Subjective data Chapter 2

Provide simple and organized information. The nurse should provide simple and organized information to reassure the client about the procedure and its expected outcomes

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?

summary/closing phase

During this phase, the nurse: - Summarizes/restates findings - Validates problems/goals - Discusses plan to solve problem - Asks about any other concerns

Working phase

During which phase of the nursing interview should the nurse ask the client about the history of the present health concern and the reasons for seeking care?

allow the client to verbalize his or her feelings. When interacting with an angry client approach this client in a calm, reassuring, in-control manner. Allow him to ventilate feelings.

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

use very basic terminology.

The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to

"Have you ever had a problem with mental or emotional illness?" The nurse should begin by asking a non-threatening open-ended question such as "have you ever had a problem with mental or emotional illness?" Asking specifically about medication for depression assumes the client has a history of depression. Asking about talking with a psychiatrist or counseling may cause the client to become defensive.

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?

Allow the client to vent feelings (helps them to talk out their feelings, which reduces anger)

A client becomes angry with the nurse for asking some of health history questions he/she is asking. How should the nurse address this?

c) past health history (this is a past health issue; symptoms are only apart of history of present illness)

A client complains of new onset abdominal pain and reports that he was treated for GERD (gastro-esophogeal reflux disease) in the past. In which section of the health history should the nurse document the treatment for GERD? a) review of systems b) history of present illness c) past health history d) chief complaints

"Do you think your wife is getting better?" Open-ended questions are used to elicit information about a client's feelings or perceptions about a particular situation.

A client presents to the health care clinic with reports of sleeplessness and loss of appetite. The client tells the nurse that his wife is seriously ill in the hospital and he has not been able to visit her much because of transportation problems. Which open-ended question should the nurse ask the client to obtain more information about his presenting symptoms?

The client may not want her sister to know her private information Using children in the family, other relatives, or close friends as interpreters violates privacy laws, because clients may not want to share personal information with others. HIPAA guidelines address privacy issues such as this scenario. Even when the client gives permission for the family member to be present, an official interpreter should be present per facility policy. The other options could be true in some situations, but the priority answer addresses privacy, both the client's right to privacy, and the facility's handling of private information.

A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client?

physical abuse 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.

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?

As many maternal and paternal relatives as the client can recall Both maternal and paternal relatives are included in the family health history. Problems can arise in families that are not genetically based but are manifest by virtue of exposure to lifestyle practices. Parents, grandparents, aunts, uncles, and children are all included in this history. If the relative is deceased, the cause and age of the relative is recorded.

A nurse collects data about a client's family health history. Which family member's health problems should the nurse include when documenting this information in the database?

"What other symptoms occurred during the spell?" 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.

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 diseases did you have as a child?" Information covered in the personal health history section includes questions about birth, growth, development, childhood diseases, immunizations, allergies, medication use, previous health problems, hospitalizations, surgeries, pregnancies, births, previous accidents, injuries, pain experiences, and emotional or psychiatric problems.

A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time?

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.

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) client denies any anxiety/distress about diagnosis (a nurse would expect for the client to feel some sort of grief/anger regarding the diagnosis)

A nurse receives an initial assessment report on a client recently diagnosed w/ lung cancer. When reviewing the report, he/she recognizes which info is *subjective* and needs further validation? a) client denies any anxiety/distress about diagnosis b) client coughs up rust-colored sputum c) reports smoking for 30 years

rephrasing the client's statements Rephrasing information the client has provided is an effective way to communicate during the interview. This technique helps you to clarify information the client has stated; it also enables you and the client to reflect on what was said.

During an interview with an adult client for the first time, the nurse can clarify the client's statements by....

Working- 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

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?

Review of health systems

In this section of the complete health history, the client is asked specific questions about the different body systems in order to elicit info about current health issues or recent health issues that may still affect the client Ex: "Any ringing, buzzing, earaches, or dizziness?" <-- refers to the ears "Any ECGs or edema/swelling?" <-- refers to heart and vessels

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. 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.

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?

Ask the client to repeat the statement or question. The nurse should ask clients to repeat questions or statments if the nurse is unable to understand what the client said. The nurse can also paraphrase client responses to verify understanding.

The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?

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

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?

provide structure and set limits with the client.

The nurse is planning to interview a client who has demonstrated manipulative behaviors during past clinic visits. During the interview process, the nurse should plan to...

explain the role and purpose of the nurse When interacting with an anxious client, provide the client with simple, organized information in a structured format and explain who you are, along with your role and purpose.

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should

"I have to share the information if it reveals something that could hurt you." The principle of confidentiality is of paramount importance in the nurse-client relationship. The nurse is obligated to protect client information and to share it only with appropriate health care team members. But the client must be told that any information provided that appears to be harmful to either the client or anyone else must be shared with the appropriate person or persons.

The nurse should respond to a client's request to "keep what I'm about to tell you a secret" with which statement?

At the beginning of the interview At the start of the interview the patient should be told with whom the information will be shared.

The principle of confidentiality is of paramount importance in the nurse-patient relationship. When should you inform the patient of with whom his or her information will be shared?

suggest methods and provide resources to assist with smoking cessation

What is the proper action to do when providing care to an 18 yr old client who has respiratory issues and smokes excessively?

Maintain a professional distance during assessment When assessing a non-native client, the nurse should maintain a professional distance during assessment; the size of personal space affects one's comfortable interpersonal distance

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

Explain the reason for taking down notes The nurse should explain the reason for taking notes during the interview and ensure that it will remain confidential; this will help the client to provide all the required information during the interview

Which behavior is appropriate for a nurse to display when collecting subjective data as part of the assessment process?

open-ended questions to encourage the client to tell his or her story 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.

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?

working phase

during this phase, the nurse: - interviews the client - takes biographical data, - takes personal and family health history - review of body systems and lifestyle, - and takes history of present concern (COLDSPA) - *finishes this phase by validating data and collaborating w/ client to create goals*

introductory phase

during this phase, the nurse: - introduces her/himself, - explains the purpose of the interview, - discusses the questions being asked, - explains the reasons why he/she is taking notes - and explains confidentiality