Jensen Prep U Chapter 2

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?"

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 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 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) Refer the client to a spiritual guide. b) Mirror the client's feelings. c) Approach the client in an in-control manner. d) Provide simple and organized information.

: Provide simple and organized information.

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?

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

Coping/stress tolerance

The nurse is focusing an interview on a patient's respiratory status. Which question should the nurse ask first to begin this interview?

Describe how you breath for me?

The nurse is conducting a patient interview and responds to the patient in a way that encourages the patient to more completely describe his or her problems. What is this called? a) Promoting elaboration b) Focusing c) Restatement d) Clarification

Promoting elaboration

What is a key element of the history of present illness?

Self-treatment

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

While interviewing a patient, the nurse asks, "What happens when you have low blood glucose?" This type of response to the patient is used for what purpose?

To clarify

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

• Cultural factors • Sensory deficits • Age of individual

The nurse is obtaining information about a client's past health history. Which client statement would best reflect this component of assessment?

"I had surgery 5 years ago to repair an inguinal hernia."

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

Facilitating the patient's fullest communication

When interviewing a patient with a language barrier, it is best to use a family member to help interpret so the patient has a level of comfort with the process.

False

When describing the purpose for obtaining a comprehensive health history to a client, which of the following would the nurse include as primary?

Provides a focus for the physical exam.

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) Those with illnesses that resulted in death or disablement b) Those with diseases that are known to have a genetic link c) Only the members with health problems that relate to the client's gender d) As many genetic relatives as the client can recall

As many genetic relatives as the client can recall

A patient comes to the Emergency Department with bruises on her upper and lower body and appears to be withdrawn. The injuries do not appear consistent with the explanations for them. The patient's boyfriend refuses to leave the examination room and is overly protective of her. The nurse suspects: a) Inability of the patient to perform ADLs b) Human violence c) Anorexia nervosa d) Hypertension

Human violence

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 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

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

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

The patient may be at risk for developing diabetes.

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? a) To obtain demographic data b) To obtain primary data c) To establish an accurate diagnosis d) To assess if the patient is a reliable historian

To establish an accurate diagnosis

A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication? a) Using a moderate amount of eye contact b) Minimizing facial expressions c) Standing while the client is seated d) Sitting across the room from the client

Using a moderate amount of eye contact

A comprehensive health history includes which components? Select all that apply. a) Income b) Past health history c) Reason for seeking care d) Employment history e) History of present illness

• Past health history • Reason for seeking care • History of present illness

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

A patient 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

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

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? a) Health patterns b) Review of systems c) Initial information d) History of present illness

History of present illness

When recording the patient's reason for seeking care (chief concerns) during the health history, it is recommended that the interviewer:

Quote the patient's words

A nurse is interviewing a 22-year-old client of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment? a) Sitting across the room from the client b) Using a moderate amount of eye contact c) Standing while the client is seated d) Minimizing facial expressions

Using a moderate amount of eye contact

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

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 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) 1212 South Maple St., Sylvan, VA 23236 b) Lamar P. Thompson c) Caucasian d) Head and neck: sore throat and enlarged lymph nodes e) Occupation: Brick mason f) Mother: Sugar L. Thompson, died 7/14/2006 from heart attack

• Lamar P. Thompson • 1212 South Maple St., Sylvan, VA 23236 • Caucasian • Occupation: Brick mason

Which item would be included in a review of the neurological system? Select all that apply.

• Numbness • Loss of coordination • Memory loss

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

Coronary artery disease

Which of the following actions is most appropriate for the nurse to take after completing a comprehensive health history with a client who is new to an acute care unit?

Provide health promotion education.

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 ventilate his or her feelings.

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? a) "Could you describe how you perform self-breast exams?" b) "Do you use condoms with each sexual encounter?" c) "Do you always wear your seatbelt when driving?" d) "How much beer, wine, or alcohol do you drink?"

"Could you describe how you perform self-breast exams?"

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?

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

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."

