Chapter 2

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? "Our schedule is very busy also. We got to you as soon as we could." "No one is forcing you to be here, and you are free to leave at any time." "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."

"You're certainly justified in being upset, but I am ready to begin your exam now." 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.

Learning about the effects of the illness does what for the nurse and the patient? Gives them the basis to establish a trusting relationship Gives them each a better understanding of the other Gives them the ability to communicate better Gives them the opportunity to create a complete and congruent picture of the problem

Gives them the opportunity to create a complete and congruent picture of the problem

The nurse is teaching the patient how to self-administer insulin. Which functional health pattern does this nursing intervention address? Health perception-health management Role-relationship Coping/stress tolerance Cognition-perception

Health perception-health management Teaching a client to self-administer insulin would be a nursing intervention addressing the health perception-health management pattern. The health perception-health management pattern assessing the patient's ability perceptions of their health and practices they perform to maintain and promote their health. The Role-Relationship pattern assesses the patient's ability to fulfill personal roles and the relationships they have with family and others. The coping-stress tolerance pattern includes the patient's general coping pattern and their effectiveness in handling stress. Sensory perceptions and though patterns are included in the cognition-perception functional health pattern.

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? C D L O

L 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.

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? Identifying data Reliability Review of systems Personal and social history

Personal and social history Health-maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety are components of the client's personal and social history.

The patient is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the patient, the nurse is obtaining what other type of data from the patient? Secondary Objective Primary Tertiary

Primary Subjective data given by the patient are considered primary data. Charts and family are sources of secondary data, while objective data are based upon tests, vital signs, and examinations. At present, no data are called tertiary

The nurse is conducting a patient interview and responds to the patient in a way that encourages the patient to more completely describe his or her problems. What is this called? Promoting elaboration Restatement Focusing Clarification

Promoting elaboration Encouraging elaboration (facilitation) is a technique that assists patients to more completely describe difficulties. You use responses that encourage patients to say more and continue the conversation. This shows patients that you are interested.

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 Summarize the patient's words Paraphrase the patient's words Describe the patient's concerns and health goals

Quote the patient's words When recording the patient's reason for seeking care (chief concern), it is preferable to quote the patient's exact words whenever possible.

A comprehensive health history includes which components? Select all that apply. Reason for seeking care History of present illness Past health history Employment history Income

Reason for seeking care History of present illness Past health history Usually the nurse collects demographical data first and then elicits from clients a complete description of their reason for seeking care, because that information usually is most important. The nurse collects information about the present illness by beginning with open-ended questions and having clients explain symptoms. A complete description of the present illness is essential to an accurate diagnosis.

During a health history a client recalls the date when being first diagnosed with hypertension. Which term should the nurse use to categorize the quality of the client's data? reliable puzzling concerning questionable

Reliable The client's memory is intact and would be considered reliable. The terms puzzling, concerning, and questionable would not apply because the client was able to provide an exact date.

The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data? "Do you always wear your seatbelt when driving?" "How much beer, wine, or alcohol do you drink?" "Do you use condoms with each sexual encounter?" "Could you describe how you perform self-breast exams?"

"Could you describe how you perform self-breast exams?" 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 correct 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.

Which of the following questions would be most important for the nurse to ask first when obtaining the health history? "Do you have adequate health insurance coverage?" "Are you generally fairly healthy?" "What is your major health concern at this time?" "Did you bring all your medications with you?"

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

When beginning the collection of the client data base, which of the following would be most important for the nurse to do? Establish a trusting relationship Determine the client's strengths Identify health problems Make inferences

Establish a trusting relationship 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 client admitted to the health care facility for new onset of abdominal pain expresses to nurse that they were treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information? History of present illness Review of Systems Chief complaint Past health history

Past health history The chief complaint is the abdominal pain. Any associated symptoms would be a part of the history of present illness. The information provided by the client about a past illnesses in the past are part of the past health history. Review of systems provides specific questions about past illnesses that might still be impacting the client.

You are taking a health history on a new patient. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the significance of this information to the health history? The patient may be at risk for developing diabetes. The patient may need teaching on preventing diabetes. The patient may need to attend a support group for diabetes. This may affect the patient's diet during hospitalization

The patient may be at risk for developing diabetes. Nurses incorporate a genetics focus into the health assessments of family history to assess for genetics-related risk factors. The information aids the nurse in determining if the patient may be predisposed to diseases that are genetic in origin.

