Chapter 2 Collecting Subjective Data: The Interview and Health History

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?"

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?"

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?

Ask the client to repeat the statement or question.

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

Maintain a professional distance during assessment.

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

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.

A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned?

Seated in a chair at eye level with the client

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have

knowledge of his or her own thoughts and feelings about these issues.

Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms?

open-ended questions to allow full freedom of response

During an initial health history, a client states, "I haven't slept in weeks." The nurse asks, "You are saying that you have not had any sleep in weeks?" What communication technique is the nurse using to obtain accurate subjective data from the client?

rephrasing

While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose?

to clarify

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

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

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?

last surgery date validated by adult daughter

During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information?

neurologic

The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document?

unable to go to the gym since having back surgery

A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status?

"Do you live alone or with someone?"

A nurse has admitted a client to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe?

"This helps us have an appropriate focus for the physical examination."

The nurse performs a focused assessment on a client who is reporting joint pain. To gain a better understanding of the client's pain, the nurse uses COLDSPA. Which question(s) should the nurse ask the client to determine the origin of the pain? Select all that apply.

"When does the pain occur?" "What makes the pain better or worse?" "How would you describe the pain?" "Could you show me where the pain is exactly?"

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

During an interview, how can the nurse best assist the client as the client tells their story?

Avoid interrupting the client.

The nurse is conducting an initial interview with a client. During the introductory phase, it is essential that the nurse perform which of the following actions? Select all that apply.

Build rapport. Provide a comfortable environment. Explain the purpose of the interview. Ensure confidentiality.

The nurse has been assigned to a group of clients on a medical surgical unit. What is the bestaction of the nurse prior to receiving a report on these clients?

Conduct a brief review of the client's charts.

A nursing instructor is talking about nonverbal communication with the nursing class. The instructor explains that facial expressions should be what?

Relaxed

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

A client is being admitted for elective surgery. What should the nurse instruct the client to do to ensure that the medication history is complete?

bring all medications and preparations used to the hospital

A client is experiencing a relapse of a urinary tract infection. Which additional information should the nurse collect when discussing this client's present health problem?

sexual history

A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?

Can you tell me about your sleep problem from when it started until now?"

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

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?

stop documenting in order to maintain eye contact with the client.

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 other symptoms occurred during the spell?"

A nurse completes an initial assessment and discusses findings with the client. What is the next best action of the nurse?

Develop a plan of care with the client

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?

Friends and family who are unfamiliar with medical terminology may misinterpret information

A nurse is running late after a quarterly quality improvement meeting at the hospital and has just been paged from the nurses' station. A client's relative wants to talk as soon as possible about the client's care. The nurse has clinic duty this afternoon and is about to see the first client. The first appointment time slot is double-booked, and three other clients have arrived, all of whom are sitting in the waiting room. Which of the following demeanors is consistent with skilled interviewing when the nurse walks into the examination room to speak with the first client at the clinic?

calm

An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary?

the client