PrepU Chapter 2

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?" "What medication do you take for your depression?" "Have you considered counseling for your mental problems? "When was the last time you talked with a psychiatrist?"

"Have you ever had a problem with mental or emotional illness?"

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 skip the sexual history avoid eye contact ask direct questions

be nonjudgmental

A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?

health maintenance

The nurse is completing a comprehensive assessment with a newly admitted client. In which area should the nurse document the client's list of immunizations?

health maintenance

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information?

past medical history

T/F When assessing the gastrointestinal system, the nurse correctly asks, "Do you have any trouble swallowing?"

true

When focusing on the client's perspective of a symptom or problem, the nurse will ask which questions? Select all that apply.

"Do you have any fears about the headaches you experience?" "Do you have any idea concerning why you are experiencing these headaches?" "Do the headaches negatively impact your day-to-day life?"

What information aids the nurse in assessing possible biases in the data collected in the health history? Source of information Ethnicity of patient Socioeconomic status of the patient Gender of patient

Source of information

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? Personal health history History of present health concern Lifestyle and health practices profile Family health history

Lifestyle and health practices profile

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus?

coping-stress-tolerance

A client 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? screening test completion risk factors health maintenance compliance with treatment

health maintenance

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should

maintain eye contact while asking the questions from the form.

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

A victim of a house fire is admitted for possible inhalation injuries. During the admission process, which type of assessment should the nurse complete? comprehensive emergency focused follow-up

emergency

During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information? neurologic cardiovascular peripheral vascular musculoskeletal

neurologic

A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview? "When did the sleep problem begin?" "How would you rate your sleep on a scale from 1 to 10?" "Can you tell me about your sleep problem from when it started until now?" "What have you tried to help with your sleep?"

"Can you tell me about your sleep problem from when it started until now?"

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 patient will require an extended period of intense physical therapy after having a compound fracture of the femur surgically repaired. What question should the nurse ask when assessing the client's perception of the injury and recovery plan? (Select all that apply.) "What did the pain feel like when you broke your femur?" "How does experiencing such a trauma make you feel?" "What do you expect from the physical therapy you will have?" "How do you plan to support yourself financially while you recover?" "What frustrations are you experiencing since your accident?"

"How does experiencing such a trauma make you feel?" "How do you plan to support yourself financially while you recover?" "What frustrations are you experiencing since your accident?" "What do you expect from the physical therapy you will have?"

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? Systematically prioritize needs beginning with the airway. Gather information about a specific client problem Provide health promotion education. Evaluate a problem.

Provide health promotion education.

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

Provide simple and organized information.

The nurse is interviewing a 78-year-old client for the first time. The nurse should first obtain biographic data. assess the client's hearing acuity. use medical terminology appropriately. establish rapport with the client.

assess the client's hearing acuity

While assessing a patient, the nurse is asking questions that help the nurse perceive and communicate an understanding of what the patient is feeling. What is this called? Sympathy Caring Therapeutic communication Empathy

empathy

A patient with acute onset of shoulder pain is answering questions during a health history. The nurse is utilizing a mnemonic specific to the attributes of a symptom. The nurse first asks about the onset of symptoms followed by

location duration characteristic symptoms associated manifestations relieving/exacerbating factors treatment

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? Beginning Working Closing Preinteraction

working

During a health history, a client reports drinking bloody Mary's several mornings a week before going to work. In which part of the CAGE questionnaire should the nurse document this information? Eye-openers Cutting down Guilty feelings Annoyance

Eye-openers

A client complains of knee pain on the nurse's arrival in the room. What should the nurse's first sentence be after greeting the client?

"Could you please describe what happened?"

A nurse is interviewing a client with a different cultural background. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?

Using a moderate amount of eye contact

A 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: Call social services. Report the findings to a supervisor. Call the police. Confront the patient.

Report the findings to a supervisor

The nurse is the primary care provider for a 21-year-old man who, as the result of a brain injury suffered in a mountain-biking accident in his teens, has the cognitive abilities of a 9-year-old. How should the nurse accommodate the client's cognition and comprehension during assessment?

Use the client's family as a source of information.

The nurse assesses an assigned client after receiving morning report to evaluate level of pain. Which type of assessment is the nurse completing?

follow up

The nurse conducts a health history with a client who reports having a dull headache over the past month. The client tells the nurse that using aromatherapy scents have helped manage the pain sometimes. This information is belongs to which attribute of a symptom? duration treatment onset associated manifestations

treatment

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

What is the best action by a nurse when a client has difficulty describing the chief complaint?

Provide the client with a laundry list of words to choose from

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? Reassurance Transition Summarization Termination

Summarization

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? Initial information Health patterns Review of systems History of present illness

History of present illness

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? A feeling of closeness between the patient and the nurse A noticeable lessening of the patient's anxiety The blockage of further disclosures by the patient The nurse to shorten the interview process

The blockage of further disclosures by the patient

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 A noticeable lessening of the patient's anxiety A feeling of closeness between the patient and the nurse The nurse to shorten the interview process

The blockage of further disclosures by the patient

A client with hypertension seeks medical attention for a new onset of a nosebleed. Which type of assessment should the nurse complete with this client?

focused

A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the

focused assessment

A pregnant woman comes to the physician's office for her first prenatal visit. The nurse knows the importance of performing a comprehensive health history in this case and understands the following must be included (check all that apply): food preferences family history obstetrical and gynecological history information about current pregnancy previous pregnancies

information about current pregnancy previous pregnancies obstetrical and gynecological history family history

Jason, a 41-year-old electrician, presents to the clinic for evaluation of shortness of breath, which occurs with exertion and improves with rest. The shortness of breath has been occurring for several months. Initially, it happened only a few times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than 12 times a day. The shortness of breath lasts for fewer than 5 minutes at a time. The client has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. Which of the following symptom attributes was not addressed in this description?

severity

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

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?"

