Assessment chapter 2
A nurse is interviewing a client who has recently been diagnosed with terminal disease. In covering the lifestyle and health practices profile, the nurse asks the client, "Are you close to any extended family members in the area?" The client objects to the question and asks why the nurse needs to know that. Which is the best rationale for the nurse posing this question? "I just wanted to see what kind of social support you might have to help care for you during your illness." "With you having a terminal illness, you will need someone to help you plan your funeral." "I just thought I might know them; I know pretty much everyone in this town." "I'm just being friendly. We like to get to know our clients at this practice."
"I just wanted to see what kind of social support you might have to help care for you during your illness." Explanation: Ask clients to describe the composition of the family into which they were born and about past and current relationships with these family members. In this way, you can assess problems and potential support from the client's family of origin. Just being friendly and determining what acquaintances the nurse might have in common with the client are not proper rationales for asking for this personal information. Mentioning plans for the client's funeral is blunt and would likely upset the client.
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? Restatement Encouraging elaboration (facilitation) Active listening Reflection
Active listening Explanation: 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.
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? Turn the television on for distraction. Change the subject to put the client at ease. Refer all questions to the client's family member in room. Ask the client to repeat the statement or question.
Ask the client to repeat the statement or question. Explanation: The nurse should ask clients to repeat questions or statements if the nurse is unable to understand what the client said. The nurse can also paraphrase client responses to verify understanding.
A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format of representing a deceased female relative? Circle with a cross Simple circle Simple square Square with a cross
Circle with a cross Explanation: The standard format of representing a deceased female relative in a genogram is using a circle with a cross. A simple circle indicates a living female relative. A simple square indicates a living male relative. A square with a cross indicates a deceased male relative.
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? "You work at a computer a lot, don't you?" "Do you perform any sustained or continually repetitive motions with that arm?" "When did the pain start?" "I recommend that you change your posture while working at the computer."
Do you perform any sustained or continually repetitive motions with that arm?" Explanation: 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.
Learning about the effects of the illness does what for the nurse and the client? Gives them each a better understanding of the other Gives them the opportunity to create a complete and congruent picture of the problem Gives them the ability to communicate better Gives them the basis to establish a trusting relationship
Gives them the opportunity to create a complete and congruent picture of the problem Explanation: 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.
Learning about the effects of the illness does what for the nurse and the client? Gives them the opportunity to create a complete and congruent picture of the problem Gives them the ability to communicate better Gives them the basis to establish a trusting relationship Gives them each a better understanding of the other
Gives them the opportunity to create a complete and congruent picture of the problem Explanation: 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.
While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is "Is stress a problem in your life?" "How often do you feel stressed?" "How do you manage your stress?" "Do you feel stress at work?"
How do you manage your stress?" Explanation: 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.
A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information? Lifestyle and health practices profile Personal health history Family health history History of present health concern
Lifestyle and health practices profile Explanation: By assessing the client with regard to nutritional habits, use of substances, education, and work and stress levels, the nurse expects to obtain a lifestyle and health practices profile. To determine the history of present health concerns, the nurse should ask questions relating to the onset, duration, and treatments, if any have been conducted on the client, for the present health concern. The questions related to personal health history assist the nurse in identifying risk factors that stem from previous health problems. Family health history helps the nurse to identify potential risk factors for the client.
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. Do not use facial expressions such as rolling the eyes or looking bored or disgusted Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally Do not look the client in the eye Laugh a lot, which puts the client at ease Make sure that dress and appearance are professional
Make sure that dress and appearance are professional Do not use facial expressions such as rolling the eyes or looking bored or disgusted Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally Explanation: The physical appearance of the nurse sends a message to the client. Thus, it is important for nurses to ensure that their dress and appearance are professional. Facial expressions should be relaxed, caring, and interested. Facial expressions common in social situations (e.g., rolling the eyes, looking bored or disgusted) reduce trust. The nurse uses gestures intentionally to illustrate points, especially for clients who cannot communicate verbally. The nurse may point with a finger or gesture an action, such as pretending to drink or pointing to the bathroom. Gestures are purposeful rather than distracting from the communication. Therefore, laughing a lot and not making eye contact are incorrect answers.
