chapter 2
The nurse is preparing to assess a female client's activities related to health promotion and maintenance. Which question would provide the most objective and thorough data? "Do you use condoms with each sexual encounter?" "How much beer, wine, or alcohol do you drink?" "Do you always wear your seatbelt when driving?" "Could you describe how you perform self-breast exams?"
"Could you describe how you perform self-breast exams?" Explanation: Asking the client to describe self-breast examination is an open-ended question that allows the client to verbalize openly about the activity and provides the nurse with information that allows determination of correctness of technique. Asking about wearing a seatbelt, how much alcohol the client drinks, or using condoms with sexual activity are closed-ended questions that would provide information of one or two words.
A client's elevated body mass index (BMI) has prompted the nurse to assess the client's activity and exercise level. Which statement would indicate to the nurse that the client is getting the recommended amount of exercise?
"I go to a step class for an hour three times a week." Explanation: The recommended exercise regimen is aerobic-type exercise for 20 to 30 minutes at least three times a week. Walking on a treadmill once or twice per week, playing basketball once a week, or swimming for half an hour once a week would not fit the aerobic exercise recommendations.
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? "No one is forcing you to be here, and you are free to leave at any time." "You're certainly justified in being upset, but I am ready to begin your exam now." "Our schedule is very busy also. We got to you as soon as we could." "Would you like to report your complaints to someone with power?"
"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.
A client with acute onset of shoulder pain is answering questions during a health history. The nurse is utilizing a mnemonic specific to the attributes of a symptom. The nurse first asks about the onset of symptoms followed by Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1relieving/exacerbating factors 2associated manifestations 3characteristic symptoms 4location 5duration 6treatment
1location 2duration 3characteristic symptoms 4associated manifestations 5relieving/exacerbating factors 6treatmen
"How many steps can you climb before you get short of breath?" is an example of what kind of question? A question that elicits a graded response A question that is qualitative in focus A question that offers multiple choices for answers A question that demands an imprecise response
A question that elicits a graded response Explanation: The nurse should ask questions that require a graded response rather than a single answer. "How many steps can you climb before you get short of breath?" is better than "Do you get short of breath climbing stairs?" This question is neither qualitative nor imprecise.
A group of students is reviewing for a quiz on verbal and nonverbal communication. The students demonstrate a need for additional studying when they identify which of the following as an example of nonverbal communication? Silence Facial expression Laundry list Attitude
Laundry list Explanation: Laundry list is an example of a verbal communication technique. Attitude, silence, and facial expression are examples of nonverbal communication.
What occurs during the termination phase of an interview? Letting the client know you understood all he or she has told you Assessing the client's mental status Addressing topics that have not yet been addressed Planning for follow-up care
Planning for follow-up care Explanation: The main activity that takes place during the termination phase is planning for follow-up and closing the interview.
Prior to a client interview, the nurse collects information from the client's medical record, such as prior surgeries, home medications, allergies, and past treatments. What phase of the interview process is this? Working Pre-interaction Closing Beginning
Pre-interaction
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.
Which of the following are aspects of the comprehensive health history? (Mark all that apply.) Strengthens the nurse-client relationship Creates platform for health promotion through education and counseling Provides baselines for future assessments Is appropriate for established clients Obtains data to evaluate the outcomes of the plan of care
Strengthens the nurse-client relationship Provides baselines for future assessments Creates platform for health promotion through education and counseling Explanation: The comprehensive health history performs multiple functions. These include strengthening the nurse-client relationship and providing baselines for assessment and health promotion. It is not normally used for specific evaluative purposes or for established clients.
A student nurse is conducting her first client interview. The student suddenly draws a blank on what to ask the client next. What is a useful interview technique for the student to use at this point? Termination Transition Summarization Reassurance SUBMIT ANSWER
Summarization Explanation: Summarization can be used at different points in the interview to structure the visit, especially at times of transition. This technique also allows the nurse to organize his or her clinical reasoning and to convey it to the client, making the relationship more collaborative. It is also a useful technique for learners when they draw a blank on what to ask the client next.
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 Explanation: Another way to clarify is to ask, "What happens when you get low blood sugar?" Such questions prompt clients to identify other symptoms or give more information so that you can better understand the situation.
