Chapter 2: Collecting Subjective Data: The Interview and Health History - ML4

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?"

During a health history, the nurse recommends using a genogram. The client asks the nurse to explain the purpose of a genogram. How should the nurse respond?

"It helps the nurse organize data on the client's family history."

What are the nursing goals for the introductory phase of the nurse-client interview?

1) Establishing a trusting, respectful rapport with the client. 2) Agreeing upon the agenda for the interview.

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.

1) Make sure that dress and appearance are professional 2) Do not use facial expressions such as rolling the eyes or looking bored or disgusted 3) Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally

A nurse who may be shy in social situations may exhibit excellent therapeutic communication by what? Select all that apply.

1) Using silence 2) Using touch 3) Communicating nonverbally through facial expression

A nurse in a clinic is preparing to meet with a new, 35-year-old male client.

1) review the client's medical record request blood tests be performed 2) explain the purpose of the interview speak to family members

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

What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?

Closing the door may help to limit background noise.

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.

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

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.

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?

The client

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?

chief complaint

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

The nurse has interviewed a Hispanic client with limited English skills for the first time. The nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. The nurse should

indicate acceptance of the client's cultural differences.

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

Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms?

open-ended questions to allow full freedom of response

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

past medical history