Health Assessment PrepU Chapter 02
During the review of systems, a client reports dizziness, tingling, and mood changes. In which area should the nurse document this information? a. Neurologic b. Cardiovascular c. Psychiatric d. Fluid and electrolytes
a Dizziness, tingling, and mood changes would be documented under neurologic. Nervousness, tension, depression, memory change, and suicide attempts should be documented under psychiatric. This information is not appropriate to document under cardiovascular or fluid and electrolytes.
During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information? a. peripheral vascular b. cardiovascular c. musculoskeletal d. neurologic
d Because the client states numbness of the hands, this information should be included under the neurologic system. Even though the symptom affects the hands, it should not be documented under musculoskeletal. This symptom is not a cardiovascular problem. Peripheral vascular is not a category within the review of systems.
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. Sitting across the room from the client c. Minimizing facial expressions d. Using a moderate amount of eye contact
d The nurse needs to avoid extremes in eye contact. Excessive eye contact may make the client uncomfortable; too little eye contact might lead the client to believe that the nurse is hiding something. A moderate amount communicates interest and focus. The nurse should be at the same level as the client. Standing while the client is seated puts the nurse in a superior position, possibly making the client feel inferior. The nurse should be within 2 to 3 feet of the client during the interview. The nurse should keep facial expressions neutral and friendly.
The nurse is preparing to complete a comprehensive assessment of a newly admitted client. Why is the nurse completing this type of assessment? a. provides a baseline for future assessments b. assesses symptoms of one body system c. addresses specific concerns d. establishes routine care needs
a A comprehensive assessment provides a baseline for future assessments. A focused assessment addresses specific concerns, establishes routine care needs, and assesses the symptoms of one body system.
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? a. Active listening b. Reflection c. Encouraging elaboration (facilitation) d. Restatement
a Active listening is the ability to focus on the client and their perspectives. It requires the nurse to constantly decode messages including thoughts, words, opinions, and emotions. For example, if a client is sad, it is appropriate for a nurse to place a hand over the client's and to show a facial expression of compassion. The purpose of restatement is to have the client elaborate on what was originally stated by the client. Reflection uses summarizing by the nurse to find the true meaning of a client's words. Encouraging elaboration encourages the client to explain or go into more detail in the client's responses.
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. "Did you bring all your medications with you?" c. "Are you generally fairly healthy?" d. "Do you have adequate health insurance coverage?"
a Asking the question about the client's major health concern assists the client to focus on the most significant issues and answers the nurse's question "why are you here?" or "how can I help you?" The nurse may inquire later on about the client's health insurance, but not if it is adequate. Asking if the client is fairly healthy is a closed-ended question that doesn't allow the client to verbalize concerns. Asking about medications would be appropriate later on during the interview when discussing the medications that the client takes.
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? a. "Do you perform any sustained or continually repetitive motions with that arm?" b. "When did the pain start?" c. "You work at a computer a lot, don't you?" d. "I recommend that you change your posture while working at the computer."
a Inferring information from what the client tells you and what you observe in the client's behavior may elicit more data or verify existing data. Be careful not to lead the client to answers that are not true. The question, "Do you perform any sustained or continually repetitive motions with that arm?" is open enough to not lead the client to an expected answer but narrow enough for the nurse to help elicit more information from the client about probable causes of his pain. Recommending that the client change his posture while working at the computer is premature, as the nurse has not confirmed that the computer work is the culprit. Likewise, "You work at a computer a lot, don't you?" is a leading question, as it encourages the client to answer in the affirmative. The question, "When did the pain start?" is a close-ended question; it will elicit more information from the client but is not an example of inferring.
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? a. last surgery date validated by adult daughter b. adult daughter controlling the interview c. unable to recall exact date of last surgery d. confused regarding dates of surgical procedures
a The client's memory was cloudy but the adult daughter was able to provide the exact date based upon a life event that can be validated. This interaction does not indicate that the adult daughter is controlling the interview. The client was unable to recall the exact date of the surgery but with the daughter's help, the date was provided. The exact information about the surgical date and the person who provided the information should be documented. The client may have been confused, but that is not what needs to be documented.
When doing a complete health history, the nurse usually collects demographical data first and a reason for seeking care. What additional data the nurse collects depends upon (check all that apply): a. time restrictions within the setting b. pertinence of the data c. reason for the visit d. the client's diet e. time of day
a, b, c The nurse determines what data to collect beyond the minimum required and bases this decision on the reason for the visit, pertinence of the data, and time restrictions within the setting. The time of day and the client's diet have nothing to do with the information collected in the health history.
