CHAPTER 2: THE HEALTH HISTORY AND INTERVIEW

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? A. "Are you looking for a new job?" B. "How are you managing financially?" C. "Have you thought of hurting yourself?" D. "Have you considered a job placement agency?"

"Have you thought of hurting yourself?"

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is A. "Do you feel stress at work?" B. "How often do you feel stressed?" C. "Is stress a problem in your life?" D. "How do you manage your stress?"

"How do you manage your stress?"

To assess self-perception, the nurse asks "How would you describe yourself?" "Are you having difficulty handling any family problems?" "What gives you hope when times are troubled?" "How do you usually deal with stress? Is it effective?"

"How would you describe yourself?"

The nurse suspects that a female client has an alcohol use disorder. When completing the AUDIT-C screening tool, which response requires further follow-up by the nurse? A. "I have one drink a night, about two to four nights a month." B. "Sometimes at parties I will have about five or six drinks." C. "I'll rarely have six or more drinks on any one occasion; I do so about once a month." D. "On the weekends I will go out and have about six to seven drinks with friends."

"On the weekends I will go out and have about six to seven drinks with friends."

Which of the following questions would be most important for the nurse to ask first when obtaining the health history? A. "Do you have adequate health insurance coverage?" B. "Are you generally fairly healthy?" C. "What is your major health concern at this time?" D. "Did you bring all your medications with you?"

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

The mother of an infant with severe asthma is extremely anxious. The nurse is treating the patient in the emergency room. When collecting the history, the best response of the nurse is A. "You must be extremely worried." B. "I'd be in worse shape than you are if it were my baby." C. "Is there anyone here that you can talk to?" D. "You seem worried, but I need to ask a few questions."

"You seem worried, but I need to ask a few questions."

Which observation would cause the nurse to suspect an abusive situation? Select all that apply. A child is persistent in trying to please a parent. A caregiver of a cognitively intact older adult dominates the interview. A preschooler rubs her perineum and complains of it hurting. The explanation of an injury seems appropriate. A parent allows the adolescent to speak privately with the nurse.

A child is persistent in trying to please a parent. A caregiver of a cognitively intact older adult dominates the interview. A preschooler rubs her perineum and complains of it hurting.

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 Restatement Reflection Encouraging elaboration (facilitation)

ACTIVE LISTENING

On a very busy day in the health care provider's office, Mrs. Donelan, age 81 years, 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, which is well controlled. The client mentions that it is hard not having her husband Bill around anymore. What would the nurse do next? A. Hand Mrs. Donelan a prescription and make sure she has a 3-month follow-up appointment. B. Make sure Mrs. Donelan understands her prescription. C. Ask why Bill is not there. D. Explain that the nurse will have more time at the next visit to discuss any problems Mrs. Donelan is having.

Ask why Bill is not there.

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? health patterns chief complaint review of systems history of present illness

CHIEFT COMPLAINT

The past history should include ___________illnesses and immunizations

CHILDHOOD

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? A. Conduct a brief review of the client's charts. B. Perform a quick assessment on all the clients. C. Provide a brief introduction to the clients. D. Validate problems and goals with the clients.

Conduct a brief review of the client's charts.

The nurse must constantly ______ messages including thoughts, words, opinions, and emotions.

DECODE

One of the initial components of the health history is the _______ information

DEMOGRAPHIC

The nurse is preparing to obtain a health history on a client who recently migrated from Asia. What is the first action of the nurse? A. Determine the client's number of pregnancies. B. Ask the client about childhood diseases. C. Determine if an interpreter is needed. D. Discuss cultural norms.

Determine if an interpreter is needed.

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? A. Establishing a trusting relationship B. Determining the client's strengths C. Identifying potential health problems D. Making clinical inferences

ESTABLISHING A TRUSTING RELATIONSHIP

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? A. Collaborate with the client to identify problems. B. Explain the purpose of the interview. C. Determine the client's vital signs. D. Obtain family health history data.

Explain the purpose of the interview.

The nurse asks a client "is there any time when you feel unsafe?" On which part of the comprehensive health history is the nurse focusing with this question? A. self-concept B. mental health C. family violence D. role-relationship

FAMILY VIOLENCE

The review of systems component of the health history is best described as a: A. Focus on diseases of the major body systems B. Detailed investigation of questions about major body systems C. Focus on common questions and issues related to each of the different body systems D. Series of questions that start at the head and finish at the feet

Focus on common questions and issues related to each of the different body systems

Learning about the effects of the illness does what for the nurse and the client? A. Gives them the basis to establish a trusting relationship B. Gives them each a better understanding of the other C. Gives them the ability to communicate better D. Gives them the opportunity to create a complete and congruent picture of the problem

Gives them the opportunity to create a complete and congruent picture of the problem

A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information? A. examination B. health maintenance C. personal and social history D. review of systems

HEALTH MAINTENANCE

Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the client's quality of life. When assessing ADLs, the nurse asks if the client can grasp small objects and open jars. This is an example of assessing the client's: A. self-perception B. mobility C. home maintenance D. values and beliefs

MOBILITY

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 Reliability Review of systems Personal and social history

PERSONAL AND SOCIAL HISTORY

During the interview process, the nurse obtains what type of data from the client? Primary Secondary Objective Oral

PRIMARY

When recording the client's reason for seeking care (chief concerns) during the health history, it is recommended that the interviewer: A. Quote the client's words B. Summarize the client's words C. Paraphrase the client's words D. Describe the client's concerns and health goals

QUOTE THE CLIENT'S WORDS

The nurse is interviewing a client. The client describes why he is visiting the clinic. The nurse then briefly summarizes the main points of what the client has just said. What type of communication is the nurse using? A. Reflection B. Elaboration C. Restatement D. Silence

REFLECTION

The nurse uses the communication technique of __________to summarize the main themes of the communication between the nurse and the patient.