A client comes to the office for evaluation of fatigue. He has come to the office many times in the past with various injuries, and the nurse suspects that the client has a problem with alcohol. Which of the following questions will be most helpful in diagnosing this problem? You are an alcoholic, aren't you? When was your last drink? Do you drink alcohol when you are supposed to be working? Do you drink 2 to 3 beers every weekend?
When was your last drink? Explanation: "When was your last drink?" is a good opening question that is general and neutral in tone; depending on the timing, the nurse will be able to ask for more specific information related to the client's last drink. The other questions may close the conversation down because they are close-ended. Asking "Do you drink alcohol when you are supposed to be working?" implies negative behavior and may also keep the person from sharing freely.
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 Working Introductory Closing
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.
During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information? review of systems health patterns history of present illness chief complaint
chief complaint Explanation: The chief complaint is the reason for the person seeking care. Health patterns focuses on the client's social history. The review of systems is where the presence or absence of common symptoms related to each major body system are reviewed and documented. The history of present illness describes how each symptom developed. It includes the client's thoughts and feelings about the illness, relevant parts of the review of systems, and medications, allergies, and lifestyle habits that impact the present illness.
A middle-aged client has an appointment for a routine physical. Which type of assessment is the most appropriate for the nurse to complete? focused emergency follow-up comprehensive
comprehensive Explanation: A comprehensive assessment includes demographic data, a full description of the reason for seeking care, individual health history, family history, functional status, and a history in all physical and psychosocial areas. A focused assessment gathers information about the current health problem. A follow-up assessment evaluates a specific problem after treatment. An emergency assessment focuses on data to quickly resolve the immediate health problem
The nurse is preparing to interview a newly admitted client. What should be done prior to hearing the client's story? establish the agenda for the interview ask specific questions about the reason for admission review the attributes of a symptom review the client's issues in a chronologic order
establish the agenda for the interview Explanation: Prior to hearing the client's story during the working phase of the interview, the nurse should establish the agenda for the interview. Attributes of a symptom are examined during the working phase. Reviewing the client's issues in chronologic order is completed during the working phase. Asking questions about the reason for admission is the first action completed during the working phase of the interview.
A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information? personal and social history health maintenance review of systems physical examination
health maintenance Explanation: Health maintenance includes any preventative diagnostics or health-promoting activities the client completed in the past. This is a subsection of the past history in the health assessment. The physical examination and review of systems capture the objective data that arises from the health assessment conducted by the nurse. Personal and social history capture client lifestyle factors such as family, employment, and habits.
While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should read the questions verbatim from the form. ask the client to complete the form. maintain eye contact while asking the questions from the form. ask leading questions throughout the interview.
maintain eye contact while asking the questions from the form. Explanation: Establish eye contact when the client is speaking to you but look down at your notes from time to time.
While gathering data for the family history portion of the health history, what would you ask about? Liver disease Coronary artery disease Low bone density Injuries
oronary artery disease Explanation: Review each of the following conditions and record whether they are present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, as well as symptoms reported by the client.
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? mental health disorder low self-esteem physical abuse cognitive disorder
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.
The nurse is reviewing the medical record before meeting a new client. In which phase of the interview process is the nurse working? introduction pre-interview working termination
pre-interview Explanation: In the pre-interview stage the medical record is reviewed to help set the stage for a smooth interview. In the working phase, the client information is collected. In the termination phase, important points are summarized and the plan of care is developed. In the introduction phase the client is greeted and rapport is established.
The nurse is preparing to complete a comprehensive assessment of a newly admitted client. Why is the nurse completing this type of assessment? addresses specific concerns assesses symptoms of one body system establishes routine care needs provides a baseline for future assessments
provides a baseline for future assessments Explanation: A comprehensive assessment provides a baseline for future assessments. A focused assessment addresses specific concerns, establishes routine care needs, and assesses the symptoms of one body system.
A client comes to the ED complaining of chest pain. This would be considered objective primary data objective secondary data subjective primary data subjective secondary data
subjective primary data Explanation: The individual client is considered the primary data source. When possible, clients provide subjective information regarding their health behaviors and situations. Subjective information is from the perspective of the client.
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 use very basic lay terminology. have a family member present during the interview. use standard medical terminology. show the client pictures of different symptoms, such as the "faces pain chart."
use very basic lay terminology. Explanation: If the client appears to have a limited vocabulary, the nurse may need to ask questions in several different ways and use very basic lay terminology.
