NUR 3065 - Prep U Chapter 3

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?" Explanation: When initiating an interview, it is important to use language that is understandable and appropriate to the client. "Dyspnea," "SOB," and "activities of daily living" are potentially unclear to a client and reflect clinical language rather than clear communication.

A nurse knocks and enters a client room, makes introductions to the client and visitors, and explains to the client that she would like to conduct an interview so a plan of care can be completed. Which statement by the nurse would be most appropriate?

"Mrs. Smith, I would like to conduct an interview with you but I see you have visitors. I will come back in about 30 minutes so you can visit before you and I sit privately to talk." Explanation: Recognizing visitors but setting a time for returning to discuss privately gives everyone time to talk and visit but does not cause a long delay for the important interview.

Which of the following questions would be most important for the nurse to ask first when obtaining the health history?

"What is your major health concern at this time?" Explanation: Asking the question about the client's major health concern assists the client to focus on his or her most significant issues and answers the nurse's question "why are you here?" or "how can I help you?" The nurse should 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.

Which of the following questions is most useful in the assessment of a client's diabetes management?

"What is your routine for checking your blood sugar these days?" Explanation: Answer D is an open-ended question, while the other answers are leading questions that elicit yes-no responses.

Upon entering an exam room, the client states, "Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!" Which response by the nurse would be most appropriate?

"You're certainly justified in being upset, but I am ready to begin your exam now." Explanation: When the nurse encounters an angry client, it is best to acknowledge the feelings of the client in a calm, reassuring, and in-control manner. Telling the client that the schedule is busy and that no one is forcing him or her to be there do not acknowledge the client's feelings. Inviting the client to "report your complaints to someone with power" deflects the complaint inappropriately.

An older client arrives for an appointment in the community clinic. Which approach should the nurse use when communicating with this client? Select all that apply.

- Speak clearly - Avoid jargon - Show respect - Use simple terms Explanation: When communicating with an older client the nurse should speak clearly, avoid jargon, show respect, and use simple terms. The use of slang should be avoided.

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 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.

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?

Ask why Bill is not there. Explanation: Sometimes, the client's greatest need is for support and empathy. It would be inappropriate to ignore this comment today. The client may have relied heavily upon Bill for care, and may be in danger. She may be depressed and even suicidal, but the nurse will not know unless the topic is explored. Most importantly, the nurse should empathize with the client by saying something like "It must be very difficult not to have him at home" and allow a pause for her to answer. The nurse may also ask "What did you rely on him to do for you?" Only a life-threatening crisis with another client should take the nurse out of her room at this point; the nurse may need to adjust the office schedule to allow adequate time for her.

When interviewing a client with a language barrier, it is best to use a family member to help interpret so the client has a level of comfort with the process.

False Explanation: Recruiting family members or friends to serve as interpreters can be hazardous—confidentiality and cultural norms may be violated, meanings may be distorted, and transmitted information may be incomplete. Untrained interpreters may try to speed up the interview by telescoping lengthy replies into a few words, losing much of what may be significant detail.

Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data?

Maintain a professional distance during assessment. Explanation: When assessing a nonnative client, the nurse should maintain a professional distance during assessment; the size of personal space affects one's comfortable interpersonal distance. The nurse should not speak to the client using local slang; if the client finds it difficult to learn the proper language, slang would be much more difficult to understand. The nurse need not avoid any eye contact with the client, but should maintain eye contact with the client as required, without giving the client reason to think that the nurse is being rude. Asking one of the client's children to interpret during the interview may actually impair the assessment process. In addition, health care institutions often have specific policies regarding interpreters that you must be aware of prior to using an interpreter.

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?

Past health history Explanation: 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.

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 Explanation: 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 illness would be part of the personal health history. Review of systems provides specific questions about past illnesses that might still be impacting the client.

In interviewing a client about substance use, a nurse asks her whether she takes any herbal supplements. Which of the following is the best rationale for asking this question?

Some herbal supplements may interact with prescribed medications. Explanation: Because many people use vitamins or a variety of herbal supplements, it is important to ask which ones and how often. These supplements and prescription medications may interact (e.g., garlic decreases coagulation and interacts with warfarin [Coumadin]). There is no indication that using herbal supplements can result in cardiac dysfunction. Taking herbal supplements may be an indicator of concern for one's health and a mechanism for coping with stress, but neither of these is as good a rationale as the one regarding interactions with prescribed medications.

A nurse is obtaining subjective data from an adult client who is new to the clinic. The nurse has asked the client, "Where do you usually turn for help in a time of crisis?" What domain is this nurse assessing?

The client's stress management and coping strategies Explanation: This assessment question helps the nurse ascertain the client's strategies for coping and for managing stress. It does not directly assess social support or family relationships, although these may become apparent from the client's response. This question does not address critical thinking or problem solving.

A client tells the nurse about her experience with prolonged therapy for her breast cancer. The nurse responds, "That must have been a very trying time for you." What is this an example of?

Validation Explanation: This is an example of validation to legitimize the client's emotional experience. An example of reassurance could be: "Now that you have had your treatment, you should not have any further troubles." An example of empathy could be: "I understand what you went through. I am a cancer survivor myself." An example of summarization (as applied to this vignette) could be: "So, you have had a lumpectomy and multiple radiation treatments."

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 Explanation: During the working phase, the nurse collects data by asking specific questions. Two types of questions are closed-ended and open-ended questions. Each type has a purpose; the nurse chooses which type will help solicit the appropriate information. Pre-interaction, beginning, and closing are all phases in the interview process. The pre-interaction phase is prior to meeting the client, when the nurse collects data from the medical record. The information gathered from the medical record is used to conduct the client interview. The beginning phase is when introductions are exchanged, privacy is ensured, and actions are made by the nurse to relax the client. The closing phase is when a review of the interview is conducting, summarizing areas of concerns or importance, allowing the client to ask any closing questions.

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 Explanation: During the working phase, the nurse collects data by asking specific questions. Two types of questions are closed-ended and open-ended. Each type has a purpose; the nurse chooses which type will help solicit the appropriate information. The pre-interaction phase is prior to meeting with the client. The nurse review the client's medical records to collect important data. The beginning phase is the phase when introductions are exchanged and the purpose of the interaction is explained to the client. The closing phase is a time for summarizing information shared with the client and assessing any learning deficits.

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 Explanation: The client's inability to sleep is being caused by anxiety which would be addressed within the coping-stress-tolerance category of the health pattern review. The client's anxiety is causing an issue within the category of sleep-rest. The client's anxiety would not be addressed within the activity-exercise or self-perception/self-concept categories within the health pattern review.

A client's spouse answers the interview questions and will not leave the examination room. What should the nurse suspect be occurring with the client?

physical abuse Explanation: Physical abuse should be considered if the partner tries to dominate the interview and will not leave the room. The spouse's behavior does not suggest low self-esteem or a cognitive or mental health disorder.

During a health history a client recalls the date when being first diagnosed with hypertension. Which term should the nurse use to categorize the quality of the client's data?

reliable Explanation: The client's memory is intact and would be considered reliable. The terms puzzling, concerning, and questionable would not apply because the client was able to provide an exact date.