A nurse has completed assessment of a client and is now validating the information gathered and reviewing goals with the client. Which phase of the interview process is this? Introductory termination Analysis Working

termination During the summary and termination, the nurse summarizes information obtained during the working phase and validates problems and goals with the client. In the introductory phase, the nurse meets the client and explains the purpose of the interview, discusses what type of questions will be asked, explains reasons for taking notes, and assures the client that confidential information will remain confidential. Analysis is not a phase of the interview process. The working phase is when data collection occurs.

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus? sleep-rest activity-exercise coping-stress-tolerance self-perception/self-concept

Coping-stress-tolerance 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.

When the nurse is conducting the health history, when would be the most natural time to ask the client about alcohol use? after asking about cigarette smoking after asking about previous surgeries after discussing reactions to allergens after reviewing current medications

after asking about cigarette smoking The most natural time to discuss alcohol use with the client during the health history is after cigarette smoking has been discussed. This part of the health history provides the nurse with information about risk factors in the context of health maintenance. Allergies and medications are often discussed together because it is common to have a medication allergy. Previous surgeries are reviewed when discussing the history of childhood or adult illnesses.

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. When interacting with an angry client approach this client in a calm, reassuring, in-control manner. Allow him to ventilate feelings.

The nurse is preparing to interview a client with a history of sexual abuse. What technique should the nurse use when conducting this interview? avoid eye contact be nonjudgmental ask direct questions skip the sexual history

be nonjudgmental The most important thing for the nurse to do when broaching a sensitive topic is to be nonjudgmental. Avoiding eye contact may communicate something different to the client. Asking direct questions may be intimidating. Skipping the sexual history would not ensure that a thorough comprehensive interview was conducted.

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?" 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 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?" 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 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? "How often do your adult children typically visit you?" "Your husband's death must have been very difficult for 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." 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.

While completing a history of present illness the nurse asks the client about risk factors. In which way should the nurse use this information? Use to determine health teaching to prepare Speculate a genetic reason for the health problem Determine if a family history of the problem exists Analyze as a contributing factor to the current problem

Analyze as a contributing factor to the current problem Risk factors or other pertinent information related to the symptom is frequently relevant, such as risk factors for health problem or a current medication that may have side effects similar to the complaint. Risk factors are not used to determine health teaching, identify a genetic cause, or determine if a family history of the problem exists.

While gathering data for the family history portion of the health history, what would you ask about? Coronary artery disease Low bone density Liver disease Injuries

Coronary artery disease 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 patient.

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? History of present health concern Personal health history Family health history Lifestyle and health practices profile

Lifestyle and health practices profile 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.

Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data? Speak to the client using local slang. Maintain a professional distance during assessment. Avoid any eye contact with the client. Ask one of the client's children to interpret.

Maintain a professional distance during assessment. 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.

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? Preinteraction Beginning Working Closing

Preinteraction Before meeting with the client, the nurse collects data from the medical record, including the previous history of medical illnesses or surgeries, current medication list, and problem list. The nurse uses this information to conduct an interview, already knowing about some of the past problems and responses to treatments. The beginning phase of the interview process is when introductions are exchanged and the nurse explains the purpose of the interview process. The working phase of the interview process is when data is collected from the client, either in subjective or objective form. The closing phase of the interview process is when the nurse summarizes the interview, assessing for any issues or concerns that need to be addressed either at that time, or in the future.

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 introductory. ongoing. working. closure.

working. 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.

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? treatment associated manifestations onset duration

treatment 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 states, "My wife died two months ago today." Which of the following responses would be most appropriate? "What did she die of?" "How does that make you feel?" "You probably must be sad." "Are you feeling sad, depressed, angry, or upset?"

"How does that make you feel?" The client's statement about his wife's death provides the nurse with an opportunity to gather information about the client's current state. Asking the open-ended question, "How does that make you feel?" would be most appropriate to obtain key information. Asking what the wife died from is a closed-ended question that ignores the client's feelings. Telling the client that he probably feels sad is imposing the nurse's personal values on the client. Asking the client the laundry list of feelings would be demeaning and doesn't allow the client to put his feelings into his own words.

Which response by the patient is appropriate when the nurse asks the patient to identify a functional goal related to the patient's left hip pain? "I want to be able to sleep on my left side." "My pain is a 7 all the time." "Climbing stairs makes my pain worse." "I think about sitting on the beach."

"I want to be able to sleep on my left side." A functional goal reflects a specific activity or task the patient would like to accomplish. The patient wanting to sleep on the left side is an example of a functional goal. A pain rating of 7 describes the intensity of the patient's pain. Climbing stairs is an aggravating factor. An example of an alleviating factor is the patient thinking about sitting on the beach.