The client presents with complaints of joint stiffness that is interfering with the client's ability to perform activities of daily living. Which of Gordon's functional health patterns should the nurse conduct a focused assessment? Activity-exercise Sleep-rest Elimination Role-relationship
Activity-exercise Explanation: Joint stiffness can lead to limited range of motion, which can impact the client's ability bathe, dress, feed, ambulate, and transfer themselves. The priory functional health pattern to assess is activity-exercise, which focuses on the client's ability to engage in activities of daily living. The Role-Relationship pattern assesses the client's ability to fulfill personal roles and the relationships they have with family and others. The sleep-rest pattern focuses on the individual's sleep, rest, and relaxation routines. The elimination pattern focuses on the individual's excretory patterns.
The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use? While completing the family history Before assessing for vaccinations During the review of systems After assessing for cigarette use
After assessing for cigarette use Explanation: Questions about alcohol and other drugs follow naturally after questions about cigarettes. Questions about alcohol intake occurs before the review of systems. Alcohol intake is a risk factor that is assessed after vaccinations. Alcohol use is assessed before completing the family history
The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use? While completing the family history During the review of systems After assessing for cigarette use Before assessing for vaccinations
After assessing for cigarette use Explanation: Questions about alcohol and other drugs follow naturally after questions about cigarettes. Questions about alcohol intake occurs before the review of systems. Alcohol intake is a risk factor that is assessed after vaccinations. Alcohol use is assessed before completing the family history.
While interviewing a new client, you notice that he is mirroring your position. What can this signify? An increasing sense of connectedness A desire to be on an equal power level The client does not take you seriously A desire for increased rapport
An increasing sense of connectedness Explanation: Matching your position to the client's can signify increased rapport, just as mirroring your position can signify the client's increasing sense of connectedness.
A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative? Simple circle Circle with a cross Simple square Square with a cross
Circle with a cross Explanation: The standard format for 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.
The review of systems component of the health history is best described as a: Detailed investigation of questions about major body systems Focus on diseases of the major body systems Series of questions that start at the head and finish at the feet Focus on common questions and issues related to each of the different body systems
Focus on common questions and issues related to each of the different body systems Explanation: The review of systems is a systematic method of addressing common questions, symptoms, and issues, rather than specific diseases, of the major body systems. As it is an overview, there should not be a large number or detailed investigation of questions about each system. Given the focus on identifying symptoms, it would be simplistic to describe it as simply a series of head-to-toe questions.
A client reports feeling depressed for several months since being fired from a long-term job. Which question should the nurse include when assessing this client? "Are you looking for a new job?" "Have you thought of hurting yourself?" "Have you considered a job placement agency?" "How are you managing financially?"
Have you thought of hurting yourself?" Explanation: If the client seems depressed, ask about thoughts of suicide: "Have you ever thought about hurting yourself or ending your life?" The severity of the depression needs to be assessed since it could be lethal. Asking about a job search or finances are not appropriate questions when a client is depressed.
The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information? Initial information Review of systems History of present illness Health patterns
History of present illness Explanation: · OLD CARTS (Onset, Location/radiation, Duration, Character, Aggravating factors, Relieving factors, Timing and Severity). The seven attributes of each principle symptom are documented within the history of present illness within the comprehensive health history. The initial information within the comprehensive health history includes date and time of history, identifying data, and reliability. The review of systems within the comprehensive health history includes the presence or absence of common symptoms related to each major body system. The health patterns section within the comprehensive health history includes personal and social history.
The nurse uses the mnemonic OLD CART when assessing a client's symptoms. Which letter represents the area of the symptom and if it radiates? L O C D
L Explanation: The letter L represents the location of the symptom and if it radiates to another body area. The C represents the characteristic symptoms that are occurring. The D represents the duration of the symptom. The O represents the onset of the symptom.
During the review of systems, a client reports having difficulty with urination and with establishing an erection. Which additional information should the nurse recognize as the highest priority to assess at this time?
Sexual history Explanation: If the chief complaint involves genitourinary symptoms, include questions about sexual health as part of "expanding and clarifying" the client's story. Lifestyle, medication, and substance use can be contributing factors but gathering a sexual history is the priority action at this time.