A middle-aged client has an appointment for a routine physical. Which type of assessment is the most appropriate for the nurse to complete? a. follow-up b. comprehensive c. focused d. emergency
b A comprehensive assessment includes demographic data, a full description of the reason for seeking care, individual health history, family history, functional status, and a history in all physical and psychosocial areas. A focused assessment gathers information about the current health problem. A follow-up assessment evaluates a specific problem after treatment. An emergency assessment focuses on data to quickly resolve the immediate health problem.
A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information? a. consider using it when planning care b. create a genogram c. include in the past medical history d. document it in a narrative note
b A genogram is a diagram of the family history. It provides a visual record that allows the provider to quickly identify disease patterns within the family. The family history does not need to be documented in a narrative note. This information is not part of the client's past medical history. It is not typically used when planning care.
The nurse is conducting a client interview and responds to the client in a way that encourages the client to more completely describe his or her problems. What is this called? a. Focusing b. Promoting elaboration c. Restatement d. Clarification
b Encouraging elaboration (facilitation) is a technique that assists clients to more completely describe difficulties. You use responses that encourage clients to say more and continue the conversation. This shows clients that you are interested.
When beginning the collection of the client data base, which of the following would be most important for the nurse to do? a. Make inferences b. Establish a trusting relationship c. Identify health problems d. Determine the client's strengths
b It is essential for the nurse to develop trust and rapport with the client to elicit accurate and meaningful information. This trust is the focus of the interview and must be developed in the initial phase of the interview. Determining the client's strengths, identifying health problems, and making inferences occur during the working phase of the interview.
The nurse is obtaining information about a client's past health history. Which client statement would best reflect this aspect? a. "My mom's still alive but my dad died 10 years ago of heart failure." b. "I had surgery 5 years ago to repair an inguinal hernia." c. "I have a brother with leukemia and a sister with hypertension." d. "I have been having some pain when I urinate for the last several days."
b The past health history focuses on questions related to the client's past from the earliest beginnings to the present. The statement about surgery would apply to this portion of the assessment. The statement about the parents and siblings would apply to the family health history. The statement about pain in urination would apply to the reason for seeking health care.
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. Call the police b. Report it to the nurse's supervisor c. Do not pursue the situation unless the client asks for help d. Counsel the client
b When abuse is suspected, nurses are obligated to report it to a supervisor and obtain assistance from social work for further assessment. It is not necessary to call the police or counsel the client, but it is necessary to pursue the situation even if the client does not ask for help.
The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data? a. "How much beer, wine, or alcohol do you drink?" b. "Do you always wear your seatbelt when driving?" c. "Could you describe how you perform self-breast exams?" d. "Do you use condoms with each sexual encounter?"
c Asking the client to describe self-breast examination is an open-ended question that allows the client to verbalize openly about the activity and provides the nurse with information that allows determination of correct technique. Asking about wearing a seatbelt, how much alcohol the client drinks, or using condoms with sexual activity are closed-ended questions that would provide information of one or two words.
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. "Do you always wear your seatbelt when driving?" b. "Do you use condoms with each sexual encounter?" c. "Could you describe how you perform self-breast exams?" d. "How much beer, wine, or alcohol do you drink?"
c Asking the client to describe self-breast examination is an open-ended question that allows the client to verbalize openly about the activity and provides the nurse with information that allows determination of correctness of technique. Asking about wearing a seatbelt, how much alcohol the client drinks, or using condoms with sexual activity are closed-ended questions that would provide information of one or two words.
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? a. "Where did the numbness and tingling occur?" b. "How bad was the tingling and numbness?" c. "What other symptoms occurred during the spell?" d. "How long did the spell last?"
c Examples of questions related to associated factors include the following: "What other symptoms occur with it? How does it affect you? What do you think caused it to start? Do you have any other problems that seem related to it? How does it affect your life and daily activities?" The question, "How bad was the tingling and numbness?" relates to severity. The question, "How long did the spell last?" relates to duration. The question, "Where did the numbness and tingling occur?" relates to location.