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? a) "What is your major health concern at this time?" b) "Are you generally fairly healthy?" c) "Did you bring all your medications with you?" d) "Do you have adequate health insurance coverage?"

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

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? a) "You're certainly justified in being upset, but I am ready to begin your exam now." b) "No one is forcing you to be here, and you are free to leave at any time." c) "Our schedule is very busy also. We got to you as soon as we could." d) "Would you like to report your complaints to someone with power?"

"You're certainly justified in being upset, but I am ready to begin your exam now."

"How many steps can you climb before you get short of breath?" is an example of what kind of question?

A question that elicits a graded response

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

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." How should the nurse best follow up this client's statement? a) Ask the client if he understands the risk factors for heart disease and diabetes. b) Briefly describe some of the potential benefits of regular exercise. c) Document the nursing diagnosis of Risk for Activity Intolerance related to sedentary lifestyle. d) Explain to the client that he should be performing aerobic exercise for 20 to 30 minutes at least three times a week.

Briefly describe some of the potential benefits of regular exercise.

The nurse is in the introductory phase of the client interview. Which of the following activities would be appropriate? a) Determining the client's reason for seeking care b) Obtaining family health history data c) Explaining the purpose of the interview d) Collaborating with the client to identify problems

Explaining the purpose of the interview

A nurse is collecting subjective data from a client as part of the assessment process. Which behavior is most appropriate for the nurse to display in this situation? a) Maintaining eye contact with the client at all times b) Remaining standing during the interview c) Explaining the reason for taking down notes d) Reading questions from the history form

Explaining the reason for taking down notes

The nurse is teaching the patient how to self-administer insulin. Which functional health pattern does this nursing intervention address? a) Role-relationship b) Cognition-perception c) Coping/stress tolerance d) Health perception-health management

Health perception-health management

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? a) Laundry list b) Attitude c) Facial expression d) Silence

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

A client has been admitted following an unexplained weight loss of 15 pounds over the past 3 months. How should the nurse best assess the subjective component of the client's nutritional status? a) Ask about the contents of one typical meal. b) Ask the client to explain MyPlate. c) Obtain a 24-hour diet recall. d) Elicit the client's favorite foods.

Obtain a 24-hour diet recall.

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

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? a) Reliability b) Identifying data c) Personal and social history d) Review of systems

Personal and social history

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? a) Preinteraction b) Beginning c) Closing d) Working

Preinteraction

A nurse is interviewing a 16-year-old girl regarding her health history. When inquiring about her chief complaint, the girl lowers her voice and says, "I've been with a guy recently, and I'm worried that I might have caught something from him." The nurse responds by saying, "So, you're concerned that you may have a sexually transmitted infection?" Which verbal communication technique is the nurse using here? a) Rephrasing b) Well-placed phrase c) Open-ended question d) Laundry list

Rephrasing

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? a) Do not pursue the situation unless the client asks for help b) Counsel the client c) Call the police d) Report it to the nurse's supervisor

Report it to the nurse's supervisor

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: a) Call social services. b) Confront the patient. c) Report the findings to a supervisor. d) Call the police.

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.

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's medical record b) The client's wife c) The physician d) The client

The client

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

mobility

The nurse understands that health promotion is a very important part of nursing care. When performing the health history, there are many different opportunities for the nurse to teach healthy behaviors. One way the nurse can do this is by focusing on which of the following topics: a) culture b) sexual history and pattern c) spirituality d) gender

sexual history and pattern

During the comprehensive health assessment, the nurse asks several questions relating to the client's family history of illnesses, such as diabetes and cancer. Why does the nurse do this? Select all that apply. a) To elicit negative family history b) To provide counseling and health teaching in high-risk areas c) To help the client feel at ease and not worry about being sick d) To help identify those diseases for which the client may be at risk e) To identify genetic family trends for which the client is at risk

• To help identify those diseases for which the client may be at risk • To provide counseling and health teaching in high-risk areas • To identify genetic family trends for which the client is at risk

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.

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