During the working phase of an interview the nurse encourages the client to continue and expand on the health issues. What technique is the nurse using? summarizing empathy active listening empowering
active listening Explanation: Active listening is the process of paying close attention to what the client is communicating, being aware of the client's emotional state, and using verbal and nonverbal skills to encourage the speaker to continue and expand. Empathy is the ability to perceive, reason, and communicate understanding of another person's feelings without criticism. Empowerment instills confidence in the client. Summarizing provides an overview of the client's story.
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.
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?
"Have you ever had a problem with mental or emotional illness?" Explanation: 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.
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? "Do you have adequate health insurance coverage?" "Did you bring all your medications with you?" "What is your major health concern at this time?" "Are you generally fairly healthy?"
"What is your major health concern at this time?"
A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview? "How would you rate your sleep on a scale from 1 to 10?" "What have you tried to help with your sleep?" "When did the sleep problem begin?" "Can you tell me about your sleep problem from when it started until now?"
Can you tell me about your sleep problem from when it started until now?" Explanation: In order to open the interview, the nurse should start with an open-ended question and then identify missing data. Asking when the sleep problem began is assessing for the onset of the problem. Asking the client to rate the sleep problem from 1 to 10 is part of assessing characteristic symptoms. Asking the client what has been tried to help with the sleep is assessing for treatments.
The nurse is focusing an interview on a client's respiratory status. Which question should the nurse ask first to begin this interview? Describe how you breathe for me? Do you experience any pain when you breathe? Do you currently have a cough? Do you have any difficulty producing sputum?
Describe how you breathe for me? Explanation: During an interview, questions should proceed from general to specific. The question that is the most general is "describe your breathing." This provides the client with an opportunity to discuss the current breathing pattern with the nurse. The other questions are specific and will elicit a yes-no response.
Which behavior is appropriate for a nurse to display when collecting subjective data as part of the assessment process? Remain standing during the interview Maintain eye contact with the client at all times Read questions from the history form Explain the reason for taking down notes
Explain the reason for taking down notes Explanation: 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. Some clients may be very uncomfortable with too much eye contact while others may believe that the nurse is hiding something from them if eye contact is avoided. Therefore, the nurse should maintain only a moderate amount of eye contact and not maintain eye contact with the client at all times. The nurse should not remain standing while taking down notes, as it could indicate that the nurse is in a hurry to complete the interview; it could also indicate that the nurse is expressing superiority over the client. The nurse should not read questions from the history form, as this deflects attention from the client and results in an impersonal interview process.
A client comes to the Emergency Department with bruises on her upper and lower body and appears to be withdrawn. The injuries do not appear consistent with the explanations for them. The client's boyfriend refuses to leave the examination room and is overly protective of her. The nurse suspects: Anorexia nervosa Inability of the client to perform ADLs Hypertension Human violence
Human violence Explanation: The indications should raise the nurse's suspicions of abuse of the client by the boyfriend. Commonly, abusers are overly protective in the presence of others and will not leave the examination room. Hypertension, inability to perform ADLs, and the eating disorder anorexia nervosa are not indicated in this scenario of bruising and withdrawal.
The nurse is interviewing a client with limited English. What can the nurse do to allow the client an opportunity to speak? Insert pauses into the conversation Use an interpreter Ask closed-ended questions that require "yes" or "no" answers Use simple and clear language
Insert pauses into the conversation Explanation: The nurse inserts pauses in the conversation to allow the client an opportunity to speak; such pauses facilitate trust, respect, and sharing. Use of closed-ended questions, simple and clear language, and an interpreter do not allow the client an opportunity to speak.
Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data? Avoid any eye contact with the client. Speak to the client using local slang. Maintain a professional distance during assessment. Ask one of the client's children to interpret.
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 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? Refer the client to a spiritual guide. Mirror the client's feelings. Approach the client in an in-control manner. Provide simple and organized information.
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.
When recording the client's reason for seeking care (chief concerns) during the health history, it is recommended that the interviewer: Paraphrase the client's words Summarize the client's words Describe the client's concerns and health goals Quote the client's words
Quote the client's words Explanation: When recording the client's reason for seeking care (chief concern), it is preferable to quote the client's exact words whenever possible.