A graduate nurse working on a medical-surgical unit is admitting a client who does not speak English. No interpreters are available. The client's spouse is present and speaks English. What should the nurse remember about the use of interpreters when communicating with clients? a. Interpreters do not understand cultural health beliefs and practices, so they are unable to help bridge the gap b. Using children in the family, other relatives, or close friends as interpreters does not violate privacy laws c. Friends and family who are unfamiliar with medical terminology may misinterpret information d. Hospital interpreters may not always be the best choice because they are unfamiliar with the client
c Friends and family who are unfamiliar with medical terminology may misinterpret information. When possible, a trained medical interpreter is preferred. Using children or other relatives violates the client's privacy. It does not matter if the hospital interpreter knows the client; the interpreter can still accurately interpret for the health care provider. Interpreters generally understand cultural beliefs and practices, so they can help to bridge the gap between cultures.
The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use? a. During the review of systems b. While completing the family history c. After assessing for cigarette use d. Before assessing for vaccinations
c Questions about alcohol and other drugs follow naturally after questions about cigarettes. Questions about alcohol intake occurs before the review of systems. Alcohol intake is a risk factor that is assessed after vaccinations. Alcohol use is assessed before completing the family history.
The client is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the client, the nurse is obtaining what other type of data from the client? a. Objective b. Secondary c. Primary d. Tertiary
c Subjective data given by the client are considered primary data. Charts and family are sources of secondary data, while objective data are based upon tests, vital signs, and examinations. At present, no data are called tertiary.
The nurse recognizes that an example of subjective data would include: a. 100 cc of emesis b. 2-inch scar right lower abdomen c. A pain rating of 7 d. Scratching
c Subjective data include signs and symptoms the client reports. Objective data are data cues the nurse can observe, while subjective data may not be observable to the nurse. A pain rating of 7 is an example of subjective data. The client must report the number that represents the intensity of his or her pain. A scar, scratching, and emesis are all data cues the nurse can observe.
A client states, "My wife died two months ago today." Which of the following responses would be most appropriate? a. "You probably must be sad." b. "Are you feeling sad, depressed, angry, or upset?" c. "How does that make you feel?" d. "What did she die of?"
c The client's statement about his wife's death provides the nurse with an opportunity to gather information about the client's current state. Asking the open-ended question, "How does that make you feel?" would be most appropriate to obtain key information. Asking what the wife died from is a closed-ended question that ignores the client's feelings. Telling the client that he probably feels sad is imposing the nurse's personal values on the client. Asking the client the laundry list of feelings would be demeaning and doesn't allow the client to put his feelings into his own words.
A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication? a. Sitting across the room from the client b. Standing while the client is seated c. Using a moderate amount of eye contact d. Minimizing facial expressions
c The nurse needs to avoid extremes in eye contact. Excessive eye contact may make the client uncomfortable; too little eye contact might lead the client to believe that the nurse is hiding something. A moderate amount communicates interest and focus. The nurse should be at the same level of the client. Standing while the client is seated puts the nurse as superior, possibly making the client feel inferior. The nurse should be within 2 to 3 feet of the client during the interview. The nurse should keep facial expressions neutral and friendly.
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? a. associated manifestations b. duration c. treatment d. onset
c The nurse should include any client reports of self treatment, such as alternative therapies, that the client has tried to alleviate the symptoms. This is captured within treatment. Associated manifestations refers to any other symptoms that accompany the chief report. The onset refers to when the headache started. Duration refers to the length of time the headaches last each time.
Which of the following describes how the health history interview differs from a social conversation? a. The interview allows more time for the client to demonstrate self-awareness. b. The interview is restricted to actual or potential illnesses. c. The interview focuses on the client's needs to improve health and well-being. d. The interview permits the clinician to express his or her needs and interests.
c Unlike social conversations, in which participants can freely express their own needs and interests and are responsible only for themselves, the primary goal of the nurse-client interview is to maximize the well-being of the client. The interview is not about the nurse's needs or interests, the well-being of the client may encompass more than the client's actual or potential illnesses, and the nurse will refocus the interview as needed to elicit the necessary information.
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 a. offer reasons why the client should not feel angry. b. provide structure during the interview. c. allow the client to verbalize his or her feelings. d. refer the client to a different health care provider.
c When interacting with an angry client approach this client in a calm, reassuring, in-control manner. Allow him to ventilate feelings.
Which statements provide information about a client's health maintenance? Select all that apply. a. A client was hospitalized for dehydration 2 years ago. b. A client had a circumcision at birth. c. A client recently a had lab test for liver function. d. A female client had a mammogram 2 weeks ago. e. A child received immunizations based on the recommended schedule.
c, d, e Immunizations, screening tests, safety measures, and any lifestyle-related risk factors all provide information about a client's health maintenance. Past hospitalizations and surgical procedures do not provide information about health maintenance as this information does not capture ongoing health factors that impact the client's overall quality of health.
