Ch 2 assessment

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?

Personal and social history

The nurse is assessing an older adult client a hospice unit. The client cannot speak or communicate, but the client's daughter is there and answers all the questions as best as she can. What type of data source is the daughter?

Secondary

The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first?

The client's sensory abilities

A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the

focused assessment

The nurse is focusing an interview on a patient's respiratory status. Which question would be the best to begin this interview?

"Describe your breathing."

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

"How do you manage your stress?"

During the interview, the client states, "Is today the 12th? My wife died 2 months ago today." Which of the following responses would be most appropriate?

"How does that make you feel right now?"

The nurse is obtaining information about a client's past health history. Which client statement would best reflect this component of assessment?

"I had surgery 5 years ago to repair an inguinal hernia."

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?

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

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?"

A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental?

"You must quit smoking because it affects others, not only you."

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."

While discussing family history with a patient who is healthy except for a current UTI requiring IV antibiotics, the patient tells the nurse that he has three sisters and two brothers. Two of his sisters have died and one brother is in a nursing home after a stroke. The nurse would include the sibling group in a genogram in what manner?

3 circles and 3 squares with lines through 2 circles

While interviewing a new patient, you notice that he is mirroring your position. What can this signify?

An increasing sense of connectedness

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

As many genetic relatives as the client can recall

A nurse, conducting a functional assessment on an adult client, assesses overall psychosocial well-being by assessing what?

Coping/stress tolerance

While gathering data for the family history portion of the health history, what would you ask about?

Coronary artery disease

The patient presents to the clinic reporting chest pain and shortness of breath. Which type of health history would the nurse would conduct?

Emergency

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?

Explain the purpose of the interview.

The nurse is teaching the patient how to self-administer insulin. Which functional health pattern does this nursing intervention address?

Health perception-health management

The nurse is assessing the seven attributes of a patient's symptom. In which section of the comprehensive health history will the nurse document this information?

History of present illness

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

Maintain a professional distance during assessment

During a comprehensive health history, a patient states the use of cigarettes for 20 years. The nurse will document this information within:

Past history

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

When recording the patient's reason for seeking care (chief concerns) during the health history, it is recommended that the interviewer:

Quote the patient's words

When performing a health assessment, what is a basic tool that the nurse uses in the caring relationship with the client?

Therapeutic communication

When assessing the gastrointestinal system, the nurse correctly asks, "Do you have any trouble swallowing?"

True

A nurse is interviewing a 22-year-old client of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?

Using a moderate amount of eye contact

A nursing instructor is teaching the student during clinical how to take a health history and perform a complete assessment on a patient. The student shows understanding of the difference between subjective and objetive data by identifying the following as objective data.

decubitus on left heel

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

explain the role and purpose of the nurse.

Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the patient's quality of life. When assessing ADLs, the nurse asks if the patient can grasp small objects and open jars. This is an example of assessing the patient's:

mobility

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

rephrasing the client's statements.

The patient's demographical/biographical data comprise an important part of the health history. Components include name, address, and billing information as well as other more pertinent areas, such as (check all that apply):

• Environmental data about exposure to contagious diseases • Travel to high-risk areas • Concerns about exposure to pollution, hazards, and allergens

An adult client presents at the ED complaining of severe pain in the left upper quadrant. The nurse uses a mnemonic to remember the important elements to assess for the presenting symptom. What elements are represented by the mnemonic OLDCARTS? Select all that apply.

• Location • Character • Timing

A comprehensive health history includes which components? Select all that apply.

• Past health history • Reason for seeking care • History of present illness

A past history is being taken by the nurse for a patient with COPD. The nurse includes which elements in this part of the health history? Select all that apply.

• allergies • childhood illnesses • health maintenance