A client is admitted to the health care facility with new onset of abdominal pain. The client becomes angry with the nurse when questions about personal information are asked. How should the nurse proceed with the interview? Encourage the client to use a more appropriate method to cope with feelings Remind the client that this information must be obtained to provide proper care Remain in control and allow the client to vent feelings Touch the client lightly on the shoulder to dissipate the anger
Remain in control and allow the client to vent feelings Explanation: An angry client should be approached in a calm, reassuring, in control manner by the nurse. Allow the client to ventilate their feelings may help to diffuse the anger. Telling the client that this information is necessary does not convey an understanding of feelings by the nurse. Touching or arguing with the client may escalate their anger. Encouraging the client to use other methods of coping may help when dealing with a seductive client.
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? "How do you feel about having to seek health care?" "Are both of your parents still living?" "What do you usually eat in a typical day?" "What diseases did you have as a child?"
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.
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 set time limits with the client. avoid discussing sensitive issues. allow the client time to calm down. explain the role and purpose of the nurse.
explain the role and purpose of the nurse. Explanation: 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.
A pregnant woman comes to the physician's office for her first prenatal visit. The nurse knows the importance of performing a comprehensive health history in this case and understands the following must be included (check all that apply): food preferences information about current pregnancy family history obstetrical and gynecological history previous pregnancies
information about current pregnancy previous pregnancies obstetrical and gynecological history family history Explanation: It is important on the first prenatal visit to perform a comprehensive health history, which includes information about the present pregnancy, previous pregnancies, obstetrical and gynecological history, the family, and psychosocial profile. Food preferences are part of a nutritional assessment and not necessary at this time.
A client comes to the emergency department with severe abdominal pain. When performing a complete assessment, the nurse would focus on which of the following areas when covering past health history? intensity of the pain aggravating factors of the pain previous medical and surgical problems duration of the pain
previous medical and surgical problems Explanation: The past health history includes asking about previous medical and surgical problems along with their dates. Aggravating factors, duration, and intensity of the pain are all part of the history of present illness.
The nurse conducts a health history with a client who reports having a dull headache over the past month. The client tells the nurse that using aromatherapy scents have helped manage the pain sometimes. This information is belongs to which attribute of a symptom? onset duration associated manifestations treatment
treatment Explanation: The nurse should include any client reports of self treatment, such as alternative therapies, that the client has tried to alleviate the symptoms. This is captured within treatment. Associated manifestations refers to any other symptoms that accompany the chief report. The onset refers to when the headache started. Duration refers to the length of time the headaches last each time.
A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing? self-perception value-belief coping-stress-tolerance role-relationship
value-belief Explanation: The value-belief health pattern describes patterns of values, beliefs or goals that guide choices or decisions. The self-perception-self-concept pattern describes body image, feeling state, self-esteem, personal identity, and social identity. The role-relationship pattern describes patterns of role interactions and relationships including family functioning and problems, and work and neighborhood environment. The coping-stress-tolerance pattern describes general coping pattern and its effectiveness in terms of stress tolerance.
During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed ongoing. introductory. closure. working.
working. Explanation: During the working phase, the nurse elicits the client's comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level. The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client. The nurse and client collaborate to identify the client's problems and goals.
A client has come to the physician's office several times in the last month with a black eye, bruises, and lacerations on the lower extremities. The client always explains having fallen and tripped. The nurse suspects abuse. The next step should be to: Call social services. Report the findings to a supervisor. Call the police. Confront the client.
Report the findings to a supervisor. Explanation: When abuse is suspected, nurses are obligated to report their concerns to a supervisor and obtain assistance from social services for further assessment. It is not in the nurse's scope of practice to call social services directly, and the nurse should never call the police independently. Also confronting the client will only isolate her and make her more uncomfortable.
A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication? Standing while the client is seated Sitting across the room from the client Minimizing facial expressions Using a moderate amount of eye contact
Using a moderate amount of eye contact Explanation: The nurse needs to avoid extremes in eye contact. Excessive eye contact may make the client uncomfortable; too little eye contact might lead the client to believe that the nurse is hiding something. A moderate amount communicates interest and focus. The nurse should be at the same level of the client. Standing while the client is seated puts the nurse as superior, possibly making the client feel inferior. The nurse should be within 2 to 3 feet of the client during the interview. The nurse should keep facial expressions neutral and friendly.
