NU210: Chapter 2 Subjective Data: The Interview & Health History

How can marital status be determined?

"Do you live alone or with someone?"

Rephrasing

A technique that helps you to clarify has started; it also enables you & the client to reflect on what was said

What occurs during the termination phase of an interview? A. Planning for follow-up care. B. Addressing topics that have not yet been addressed. C. Assessing the client's mental status. D. Letting the client know you understood all he or she has told you.

A. Planning for follow-up care. (The main activity that takes place during the termination phase is planning for follow-up and closing the interview.)

During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information? A. neurologic. B. cardiovascular. C. musculoskeletal. D. peripheral vascular.

A. neurologic. (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.)

A client is experiencing a relapse of a urinary tract infection. Which additional information should the nurse collect when discussing this client's present health problem? A. sexual history. B. family history. C. past medical history. D. health maintenance.

A. sexual history. (Although questions about sexual behavior can be used at multiple points in an interview, if the chief complaint involves genitourinary symptoms, questions about sexual health can be included as part of expanding and clarifying the client's story. The issue of repeated urinary tract infections is not appropriate when collecting data about the client's family history, past medical history, or health maintenance.)

How should an angry client be handled?

Allow client to vent feelings

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? A. Maintaining eye contact with the client at all times. B. Explaining the reason for taking down notes. C. Remaining standing during the interview. D. Reading questions from the history form.

B. Explaining the reason for taking down notes. (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.)

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

B. 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.)

During the interview of an adult client, the nurse should A. use leading questions for valid responses. B. provide the client with information as questions arise. C. read each question carefully from the history form. D. complete the interview as quickly as possible.

B. provide the client with information as questions arise. (Another important thing to do throughout the interview is to provide the client with information as questions and concerns arise. Make sure that you answer every question as thoroughly as you can. If you do not know the answer, explain that you will find out for the client. The more clients know about their own health, the more likely they are to become equal participants in caring for their health.)

How should the nurse being with questions?

Begin with non-threatning, open-ended questions. Example: Even of the nurse knows about mental illness, ask "have you ever has a problem with mental illness?"

A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems? A. "High school diploma plus 2 years of college" B. "Caregiver reliable source of information" C. "Menarche at age 13" D. "Lungs clear to auscultation bilaterally"

C. "Menarche at age 13" (A review of systems is the client's description of his or her health status for each body system. The data are given to the interviewer as it was stated. High school diploma and caregiver as a reliable source of information reflect biographical data. Lungs clear to auscultation reflect physical examination data.)

"How many steps can you climb before you get short of breath?" is an example of what kind of question? A. A question that offers multiple choices for answers. B. A question that is qualitative in focus. C. A question that elicits a graded response. D. A question that demands an imprecise response

C. A question that elicits a graded response. (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.)

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? A. adult daughter controlling the interview. B. unable to recall exact date of last surgery. C. last surgery date validated by adult daughter. D. confused regarding dates of surgical procedures.

C. last surgery date validated by adult daughter. (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.)

What does COLDSPA stand for?

Character (Describe the sign or symptom). Onset (When did it begin?). Location (Where is it?). Duration (How long does it last? Recurring?). Severity (How bad is it? Bothers you?). Pattern (What makes it better/worse?). Associated factors/Affects client (What other symptoms occur with it?). Always ask about pain medication/supplements taken.

Health patterns

Clients social/personal history & lifestyle that may influence health/illness

A client with abdominal pain says that the last time it the pain occurred, over-the-counter laxatives helped. In which part of the assessment should the nurse document this information? A. chief complaint. B. past health history. C. review of symptoms. D. history of present illness.

D. history of present illness. (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. The history of present illness includes any attempts at self-treatment for the problem. The chief complaint is the reason for the person seeking care. The past history lists childhood illnesses, adult illnesses with dates, health maintenance practices, and risk factors. The review of systems is where the presence or absence of common symptoms related to each major body system are reviewed and documented.)