Which statements demonstrate the nurse's attempt to empower the client during an assessment interview? Select all that apply.

"Please tell about what brought you here today." "I'm not sure when the test will be scheduled, but I will find that out before you leave." "Falling as you did must be a very frightening experience."

Which statements demonstrate the nurse's attempt to empower the client during an assessment interview? Select all that apply. vitamin D birth control pills echinacea

"Please tell about what brought you here today." "I'm not sure when the test will be scheduled, but I will find that out before you leave." "Falling as you did must be a very frightening experience."

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? Reflection Restatement Active listening Encouraging elaboration (facilitation)

Active listening

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen?

Ask the client to bring all the medications and supplements to an interview.

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? Location Characteristic Duration Onset

Characteristic

As a nurse assessing the endocrine and hematologic systems, it is important to ask the client about what? Select all that apply. Explained weight gain or loss Intolerance to cold Excessive bruising Swelling of the lower extremities Changes in body hair

Excessive bruising Changes in body hair Intolerance to cold

During the review of systems within the comprehensive health history, the nurse notes that a client has multiple previous injuries and accidents. Which of the following issues is a priority in the nurse's assessment?

Investigate the possibility of physical abuse

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? Identifying data Personal and social history Review of systems Reliability

Personal and social 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

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? Secondary Tertiary Objective Primary

Primary

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 values and beliefs self-perception home maintenence

mobility

How does giving false reassurance to a client hurt the nurse-client relationship? Select all that apply. It indicates to a client that his or her concerns are not worth discussing

It indicates to a client that his or her concerns are not worth discussing It enhances anxiety, which can increase a client's urge to seek further reassurance It diminishes his or her trust

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

Neurologic

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?"

A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental? "How would you describe your feelings about getting older?" "Your husband's death must have been very difficult for you." "You must quit smoking because it affects others, not only you." "How often do your adult children typically visit you?"

"You must quit smoking because it affects others, not only you."

Which statements provide information about a client's health maintenance? Select all that apply. A female client had a mammogram 2 weeks ago. A client had a circumcision at birth. A client was hospitalized for dehydration 2 years ago. A client recently a had lab test for liver function. A child received immunizations based on the recommended schedule.

A child received immunizations based on the recommended schedule. A female client had a mammogram 2 weeks ago. A client recently a had lab test for liver function.

A nurse is interviewing a client complaining of abdominal pain for the last 2 weeks. Why is a history of the present illness vital to treating this client?

A complete description of the present illness is essential to an accurate diagnosis

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?

As many genetic relatives as the client can recall

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? Hand her a script and make sure she has a 3 month follow-up appointment. Make sure she understands the script. Explain that the nurse will have more time at the next visit to discuss this. Ask why Bill is not there.

Ask why Bill is not there.

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? Setting in which the symptom occurs Timing Quality Associated symptoms and signs

Associated symptoms and signs

During the nurse's assessment of the client's exercise and activity habits, the client laughs and then states, "Unless you're including channel surfing, I don't really do much of anything." What would the nurse do next?

Briefly describe some of the potential benefits of regular exercise

The nurse is focusing an interview on a patient's respiratory status. Which question should the nurse ask first to begin this interview? Do you experience any pain when you breathe? Do you have any difficulty producing sputum? Describe how you breathe for me? Do you currently have a cough?

Describe how you breathe for me?

The nurse is collecting information regarding the individual's medications. Which nursing activities does the nurse perform during this component of the health history? Select all that apply.

Differentiate among adverse versus allergic responses to medications Validate names and dosages of medications currently being taken Assess the individual's understanding of each medication's purpose

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

Health perception-health management

As the nurse completes a review of systems, what is it important to ask the client regarding the review of the area of the thorax and lungs. Select all that apply.

History of emphysema History of asthma Last chest x-ray

Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data? Speak to the client using local slang. Maintain a professional distance during assessment. Ask one of the client's children to interpret. Avoid any eye contact with the client.

Maintain a professional distance during assessment.

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? Clarification Focusing Restatement Promoting elaboration

Promoting elaboration

A client is admitted to the health care facility with new onset of abdominal pain. The client becomes angry with the nurse when questions about personal information are asked. How should the nurse proceed with the interview?

Remain in control and allow the client to vent feelings

During a health history, a client states "I want to know why my feet are swelling" whereas the primary diagnosis is arthritis. What should the nurse do with the client's statement? Write is as the chief complaint Document it within health history Identify it as referral information Designate it as a health promotion goal

Write is as the chief complaint

During the working phase of an interview the nurse encourages the client to continue and expand on the health issues. What technique is the nurse using?

active listening

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 To restate what the patient has said To summarize the conversation To promote objectivity

to clarify

When the nurse asks the client with abdominal pain about what medications are currently being taken, which medications must be documented in the health history? Select all that apply. salicylic acid face wash petroleum jelly echinacea birth control pills vitamin D

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