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?" "Is stress a problem in your life?" "How often do you feel stressed?" "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.
Which of the following questions would be most important for the nurse to ask first when obtaining the health history? "Are you generally fairly healthy?" "What is your major health concern at this time?" "Do you have adequate health insurance coverage?" "Did you bring all your medications with you?"
"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.
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? "Your husband's death must have been very difficult for you." "How often do your adult children typically visit you?" "You must quit smoking because it affects others, not only you." "How would you describe your feelings about getting older?"
"You must quit smoking because it affects others, not only you." Explanation: Saying that smoking is harmful to others and telling the client that she must quit forces a sense of guilt on the client. The statement may be seen as "preaching," without focusing on assisting the client to attain optimal health. Asking how often the adult children visit or how the client feels about getting older focuses on information gathering. The statement about the husband's death being difficult is plausible and acknowledges the client's feelings.
The nurse has just asked a client how he feels about his emphysema. He becomes silent, folds his arms across his chest, and leans back in his chair. Then the client replies "It is what it is." How should the nurse respond? "You seem bothered by this question." "Next, I would like to talk with you about your smoking habit." "Okay, let's move on to your other problems." "You have adopted a practical attitude toward your problem."
"You seem bothered by this question." Explanation: The nurse has astutely noted that the client's body language changed at the time of this question. Despite the client's response, the nurse suspects there is more beneath the surface. Maybe the client is afraid of being browbeaten about his smoking, maybe a relative has recently died from this disorder, or maybe his friend told him 20 years ago, he would eventually get emphysema. Regardless, through the nurse sharing an observation and leaving a pause, the client may begin to talk about some issues that are very important to him.
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 Reflection Encouraging elaboration (facilitation) Restatement
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.
A nurse is creating a genogram of a client's family health history. The nurse should use which of the following symbols to denote the client's female relatives? Triangle Square Circle Rectangle SUBMIT ANSWER
Circle Explanation: When creating a genogram, female relatives are usually indicated by a circle and male relatives by a square. Triangles and rectangles are generally not used.
The client'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): List of current medications Current diet Concerns about exposure to pollution, hazards, and allergens Environmental data about exposure to contagious diseases Travel to high-risk areas
Environmental data about exposure to contagious diseases Travel to high-risk areas Concerns about exposure to pollution, hazards, and allergens Explanation: Demographical/biographical data include more that just insurance information and name and address. They include important details about the client's home and work environment, previous travel, and harmful exposures. They do not include a list of medications or current diet.
When beginning the collection of the client data base, which of the following would be most important for the nurse to do? Make inferences Establish a trusting relationship Identify health problems Determine the client's strengths SUBMIT ANSWER
Establish a trusting relationship Explanation: It is essential for the nurse to develop trust and rapport with the client to elicit accurate and meaningful information. This trust is the focus of the interview and must be developed in the initial phase of the interview. Determining the client's strengths, identifying health problems, and making inferences occur during the working phase of the interview.
A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? Making clinical inferences Determining the client's strengths Establishing a trusting relationship Identifying potential health problems SUBMIT ANSWER
Establishing a trusting relationship
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. Obtain family health history data. Collaborate with the client to identify problems. Determine the client's vital signs.
Explain the purpose of the interview. Explanation: During the introductory phase, the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client about the confidentiality of the information. Collaborating to identify problems and obtaining family health history data are components of the working phase. Vital signs are not obtained during the interview.
A nurse is collecting subjective data from a client as part of the assessment process. Which behavior is most appropriate for the nurse to display in this situation? Explaining the reason for taking down notes Maintaining eye contact with the client at all times Reading questions from the history form Remaining standing during the interview
Explaining the reason for taking down notes Explanation: 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. Some clients may be very uncomfortable with too much eye contact, while others may believe that the nurse is hiding something from them if eye contact is avoided. Therefore, the nurse should maintain only a moderate amount of eye contact and not maintain eye contact with the client at all times. The nurse should not remain standing while taking down notes, as it could indicate being in a hurry to complete the interview; it could also indicate that the nurse is expressing superiority over the client. The nurse should not read questions from the history form, as this deflects attention from the client and results in an impersonal interview process.
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 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 Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally
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.