During a client interview, the nurse asks questions about the client's past health history. The primary purpose of asking about past health problems is to A. determine whether genetic conditions are present. B. summarize the family's health problems. C. evaluate how the client's current symptoms affect his or her lifestyle. D. identify risk factors to the client and the client's significant other, if any.

D. identify risk factors to the client and the client's significant other, if any. (The past health history focuses on questions related to the client's personal history, from the earliest beginnings to the present. These questions elicit data related to the client's strengths and weaknesses in his or her health history. The information gained from these questions assists the nurse in identifying risk factors that stem from previous health problems. Risks may be to the client or to significant other. The taking of past health history may collect information on how past life events impact the client's current health status, but it does not relate to how the client's current symptoms are affecting the client's lifestyle. It may suggest the possibility of a genetic etiology to health issues but does not determine this. The focus is not on the client's family.)

How can a nurse start to collect information about a clients culture, ethnicity, & subculture?

Date & place of birth, Nationality/ethnicity, Marital status, Religious/Spiritual practices, Primary/Secondary languages.

Genogram: circle with X in it

Deceased female relative

Genogram: box with X in it

Deceased male relative

Past medical history

Documented medical illness

Examples of Non-verbal communication to gain trust

Dress professionally, Gestures to illustrate points, No eye rolling or looking bored or disgusted.

Encouraging elaboration

Encourage client to go into more detail

Active listening

Focus on client & perspectives, decode messages like thoughts, words, opinions, & emotions

3 variations of communication during an interview

Gerontologic, Cultural, & Emotional

What is the goal of guided questioning?

Getting the fullest communication

Restatement

Have client elaborate on original statement

Working Phase of the Nursing Interview

Health History: Biographical data, Reasons for seeking care, History of present health concern, Past health history, Family history, Review of systems (ROS) for current health problems, Life style & health practices, Developmental level. Interpret & validate information. Identify problems & goals.

History of present illness

How each symptom developed & how they are associated to the chief complaint. Clients thoughts & feelings, relevent ROS, meds, allergies, & lifestyle related to the illness.

Personal health history

Information provided by the client about past illness

Where should the interpreter be in relation to the nurse?

Interpreter should be next to the client so examiner can keep eye contact & nonverbal cues with client

Introductory Phase of the Nursing Interview

Introduce yourself, Explain the purpose of the interview, Discuss the types of questions, Explain the reason for taking notes, Assure that information will remain confidential, Develop trust & rapport.

What happens in the bringing phase?

Introduction, privacy, relax client

How can the nurse modify the environment for a client that is a little hard of hearing?

Limit background noise

Genogram: circle

Living female relative

Genogram: box

Living male relative

What should clients food intake be compared to?

MyPlate

Biographical data

Name, Address, Phone number, Gender, Who provided information, Birth date, SSN, Medical record number, Health insurence information, etc.

What does it mean when a patient has numbness?

Neurologic

When a patient denies something, what should be done?

Note clients denial of signs, symptoms, diseases, or problems asked about

Summary & Closing Phase of the Nursing Interview

Nurse summarizes information obtained in the working phase & validates problems and goals. Discuss ways to resolve the problem (client concerns & collaborative problems). Ask of anything else concerns the client.

What does IPV include?

Physical, psychological, economic, & sexual abuse

Review of systems

Presence/absence of common symptoms related to body systems are reviewed & documented

What happens in the Preinteraction phase?

Prior to meeting the client & collect medical record

How is stress & copping investigated?

Questions to find causes of stress & how they respond. "How do you manage your stress?"

Chief complaint

Reason for seeking care

What should the nurse be aware of when speaking to a client?

Recognize how your own thoughts & feelings could impact a patient in a vulnerable place

How should nurses facial expressions be?

Relaxed

Preintroductory Phase of the Nursing Interview

Review medical record

What happens in the closing phase?

Review of interview, summary of problems, questions

How can the nurse stay on subject?

Summarize the first 5 min & try to focus on 1 part of what was said

Reflection

Summarizing clients words to find meaning

What should a nurse do when a client has limited vocabulary?

Use basic terminology