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? Approach the client in an in-control manner. Provide simple and organized information. Refer the client to a spiritual guide. Mirror the client's feelings.
Provide simple and organized information. Explanation: The nurse should provide simple and organized information to reassure the client about the procedure and its expected outcomes. The nurse approaches the aggressive, not anxious, client in an in-control manner. The nurse refers the dying client or client with spiritual concerns to a spiritual guide. The nurse should avoid expressing anxiety or becoming anxious like the client, as it would make the client more anxious.
A nursing instructor is talking about nonverbal communication with the nursing class. The instructor explains that facial expressions should be what? Relaxed Inquisitive Happy Detached
Relaxed Explanation: Facial expressions should be relaxed, caring, and interested. Facial expressions that are happy, inquisitive, or detached can interfere with the therapeutic communication process.
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? Avoid maintaining eye contact while the client is discussing spouse abuse. Write down the information as the client is speaking. Stop documenting in order to maintain eye contact with the client. Key the information into the electronic medical record as the client is speaking.
Stop documenting in order to maintain eye contact with the client. Explanation: Whenever the client is talking about sensitive or disturbing information, the nurse should stop documenting or move away from the keyboard and maintain eye contact with the client. The nurse should not write down the information as the client is speaking and should not continue keying the information into the electronic medical record while the client is speaking. Avoiding eye contact minimizes the importance of the information that the client is providing and should not be done.
What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking? Remind the client that excessive smoking could cause cancer Keep a stern expression to communicate the severity of the issue Suggest methods and provide resources to assist with smoking cessation Ask the client why he started smoking at a young age
Suggest methods and provide resources to assist with smoking cessation Explanation: The client will know that the nurse understands that it is hard to quit smoking if the nurse suggests methods available to help kick the smoking habit. The nurse should keep a neutral and friendly expression, and avoid any display of surprise or shock at the situation. A neutral, friendly expression will help the client to open up and explain to the nurse his efforts at breaking free from the habit. The nurse need not tell the client that excessive smoking could cause cancer, as the client will be well aware of the dangers of smoking.
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? "Are both of your parents still living?" "What do you usually eat in a typical day?" "What diseases did you have as a child?" "How do you feel about having to seek health care?"
What diseases did you have as a child?" Explanation: 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. The question, "How do you feel about having to seek health care?" would be asked during the reason for seeking health care section of the interview. The question regarding the status of the client's parents would be posed in the family health history section. The question regarding what the client usually eats in a typical day would be included in the lifestyle and health practices profile section.
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? "How long did the spell last?" "What other symptoms occurred during the spell?" "How bad was the tingling and numbness?" "Where did the numbness and tingling occur?"
What other symptoms occurred during the spell?" Explanation: 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 nurse assesses a client who reports the onset of a severe headache. 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? Summary Closing Working Introductory
Working Explanation: During the working phase, the nurse asks the client about the history of the present health concern and the reasons for seeking care. In the introductory phase the nurse explains the purpose of the interview and assures the client that confidential information will remain confidential. During the summary phase or the closing phase, the nurse summarizes information obtained during the working phase and validates problems and goals with the client.
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 allow the client to verbalize his or her feelings. offer reasons why the client should not feel angry. provide structure during the interview. refer the client to a different health care provider.
allow the client to verbalize his or her feelings. Explanation: When interacting with an angry client approach this client in a calm, reassuring, in-control manner. Allow him to ventilate feelings
The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus? activity-exercise coping-stress-tolerance sleep-rest self-perception/self-concept
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 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? screening test completion health maintenance compliance with treatment risk factors
health maintenance Explanation: One area within health maintenance is completion of vaccinations. If the client cannot recall when the last immunizations were received, this would impact health maintenance. Risk factors focus on tobacco use, environment, safety, and substance use. Screening tests are a subcategory within health maintenance. It is possible that the client is unaware of which vaccinations should be obtained. If this is the case, the client should not be labeled as not being compliant with treatment.
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? confused regarding dates of surgical procedures last surgery date validated by adult daughter unable to recall exact date of last surgery adult daughter controlling the interview
last surgery date validated by adult daughter Explanation: 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.