A nurse in the ED is assessing an adult client who, the nurse suspects, has been beaten by her husband. What is the nurse's legal obligation in this situation? Report it to the nurse's supervisor Call the police Counsel the client Do not pursue the situation unless the client asks for help

Report it to the nurse's supervisor When abuse is suspected, nurses are obligated to report it to a supervisor and obtain assistance from social work for further assessment. It is not necessary to call the police or counsel the client, but it is necessary to pursue the situation even if the client does not ask for help.

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 2 to 3 beers every weekend? Do you drink alcohol when you are supposed to be working?

When was your last drink? "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.

The nurse prepares to complete a past medical history with a client. Which areas should the nurse include in this history? (Select all answer choices that apply) Location Allergies Medications Adult illnesses Exacerbating factors

Allergies Medications Adult illnesses Key elements of the past history include allergies, medications, and adult illnesses. Location and exacerbating factors are a part of the history of present illness.

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? "I recommend that you change your posture while working at the computer." "You work at a computer a lot, don't you?" "When did the pain start?" "Do you perform any sustained or continually repetitive motions with that arm?"

"Do you perform any sustained or continually repetitive motions with that arm?" 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.

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? "I recommend that you change your posture while working at the computer." "You work at a computer a lot, don't you?" "When did the pain start?" "Do you perform any sustained or continually repetitive motions with that arm?"

"Do you perform any sustained or continually repetitive motions with that arm?" 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. Reference:

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? "What was the cause of your wife's death?" "How does that make you feel right now?" "You probably must be sad." "Are you feeling sad, depressed, angry, or upset?"

"How does that make you feel right now?" The client's statement about his wife's death provides the nurse with an opportunity to gather information about the client's current state. Asking an open-ended question such as "How does that make you feel?" would be most appropriate to obtain key information. Asking what the wife died from is a closed-ended question that ignores the client's feelings. Telling the client that he probably feels sad is imposing the nurse's personal values on the client. Asking the client the laundry list of feelings would be demeaning and doesn't allow the client to put his feelings into his own words.

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." 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 Restatement Reflection Encouraging elaboration (facilitation)

Active listening Active listening is the ability to focus on the client and their perspectives. It requires the nurse to constantly decode messages including thoughts, words, opinions, and emotions. 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.

During an interview, the nurse remains silent and nods the head periodically while the patient is talking. The therapeutic communication technique the nurse is using would be: Reflection Validation Summarization Continuers

Continuers The nurse who uses gestures, posture, silence, and head nodding is using cues for the patient to continue or continuers. Reflection is repeating the patient's last words to encourage the patient to express both factual details and feelings. Validation is a way to make a patient feel affirmed to acknowledge the legitimacy of an emotional experience. Summarization is providing a review of the patient's story during the interview.

A nurse, conducting a functional assessment on an adult client, assesses overall psychosocial well-being by assessing what? Past history/genetic influence Coping/stress tolerance Family/friends Sleep/dreaming

Coping/stress tolerance The nurse assesses overall psychosocial well-being as part of the screening of the functional health patterns, including self-perception/self-concept, roles/relationships, and coping/stress tolerance. The nurse obtains detailed information when the client has a history of psychosocial problems or indicators of current distress. The other options are not part of an overall psychosocial well-being assessment.

A nurse is eliciting a client's health history and the client asks, "Can I take the herb ginkgo biloba with my other medications?" What action would be best if the nurse is unsure of the answer? Explain that you will find out the information for the client. Change the subject and return to this topic later. Teach the client to only take prescribed medications. Encourage the client to ask the pharmacist or primary care provider.

Explain that you will find out the information for the client. The nurse should address all questions asked by a client as best as possible and should make every effort to find unknown answers. Ignoring the question and telling the client to ask the pharmacist interferes with trust and does not ensure adequate follow-up. Telling the client to take only prescribed medication ignores the client's feelings and may not be accurate.

During a health history, a client reports drinking bloody Mary's several mornings a week before going to work. In which part of the CAGE questionnaire should the nurse document this information? Annoyance Eye-openers Cutting down Guilty feeling

Eye-openers The client drinking alcohol in the morning would be applicable to the area on eye-openers specifically the question "Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? This information is not applicable to the other areas of the CAGE questionnaire, specifically, annoyance, cutting down, or guilty feelings.

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 Health patterns History of present illness

History of present illness 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.

