagram beneficial?

Family history

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 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?

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

Learning about the effects of the illness does what for the nurse and the client?

Gives them the opportunity to create a complete and congruent picture of the problem

The nurse is teaching the client how to self-administer insulin. Which functional health pattern does this nursing intervention address?

Health perception-health management

The nurse includes an assessment of the developmental level of the individual in order to: (Select all that apply.)

Individualize nursing interventions for the individual's plan of care Determine the achievement of growth and development milestones

The nurse uses the mnemonic OLD CART when assessing a client's symptoms. Which letter represents the area of the symptom and if it radiates?

L

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

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?

Lifestyle and health practices profile

Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data?

Maintain a professional distance during assessment.

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.

Make sure that dress and appearance are professional Do not use facial expressions such as rolling the eyes or looking bored or disgusted Use gestures intentionally to illustrate points, especially for clients who cannot communicate

During the review of systems, a client reports dizziness, tingling, and mood changes. In which area should the nurse document this information?

Neurologic

A nurse in the ED is assessing an adult client who, the nurse suspects, has been beaten by her husband. What is the nurse's legal obligation in this situation?

Report it to the nurse's supervisor

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?

Onset

A client admitted to the health care facility for new onset of abdominal pain expresses to nurse that they were treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

Past health history

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

During a health history, a client lists the most recent immunizations received and the date and reason for surgeries. In which area of the history should the nurse document this information?

Past history

The nurse is collecting data for a comprehensive health history on a client new to the clinic. Under what component of the health history would the nurse place data on a chronic childhood illness?

Past history

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?

Personal health history

What is the nurse assessing when asking the client, "What things seem to make it better?"

Relieving/Exacerbating factors

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

The nurse is assessing an older adult client a hospice unit. The client cannot speak or communicate, but the client's daughter is there and answers all the questions as best as she can. What type of data source is the daughter?

Secondary

In interviewing a client about substance use, a nurse asks her whether she takes any herbal supplements. Which of the following is the best rationale for asking this question?

Some herbal supplements may interact with prescribed medications.

An older client arrives for an appointment in the community clinic. Which approach should the nurse use when communicating with this client? Select all that apply.

Speak clearly Avoid jargon Show respect Use simple terms

An elderly female client is accompanied by her daughter on a visit to the health care facility. The nurse observes that the client is doing quite well, except for the use of a hearing aid. How can the nurse best facilitate the interview process with this client?

Speak slowly and clearly, using straightforward language

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?

Stop documenting in order to maintain eye contact with the client.

A client reports chest pain that occurs with exercise but subsides with rest. The nurse recognizes this at what type of data?

Subjective

What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking?

Suggest methods and provide resources to assist with smoking cessation

The nurse feels uncomfortable talking about certain subjects when conducting an assessment with a client. Which actions should the nurse take to improve personal level of comfort with these topics? (Select all answer choices that apply)

Take courses Talk to colleagues Read about the topics Reflect on life experiences

You are taking a health history on a new client. While performing your assessment, the client informs you that her mother has type 1 diabetes. What is the significance of this information to the health history?

The client may be at risk for developing diabetes.

When performing a health assessment, what is a basic tool that the nurse uses in the caring relationship with the client?

Therapeutic communication

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 clarify

A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication?

Using a moderate amount of eye contact

The nursing instructor is discussing unprofessional actions. What would the instructor cite as the clearest example of unprofessional conduct?

Violating a sexual boundary

The nurse is performing a health history on a client with mild chest pain who came to the Emergency Department. When asked about his allergies, the client states that he is allergic to codeine for pain. The nurse asks if that is the only allergy and then proceeds with the rest of the assessment. What other information should the nurse obtain when a client states an allergy?

What type of reaction did the client experience?

A client comes to the office for evaluation of fatigue. He has come to the office many times in the past with various injuries, and the nurse suspects that the client has a problem with alcohol. Which of the following questions will be most helpful in diagnosing this problem?

When was your last drink?

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

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

A middle-aged client has an appointment for a routine physical. Which type of assessment is the most appropriate for the nurse to complete?

comprehensive

A nursing instructor is teaching the student during clinical how to take a health history and perform a complete assessment on a client. The student shows understanding of the difference between subjective and objective data by identifying the following as objective data.

decubitus on left heel

The nurse is preparing to interview a client through the use of an interpreter. Which approach should the nurse use for this interview?

face the client during the interview

A client comes to the community clinic seeking help for acute low back pain. Which type of assessment should the nurse complete for this client?

focused

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

Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the client's quality of life. When assessing ADLs, the nurse asks if the client can grasp small objects and open jars. This is an example of assessing the client's:

mobility

A client says that food is not important and meals are not enjoyable. Where should the nurse document this information?

nutrition health pattern

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?

open-ended questions to encourage the client to tell his or her story

During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client's

perception of pain.

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

A client comes to the emergency department with severe abdominal pain. When performing a complete assessment, the nurse would focus on which of the following areas when covering past health history?

previous medical and surgical problems

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?

reliable

The nurse is taking a health history on a newly admitted client. When the nurse asks, "How would you describe yourself?" the nurse is assessing which of the following?

self-perception/self-concept

An elderly client arrives in the Emergency Department with nonspecific symptoms. When the nurse attempts to take the health history, the client appears not to understand and does not answer the questions. The nurse realizes that this might be because of a common problem in the elderly, which is:

sensory deficits

The nurse understands that when performing a health history it is important to include subjective data, which includes:

symptoms that the client reports

Which of the following are part of the preinterview of the nurse-client interview? Select all that apply.

taking time for reflection setting goals for the interview taking notes