Chapter 2: Collecting Subjective Data: The Interview and Health History

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?

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

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?"

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

Establishing a trusting relationship

A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned?

Seated in a chair at eye level with the client

During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?

Working

During an initial health history, a client states, "I haven't slept in weeks." The nurse asks, "You are saying that you have not had any sleep in weeks?" What communication technique is the nurse using to obtain accurate subjective data from the client?

rephrasing

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?"

The nurse is performing a follow-up assessment and interview of a 72-year-old woman with a history of congestive heart failure. The nurse asks the client, "Have you been experiencing any activity intolerance since I last saw you?" What would be a more appropriate way for the nurse to elicit this information?

"Has this been having an effect on your ability to carry out your routines and get around your home?"

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?"

When conducting the health assessment, the nurse interacts with the client in a caring manner. How would the nurse demonstrate caring to the client? Select all that apply.

Being nonjudgmental Showing respect to the client Valuing the client unconditionally

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?

Circle with a cross

A nurse completes an initial assessment and discusses findings with the client. What is the next best action of the nurse?

Develop a plan of care with the client.

The nurse is reviewing a new client's chart prior to the initial interview. The chart reveals the client has a visual impairment. What actions should the nurse take to ensure a successful interview?

Knock and announce self before entering the client's room.

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?

Summary

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 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?

health maintenance

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?

value-belief

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

Facilitating the client's fullest communication

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?

Provide simple and organized information.

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

The nurse has been assigned to a group of clients on a medical surgical unit. What is the best action of the nurse prior to receiving a report on these clients?

Conduct a brief review of the client's charts.

A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?

Explain the purpose of the interview.

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 nurse performs a focused assessment on a client who is reporting joint pain. To gain a better understanding of the client's pain, the nurse uses COLDSPA. Which question(s) should the nurse ask the client to determine the origin of the pain? Select all that apply.

When does the pain occur? What makes the pain better or worse? How would you describe the pain? Could you show me where the pain is exactly?

The nurse is caring for a client in the health care provider's office. In reviewing the client's chart, the nurse recognizes the need for providing the client with additional education related to COVID-19 when noting which of the following about the client?

Works in the service industry