The nurse is conducting a client interview and responds to the client in a way that encourages the client to more completely describe his or her problems. What is this called? Clarification Promoting elaboration Restatement Focusing
Promoting elaboration Explanation: Encouraging elaboration (facilitation) is a technique that assists clients to more completely describe difficulties. You use responses that encourage clients to say more and continue the conversation. This shows clients that you are interested.
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. Taking herbal supplements may be the client's mechanism for coping with stress. Abuse of herbal supplements can result in cardiac dysfunction. Taking herbal supplements is an indicator that the client is concerned with maintaining her health.
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.
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's medical record The physician The client The client's wife
The client Explanation: Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client is considered the primary source and all others (including the client's medical record) are secondary sources. In some cases, the client's immediate family or caregiver may be a more accurate source of information than the client. An example would be an older adult client's wife who has kept the client's medical records for years or the legal guardian of a mentally compromised client. In any event, validation of the information by a secondary source may be helpful.
During the comprehensive health assessment, the nurse asks several questions relating to the client's family history of illnesses, such as diabetes and cancer. Why does the nurse do this? Select all that apply. To elicit negative family history To identify genetic family trends for which the client is at risk To provide counseling and health teaching in high-risk areas To help identify those diseases for which the client may be at risk To help the client feel at ease and not worry about being sick
To help identify those diseases for which the client may be at risk To provide counseling and health teaching in high-risk areas To identify genetic family trends for which the client is at risk Explanation: The nurse asks the client about the health of close family members (i.e., parents, grandparents, siblings) to help identify those diseases for which the client may be at risk and to provide counseling and health teaching. Information concerning client and family history may be elicited to identify genetic family trends. The primary reasons are not to identify a negative family history or help the client feel at ease and not worry about being sick.
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 bad was the tingling and numbness?" "How long did the spell last?" "Where did the numbness and tingling occur?" "What other symptoms occurred during the spell?"
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.
The nurse asks a client "is there any time when you feel unsafe?" On which part of the comprehensive health history is the nurse focusing with this question? role-relationship mental health family violence self-concept
family violence Explanation: The family violence portion of the comprehensive health history focuses on personal safety. Self-concept and role-relationship are health patterns. The mental health portion of the comprehensive health history focuses on emotional and mental health.
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? adult daughter controlling the interview confused regarding dates of surgical procedures unable to recall exact date of last surgery last surgery date validated by adult daughter
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.
Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the client's quality of life. When assessing ADLs, the nurse asks if the client can grasp small objects and open jars. This is an example of assessing the client's: mobility values and beliefs self-perception home maintenance
mobility Explanation: This is an example of assessing the client's mobility. Self-perception is how the client views himself or herself. Home maintenance includes such things as housekeeping chores, cooking, shopping, and driving. Values and beliefs guide a person's choices or decisions.
During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information? cardiovascular neurologic musculoskeletal peripheral vascular
neurologic Explanation: Because the client states numbness of the hands, this information should be included under the neurologic system. Even though the symptom affects the hands, it should not be documented under musculoskeletal. This symptom is not a cardiovascular problem. Peripheral vascular is not a category within the review of systems.
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? specific questions to secure a description of every symptom pertinent positive and negative questions to determine relevant details yes-or-no questions to determine relevant areas of the physical examination open-ended questions to encourage the client to tell his or her story
open-ended questions to encourage the client to tell his or her story Explanation: 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.
A client has a 10-year history of being treated for hypertension. Where should the nurse document this information? health maintenance past medical history review of systems health patterns
past medical history Explanation: An adult medical illness is documented as part of the past medical history. Health patterns identify the client's personal/social history and daily living routines that may influence health and illness. The review of systems focuses on the presence or absence of common symptoms related to each major body system. Health maintenance is a part of the past medical history and identifies actions taken to improve or maintain health.
The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document? misses seeing friends who used to go for walks together experiences panic attacks several times a week unable to go to the gym since having back surgery gained 15 lbs. over the last 6 months
unable to go to the gym since having back surgery Explanation: The client's inability to go to the gym after having back surgery is affecting the activity-exercise health pattern. Gaining weight affects the nutrition health pattern. Panic attacks affects coping-stress-tolerance health pattern. Missing friends affects the role-relationship health pattern.
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?
· 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.
