Jensen Exam #1 ch. 2

Which of the following questions would be most important for the nurse to ask first when obtaining the health history?

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

A client reports a weight loss and fatigue during the review of systems. In which area should the nurse document this information?

: General

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

The patient is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the patient, the nurse is obtaining what other type of data from the patient?

: Subjective data given by the patient are considered primary data.

Alexandra, 28 years old, presents to the clinic. She has abdominal pain that she describes as a dull ache, located in the right upper quadrant, and that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago; it lasts for 2 to 3 hours at a time, comes and goes, and seems to be worse a few hours after eating. The client has noticed that the pain starts after eating greasy foods, so she has cut down on this as much as she can. Initially the pain occurred once a week, but now it happens every other day. Nothing makes it better. From this description, which of the attributes of a symptom has been omitted?

Associated symptoms and signs

A nurse, conducting a functional assessment on an adult client, assesses overall psychosocial well-being by assessing what?

Coping/stress tolerance

How should a nurse begin an interview?

During an interview, questions should proceed from general to specific. Start with open ended first.

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 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

Working phase of an interview:

the nurse asks the client about the history of the present health concern and the reasons for seeking care

Introductory phase:

the nurse explains the purpose of the interview and assures the client that confidential information will remain confidential.

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:

use very basic lay terminology.

The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first?

: The client's sensory abilities

The nurse is taking a comprehensive health history on a new patient. Why would it be essential for the nurse to obtain a complete description of the present illness?

: To establish an accurate diagnosis

How would the nursing instructor explain the goal of guided questioning to his or her students?

:Facilitating the patient's fullest communication

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

The nurse is taking a health history on a new client. The nurse first collects demographic data. What data would the nurse collect next?

:History of present illness

When using an interpreter to facilitate an interview, where should the interpreter be positioned?

:Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client

While discussing health patterns, a client says, "I hate my job." In which category should the nurse document and further assess this information?

:Role-relationship

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

:explain the role and purpose of the nurse.

A client reports experiencing chest pain after eating. Which category within the review of systems should the nurse document this information?

:gastrointestinal

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.

Your new patient becomes visibly anxious during the nursing interview. You respond by telling her, "Don't worry, everything will be okay." What might this premature reassurance cause?

The blockage of further disclosures by the patient

Premature Reassurance:

may block further disclosures, especially if the patient feels that the clinician is uncomfortable with the anxiety or has not appreciated the extent of the patient's distress.

Summary/closing phase:

the nurse summarizes information obtained during the working phase and validates problems and goals with the client.