Nursing Health Assessment - prepU ch2

explain purpose of the interview

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?

health maintenance

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?

Provide simple and organized information.

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?

circle with a cross

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?

Do you perform any sustained or continuous movement with that arm

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?

active listening

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?

decubitus on left heel

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

emergency

A patient arrives at the Emergency Department reporting shortness of breath. She is cyanotic with bilateral wheezing. The patient begins to gasp for air and cannot speak. The nurse begins to gather information so that interventions can resolve the immediate breathing problem. Her assessment and interventions are concurrent. The nurse is performing what type of health history?

Pregnancy, birth, and perinatal histories

A woman brings her newborn to the clinic for a well-baby visit. The nurse knows that the focus of this health history should be on which of the following:

reliable

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?

Working

During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved?

preinteraction phase

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?

treatment

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?

"you seem bothered by this question"

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?

reflection

The nurse is interviewing a client. The client describes why he is visiting the clinic. The nurse then briefly summarizes the main points of what the client has just said. What type of communication is the nurse using?

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

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?

"My family doesn't deserve my bad behavior."

The nurse suspects that a client is experiencing alcohol abuse. When completing the CAGE questionnaire, the nurse can confirm the client is having guilty feelings when she makes which statement?

Quote the patient's words

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

quote the patient

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

"Let me stress the importance of being medication adherent."

Which statement made by the nurse demonstrates an understanding of the termination phase of the interviewing process?

open-ended questions to encourage the client to tell his or her story

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?

how do you manage your stress?

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

Is someone hurting you?

You are the nurse assessing an 18-year-old woman. You note bruising to the patient's upper arm that appears as fingerprints as well as yellow bruising to the lower eye. The patient makes minimal eye contact during the assessment. How might you best inquire about the bruising?

Pain rating

example of subjective data