PrepU Chapter 2: Collecting Subjective Data: The Interview and Health History
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?
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.
A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned?
Seated in a chair at eye level with the client Explanation: To facilitate optimal eye contact, the nurse needs to be at eye level with the client. Those who stand while clients are in bed will be taller than clients, assuming a position of power. Thus, the nurse should be seated in a chair at eye level with clients who are in bed during interviews. Leaning on the nightstand and sitting on the bed do not promote therapeutic communication or professionalism.
A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?
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.
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.
The nurse is performing a follow-up assessment and interview of a 72-year-old woman with a history of congestive heart failure. The nurse asks the client, "Have you been experiencing any activity intolerance since I last saw you?" What would be a more appropriate way for the nurse to elicit this information?
"Has this been having an effect on your ability to carry out your routines and get around your home?" Explanation: When initiating an interview, it is important to use language that is understandable and appropriate to the client. "Dyspnea," "SOB," and "activities of daily living" are potentially unclear to a client and reflect clinical language rather than clear communication.
How would the nursing instructor explain the goal of guided questioning to his or her students?
Facilitating the client's fullest communication Explanation: The main goal of guided questioning is to facilitate the client's fullest communication. The early generation of a plan is not a paramount goal and it is incorrect to suggest particular answers to the client.
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 Explanation: 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 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. 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 nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?
Ask the client to repeat the statement or question. Explanation: The nurse should ask clients to repeat questions or statements if the nurse is unable to understand what the client said. The nurse can also paraphrase client responses to verify understanding.
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?" 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.
During an interview, how can the nurse best assist the client as the client tells their story?
Avoid interrupting the client. Explanation: Correcting the client when they make erroneous statements and suggesting information the client has appeared to have forgotten are both actions that bias the client's story. The nurse should avoid biasing the client's story with unnecessary interruptions, corrections, or suggestions about missing information. Detailed closed or focused questioning should be introduced after the client has finished sharing their story.
Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client did not want to wait. The nurse has heard about this client many times from colleagues and is aware that she is very talkative. Which of the following is a helpful technique to improve the quality of the interview for both provider and client?
Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed. Explanation: The nurse can also say, "I want to make sure I take good care of this problem because it is very important. We may need to talk about the others at the next appointment. Is that OK with you?" This is a helpful technique that can help the nurse to change the subject, but at the same time, validate the client's concerns; this can provide more structure to the interview.
The nurse is conducting an initial interview with a client. During the introductory phase, it is essential that the nurse perform which of the following actions? Select all that apply.
Build rapport. Provide a comfortable environment. Explain the purpose of the interview. Ensure confidentiality. During the introductory phase of the interview, it is essential that the nurse gain the client's trust and build rapport, provide a comfortable physical and emotional environment, explain the purpose of the interview, and ensure information will remain confidential as per HIPAA (Health Insurance Portability and Accountability Act) guidelines. Summarizing findings occurs during the summary and closing phase of the interview.
The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document?
unable to go to the gym since having back surgery 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.
What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?
Closing the door may help to limit background noise. Closing the door may help to limit background noise, making it easier for the client to hear. Not all clients with minimal hearing loss wear hearing aids. Pre-written questions and hand gestures are interventions reserved for those diagnosed with severe hearing limitations.
What occurs during the termination phase of an interview?
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.
A client's spouse answers the interview questions and will not leave the examination room. What should the nurse suspect may be occurring with the client?
intimate partner violence Explanation: Intimate partner violence should be considered if the partner tries to dominate the interview and will not leave the room. Intimate partner violence can include physical abuse, psychological abuse, economic abuse, and sexual abuse. The client may or may not have low self-esteem or a cognitive or mental health disorder; the partner's behavior is not evidence for these conditions.
During an interview with an adult client for the first time, the nurse can clarify the client's statements by
rephrasing the client's statements. Explanation: Rephrasing information the client has provided is an effective way to communicate during the interview. This technique helps you to clarify information the client has stated; it also enables you and the client to reflect on what was said.
The nurse is caring for a client in the health care provider's office. In reviewing the client's chart, the nurse recognizes the need for providing the client with additional education related to COVID-19 when noting which of the following about the client?
Works in the service industry Explanation: Health disparities that came to the forefront during the COVID-19 pandemic included underrepresented groups and people living in low-income households who were more likely to work in the service industries that remained open during the pandemic. Having high income, low blood pressure, and a diet low in carbohydrates are not factors associated with increased risk for COVID-19.
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?
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.
The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus?
coping-stress-tolerance 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.
A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?
create a genogram Explanation: A genogram is a diagram of the family history. It provides a visual record that allows the provider to quickly identify disease patterns within the family. The family history does not need to be documented in a narrative note. This information is not part of the client's past medical history. It is not typically used when planning care.
A client will require an extended period of intense physical therapy after having a compound fracture of the femur surgically repaired. What question should the nurse ask when assessing the client's perception of the injury and recovery plan? (Select all that apply.)
"How does experiencing such a trauma make you feel?" "How do you plan to support yourself financially while you recover?" "What frustrations are you experiencing since your accident?" "What do you expect from the physical therapy you will have?" It is important for the nurse to understand how the client perceives/views the illness they have experienced. Their perception helps the nurse identify their needs and so directs their plan of care. The client's feelings about the injury as well as their expectations about recovery are relevant and should be a focus on the nurse's questions. It is also important to understand the client's viewpoint regarding how the situation affects their ability to function daily and the types of frustrations they are experiencing. A question about the sensation of pain when the injury occurred does not provide an understanding of the client's perspective on an illness.