REFLECTION

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? A. well-placed phrasing B. close-ended questioning C. rephrasing D. active listening

REPHRASING

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

Reason for seeking care History of present illness Past health history

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. Report it to the nurse's supervisor B. Call the police C. Counsel the client D. Do not pursue the situation unless the client asks for help

Report it to the nurse's supervisor

A patient says that they are having throbbing pain that they rate as 6 on a 10-point scale. This is referred to as subjective primary data. subjective secondary data. objective primary data. objective secondary data.

SUBJECTIVE PRIMARY DATA

When the nurse is conducting the health history, when would be the most natural time to ask the client about alcohol use? a. after asking about cigarette smoking b. after asking about previous surgeries c. after discussing reactions to allergens d. after reviewing current medications

after asking about cigarette smoking

During an interview, the client 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 client is providing? A. Write down the information as the client is speaking. B. Key the information into the electronic medical record as the client is speaking. C.Avoid maintaining eye contact while the client is discussing spouse abuse. D. Stop documenting in order to maintain eye contact with the client.

Stop documenting in order to maintain eye contact with the client.

While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose? To summarize the conversation To restate what the client has said To promote objectivity To clarify

TO CLARIFY

Active listening is the ability to focus on a patient and their perspectives.

TRUE

All nursing practice revolves around the nurse-patient relationship.

TRUE

The nurse with a comfortable self- awareness can communicate more therapeutically than the nurse who lacks experiences and self-awareness

TRUE

You are taking a health history on a new client. While performing your assessment, the client informs you that her mother has type 1 diabetes. What is the significance of this information to the health history? A. The client may be at risk for developing diabetes. B. The client may need teaching on preventing diabetes. C. The client may need to attend a support group for diabetes. D. This may affect the client's diet during hospitalization.

The client may be at risk for developing diabetes.

Which is an example of subjective data from a primary source? A. The client states, "My chest hurts and my left arm feels numb." B.A baby's mother states, "He pulls at his ear when he has pain." C. The client's chart indicates the client felt nauseous. D. The client asks, "Does my incision look like it is healing?"

The client states, "My chest hurts and my left arm feels numb."

A male older adult client reports a 2-week history of sleep disruption due to frequently waking up to void in the middle of the night. Where in the review of systems should the nurse document this symptom? urinary psychiatric neurologic gastrointestinal

URINARY

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? A. Standing while the client is seated B. Using a moderate amount of eye contact C. Sitting across the room from the client D. Minimizing facial expression

Using a moderate amount of eye contact

The nurse asks, "What are the most important things to you in life?" to assess the functional pattern related to A. role. B. self-perception. C. coping. D. values.

VALUES

A nursing instructor is teaching students about the importance of assessing for medication allergies. A complete assessment of allergies would include which of the following components? Check all that apply. Verifying allergies with the client Asking the client to furnish the medication from home Comparing allergies to the legal record Noting the type of response Documenting both medications and reactions for future reference

Verifying allergies with the client Comparing allergies to the legal record Noting the type of response Documenting both medications and reactions for future reference

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? A. Working B. Beginning C. Closing D. Pre-interaction

WORKING

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus? A. sleep-rest B. activity-exercise C. coping-stress-tolerance D. self-perception/self-concept

coping-stress-tolerance

A nursing instructor is teaching the student during clinical how to take a health history and perform a complete assessment on a client. The student shows understanding of the difference between subjective and objective data by identifying the following as objective data. A. decubitus on left heel B. pain rated 5 on scale of 1-10 C. itching on lower left leg D. nausea

decubitus on left heel

When gathering the family history, the nurse draws a genogram A. using circles for males and squares for females. B. putting the patient on the left to show birth order. C. inserting lines between parents to show marriage. D. listing health problems above the symbol for the patient.

inserting lines between parents to show marriage.

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: A. pattern and relationship of illnesses B. religious and spiritual factors C. self-perception and stress tolerance D. pregnancy, birth, and perinatal histories

pregnancy, birth, and perinatal histories

The nurse assessing an older adult focuses the health history on A. previous pregnancies, obstetric history, and psychosocial factors. B. birth history, immunizations, and growth and development. C. sensory deficits, illness history, and lifestyle factors. D. religion, spirituality, culture, and values.

sensory deficits, illness history, and lifestyle factors.

A client comes to the ED complaining of chest pain. This would be considered a. subjective secondary data b. subjective primary data c. objective secondary data d. objective primary data

subjective primary data

Which of the following are part of the preinterview of the nurse-client interview? Select all that apply. taking time for reflection setting goals for the interview taking notes establishing the agenda identifying client's emotional clues generating diagnostic hypotheses

taking time for reflection setting goals for the interview taking notes

The nurse performs patient teaching after assessing that the nutritional history reveals that the patient generally consumes a high-fat, high-calorie diet. This critical thinking A. uses subjective data to analyze findings and intervene. B. documents and communicates data using appropriate medical terminologies. C. individualizes health assessment considering the age, gender, and culture of the patient. D. uses assessment findings to identify medical and nursing diagnoses.

uses subjective data to analyze findings and intervene.