When using an interpreter to facilitate an interview, where should the interpreter be positioned? Behind the examiner, so the interpreter can pick up the movements of the lips of the client and the client's nonverbal cues Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client Between the examiner and the client, so all parties can make the necessary observations In a corner of the room, so as to provide minimal distraction to the interview

Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client A priority is for the examiner is to have a good view of the client and to avoid having to look back and forth between client and interpreter. The nurse should remember to use short simple phrases while speaking directly to the client and ask the client to repeat back what he or she understands.

The nurse knows that the reason for a complete health assessment in regard to any client is to? Select all that apply. (Select all that apply.) Obtain accurate and complete data Plan interventions Help the nurse diagnose the client's illness Validate laboratory results Complete a family history

Obtain accurate and complete data Plan interventions The reason for completing the assessment is to have data that are accurate and complete so that a plan can be developed with interventions that promote health. A nurse does not complete the assessment to help the nurse diagnose the illness, validate laboratory results, or complete a family history.

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? Preinteraction Beginning Working Closing

Preinteraction Before meeting with the client, the nurse collects data from the medical record, including the previous history of medical illnesses or surgeries, current medication list, and problem list. The nurse uses this information to conduct an interview, already knowing about some of the past problems and responses to treatments. The beginning phase of the interview process is when introductions are exchanged and the nurse explains the purpose of the interview process. The working phase of the interview process is when data is collected from the client, either in subjective or objective form. The closing phase of the interview process is when the nurse summarizes the interview, assessing for any issues or concerns that need to be addressed either at that time, or in the future. Reference:

The nurse is interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of guided questioning? Use directed questioning: start with the general and proceed to the specific in a manner that does not make the client give a yes/no answer. Reassure the client that the urinary symptoms are most often treated successfully. Offer the client multiple choices to clarify the character of the urinary symptoms that she is experiencing. Ask the client to tell you exactly what she means when she states that she has a urinary tract infection.

Reassure the client that the urinary symptoms are most often treated successfully. Reassurance is not part of clarifying the client's story; it is part of establishing rapport and empathizing with the client.

An older adult client is brought to the ED. The client tells the nurse, "I feel like something really heavy is sitting on my chest." The nurse then says to the client, "You feel as if something heavy is sitting on your chest?" Of what type of nurse-client communication is this an example? Restatement Active listening Encouraging elaboration Reflection

Restatement Restatement relates to the content of the communication. The nurse makes a simple statement, usually using the words of client. The purpose is to ask client to elaborate. Active listening is a communication skill where the listener uses both verbal context and nonverbal signals to interpret the message. Encouraging elaboration, also known as facilitation, uses therapeutic response from the listener to encourage the client to respond in more detail. Reflection is the summarizing of the main themes of the communication that occurred.

While interviewing a patient, the nurse asks, "What happens when you have low blood glucose?" This type of response to the patient is used for what purpose? To summarize the conversation To restate what the patient has said To promote objectivity To clarify

To clarify Another way to clarify is to ask, "What happens when you get low blood sugar?" Such questions prompt patients to identify other symptoms or give more information so that you can better understand the situation.

The nurse is the primary care provider for a 21-year-old man who, as the result of a brain injury suffered in a mountain-biking accident in his teens, has the cognitive abilities of a 9-year-old. How should the nurse accommodate the client's cognition and comprehension during assessment? Rely on the client's documented history rather than the client interview. Perform objective assessments rather than eliciting subjective information. Use the client's family as a source of information. Address interview questions to the client's mother rather than the client.

Use the client's family as a source of information. Limitations on intelligence often require the clinician to use the client's family as a source of assessment data, though it is still appropriate to direct questions to the client himself. It would be simplistic to downplay the interview and rely solely on the written history or to categorically reject subjective assessment.

A nurse is interviewing a client with a different cultural background. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment? Standing while the client is seated Using a moderate amount of eye contact Sitting across the room from the client Minimizing facial expressions

Using a moderate amount of eye contact 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 as the client. Standing while the client is seated puts the nurse in a superior position, 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.

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? risk factors health maintenance s creening test completion compliance with treatment

health maintenance 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

The nurse understands that health promotion is a very important part of nursing care. When performing the health history, there are many different opportunities for the nurse to teach healthy behaviors. One way the nurse can do this is by focusing on which of the following topics: gender spirituality culture sexual history and pattern

sexual history and pattern There are many opportunities for the nurse to promote healthy behaviors. When assessing high-risk patients with multiple partners, the nurse can seize this opportunity to provide information that can prevent disease and illness. Gender, culture, and spirituality are not generally factors in teaching about health promotion.