Which observation would cause the nurse to suspect an abusive situation? Select all that apply. a. A parent allows the adolescent to speak privately with the nurse. b. The explanation of an injury seems appropriate. c. A preschooler rubs her perineum and complains of it hurting. d. A caregiver of a cognitively intact older adult dominates the interview. e. A child is persistent in trying to please a parent.
c, d, e Observations suggestive of possible abuse include a caregiver of a cognitively intact older adult dominating the interview, a child being persistent in trying to please a parent, and a preschooler rubbing her perineum and complaining of it hurting. Observations not suggestive of abuse include a parent allowing an adolescent to speak privately with the nurse and an explanation that is appropriate for an injury.
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 the ability to communicate better c. Gives them each a better understanding of the other d. Gives them the opportunity to create a complete and congruent picture of the problem
d Learning about the effects of the illness gives the nurse and the client the opportunity to create a complete and congruent picture of the problem.
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. This may affect the client's diet during hospitalization. b. The client may need to attend a support group for diabetes. c. The client may need teaching on preventing diabetes. d. The client may be at risk for developing diabetes.
d Nurses incorporate a genetics focus into the health assessments of family history to assess for genetics-related risk factors. The information aids the nurse in determining if the client may be predisposed to diseases that are genetic in origin.
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? a. History of present illness b. Review of Systems c. Chief complaint d. Past health history
d The chief complaint is the abdominal pain. Any associated symptoms would be a part of the history of present illness. The information provided by the client about a past illnesses in the past are part of the past health history. Review of systems provides specific questions about past illnesses that might still be impacting the client.
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? a. Allow the client to speak uninterrupted for the duration of the appointment. b. Allow impatience to show so that the client picks up on nonverbal cues that the appointment needs to end. c. Set the time limit at the beginning of the interview and stick with it, no matter what occurs in the course of the interview. d. 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.
d The nurse can also say, "I want to make sure I take good care of this problem because it is very important. We may need to talk about the others at the next appointment. Is that OK with you?" This is a helpful technique that can help the nurse to change the subject, but at the same time, validate the client's concerns; this can provide more structure to the interview.
While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is a. "How often do you feel stressed?" b. "Do you feel stress at work?" c. "Is stress a problem in your life?" d. "How do you manage your stress?"
d To investigate the amount of stress clients perceive they are under and how they cope with it, ask questions that address what events cause stress for the client and how they usually respond. In addition, find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive.
Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms and to generate and test diagnostic hypotheses? a. specific questions to secure a description of every symptom b. pertinent positive and negative questions to determine relevant details c. yes-or-no questions to determine relevant areas of the physical examination d. open-ended questions to encourage the client to tell his or her story
d Using the visualization of "the cone," the process begins with open-ended questions to hear "the story of the symptom," ideally in the client's own words. Specific questions are then used to get the features of every symptom. Yes-or-no questions, also referred to as pertinent positives and negatives, are used to retrieve information from the review of systems assessment.
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
d When doing a health history on children, the focus should be on the pregnancy, birth, and perinatal histories. Immunizations and growth and development are also special areas of attention. Patterns of illnesses are included for older adults, and self-perception and stress tolerance are reviewed to assess the client's well-being, especially if he or she has a history of psychosocial problems. Religious and spiritual belief systems play a role during the functional health screening related to values or beliefs.
The nurse uses the mnemonic OLD CART when assessing a client's symptoms. Which letter represents the area of the symptom and if it radiates? a. C b. O c. D d. L
d. (L) The letter L represents the location of the symptom and if it radiates to another body area. The C represents the characteristic symptoms that are occurring. The D represents the duration of the symptom. The O represents the onset of the symptom.
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? a. psychiatric b. gastrointestinal c. neurologic e. urinary
e The problem underlying the sleep disturbance for this client is frequency of voiding at night, also known as nocturia. In the review of systems, this symptom fits within the urinary section of the review of systems. Symptoms such as anxiety, mood fluctuations, and memory changes should be captured in the psychiatric section of the review of systems. Symptoms such as headaches, fainting, and orientation should be captured in the neurologic section of the review of symptoms. Symptoms such as stool consistency, difficulty swallowing, or heartburn should be recorded in the gastrointestinal section of the review of systems.