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?
"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.
Which of the following questions is most useful in the assessment of a client's diabetes management?
"What is your routine for checking your blood sugar these days?" Explanation: "What is your routine for checking your blood sugar these days?" is an open-ended question designed to elicit as much information as possible about how the client is monitoring blood sugar. The other choices are leading questions that clearly signal a "right" answer; the client might feel reluctant to respond "incorrectly." These questions also elicit yes-no responses; closed-ended questions such as these are appropriately used to clarify or obtain more accurate information about issues disclosed in response to open-ended questions.
A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?
"What other symptoms occurred during the spell?" 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?"
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?
"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.
A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format of representing a deceased female relative?
Circle with a cross Explanation: The standard format of 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 nurse has been assigned to a group of clients on a medical surgical unit. What is the best action of the nurse prior to receiving a report on these clients?
Conduct a brief review of the client's charts. Explanation: During the pre-introductory phase of the interview, the nurse should review the client's chart. Information from the chart may assist the nurse with conducting the interview. Physical assessment is conducted during the working phase of the interview. The introduction is done during the introductory phase of the interview. Validating problems and goals is performed during the summary and closing 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's data, which of the following actions should the nurse prioritize?
Establishing 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.
When interacting with a client, what conveys the extent of interest, attention, acceptance, and understanding of the nurse? (Select all that apply.)
Eye contact Gestures Posture Tone of voice Consciously or not, the nurse sends messages through both words and behavior. Posture, gestures, eye contact, and tone of voice all convey the extent of interest, attention, acceptance, and understanding.
The nurse is reviewing a new client's chart prior to the initial interview. The chart reveals the client has a visual impairment. What actions should the nurse take to ensure a successful interview?
Knock and announce self before entering the client's room. Explanation: Reviewing a client's chart prior to an initial interview will provide the nurse with information that may improve their first encounter and build rapport; for example, if the nurse is aware of a visual deficit, interventions can be implemented from the start of the interview process to ensure a successful interview. The nurse should always announce self at the door before entering a client's room. This is especially important if the client has a sensory deficit such as vision or hearing. If the nurse enters the room unannounced it might startle the client. There is no need to speak loudly while approaching a client with a visual deficit. The nurse should approach the client on their unaffected side but should have announced self before entering the room. Turning the lights on is not necessary in this situation; however, if the client has a hearing deficit, good lighting would be needed for the client to read the nurse's lips.
Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data?
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 admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?
Personal health history Explanation: 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 illness would be part of the personal health history. Review of systems provides specific questions about past illnesses that might still be impacting the client.
A nurse in a clinic is preparing to meet with a new, 35-year-old male client. Complete the following sentence by choosing from the lists of options.
Prior to meeting the new client, the nurse should first review the client's medical record and then explain the purpose of the interview Explanation: Prior to meeting with the client, the nurse should first review the client's chart, in particular the client's past medical history. After reviewing the client's chart, the nurse should introduce themselves and let the client know their role and what to expect during the interview and assessment. Conducting a comprehensive phone interview would not be appropriate unless the client was unable to attend the clinic and arrangements for a phone or video appointment were agreed upon. Requesting that blood tests be performed prior to the appointment is premature, and would require a health care provider prescription. Speaking to family members regarding the client's visit would violate the Health Insurance Portability and Accountability Act (HIPAA). The client's past medical history is included in the client's medical record. The nurse should have already read the client's past medical history when they reviewed the client's medical record. After introducing themselves, the nurse may clarify any questions they may have about the client's past medical history.
A nurse is interviewing a 16-year-old girl regarding her health history. When inquiring about her chief complaint, the girl lowers her voice and says, "I've been with a guy recently, and I'm worried that I might have caught something from him." The nurse responds by saying, "So, you're concerned that you may have a sexually transmitted infection?" Which verbal communication technique is the nurse using here?
Rephrasing Explanation: Rephrasing information the client has provided is an effective way to communicate during the interview. This technique helps to clarify information the client has stated; it also enables the nurse and the client to reflect on what was said. Open-ended questions are used to elicit the client's feelings and perceptions, and typically begin with the words "how" or "what." The laundry list approach involves providing the client with a choice of words describing symptoms, conditions, or feelings, which reduces the likelihood of the client's perceiving or providing an expected answer. The nurse can encourage client verbalization by using well-placed phrases such as "uh-huh," "yes," or "I agree."
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. 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.
A nurse in a community clinic is attempting to collect a health history on a 26-year-old female new client who appears anxious.
To help reduce the client's anxiety, the nurse should decrease environmental stimuli, introduce oneself, explain the nurse's role, and ask simple, concise questions. explanation: With any first encounter, the nurse should introduce themselves, explain their role, and describe what they will be doing during the interview and assessment. If a client appears anxious, the nurse should ask simple, concise questions in a calm manner. The nurse should also decrease environmental stimuli to reduce anxiety. The nurse should not perform the health history at a fast pace, because this would most likely increase the client's anxiety. A client who is anxious may be unable to focus; therefore, the nurse should avoid open-ended questions and instead stick to simple, concise questions.
For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have
knowledge of his or her own thoughts and feelings about these issues. Explanation: Be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then recognize that these factors may affect the client's health and may need to be discussed with someone.
An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?
last surgery date validated by adult daughter 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.
Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms?
open-ended questions to allow full freedom of response Explanation: Open-ended questions such as "How can I help you?" should be asked by the nurse first to allow full freedom of response. 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?
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.
A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?
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
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.
