Chapter 2
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?
"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. (less)
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?" 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. (less)
A client who takes oral contraceptives states that she often experiences breast pain just before her menstrual cycle begins. When using the COLDSPA mnemonic to assess the client's pain, the nurse should begin by asking which of the following?
"How would you describe your pain? Is it sharp? Is it an ache?" The "C" in COLDSPA elicits the character of the client's pain. It does not address alleviating and aggravating factors or the timing. COLDSPA Character, Onset, Location, Duration, Severity, Pattern, Associated Factors C- character CHARACTERISTICS OF THE SYMPTOMS O- onset WHEN DID THE SYMPTOMS BEGIN L-location WHERE ARE THE SYMPTOMS D-duration HOW LONG DO THE SYMPTOMS LAST S-severity P-pattern WHAT MAKES THE SYMPTOMS BETTER OR WORSE A- aggrevating or alleviating factors WHAT AFFECTS THE SYMPTOMS
A client's elevated body mass index (BMI) has prompted the nurse to assess the client's activity and exercise level. Which statement would indicate to the nurse that the client is getting the recommended amount of exercise?
"I go to a step class for an hour three times a week." The recommended exercise regimen is aerobic-type exercise for 20 to 30 minutes at least three times a week. Walking on a treadmill once or twice per week, playing basketball once a week, or swimming for half an hour once a week would not fit the aerobic exercise recommendations.
The nurse is obtaining information about a client's past health history. Which client statement would best reflect this component of assessment?
"I had surgery 5 years ago to repair an inguinal hernia." The past health history focuses on questions related to the client's past from the earliest beginnings to the present. The statement about surgery would apply to this portion of the assessment. The statement about the parents and siblings would apply to the family health history. The statement about pain in urination would apply to the reason for seeking health care.
A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history?
"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 the most significant issues and answers the nurse's question "why are you here?" or "how can I help you?" The nurse may inquire later on about the client's health insurance, but not if it is adequate. Asking if the client is fairly healthy is a closed-ended question that doesn't allow the client to verbalize concerns. Asking about medications would be appropriate later on during the interview when discussing the medications that the client takes.
A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental?
"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.
"How many steps can you climb before you get short of breath?" is an example of what kind of question?
A question that elicits a graded response The nurse should ask questions that require a graded response rather than a single answer. "How many steps can you climb before you get short of breath?" is better than "Do you get short of breath climbing stairs?" This question is neither qualitative nor imprecise.
A nurse collects data about a client's family health history. Which family members' health problems should the nurse include when documenting this information in the database?
As many genetic relatives as the client can recall Both maternal and paternal genetic relatives are included in the family health history. Problems can arise in families that are not genetically based but are manifest by virtue of exposure to lifestyle practices. Parents, grandparents, aunts, uncles, and children are all included in this history. If the relative is deceased, the cause of death and age of death of the relative is recorded.
A nurse, conducting a functional assessment on an adult client, assesses overall psychosocial well-being by assessing what?
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. (less)
A nurse is assessing the effects of a broken arm on an teenaged client's functional ability. What question would be important to ask?
Does the pain keep you from studying? Pain can affect the ability to perform common movements and tasks. The nurse assesses the effects of pain on functional ability by questioning the client about sitting, rising from a chair, standing for periods, climbing stairs, shopping, driving, and participating in sports. Pain is dynamic and increases with activity.
How would the nursing instructor explain the goal of guided questioning to his or her students?
Facilitating the patient's fullest communication The main goal of guided questioning is to facilitate the patient's fullest communication. The early generation of a plan is not a paramount goal and it is incorrect to suggest particular answers to the patient.
The nurse is teaching the patient how to self-administer insulin. Which functional health pattern does this nursing intervention address?
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.
A client has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the client's complaint?
Provide a laundry list of descriptive words. Providing the client with a list of descriptive words allows the nurse to obtain the answer and reduces the likelihood of the client's perceiving or providing an expected answer. Ignoring the complaint would be inappropriate. Restating the question would be inappropriate because it may be demeaning to the client, especially since she is having difficulty in describing the complaint. Silence would be helpful if the client was having trouble organizing her thoughts.
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. 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.
What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking?
Suggest methods and provide resources to assist with smoking cessation The client will know that the nurse understands that it is hard to quit smoking if the nurse suggests methods available to help kick the smoking habit. The nurse should keep a neutral and friendly expression, and avoid any display of surprise or shock at the situation. A neutral, friendly expression will help the client to open up and explain to the nurse his efforts at breaking free from the habit. The nurse need not tell the client that excessive smoking could cause cancer, as the client will be well aware of the dangers of smoking. (less)
An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary?
The client Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client is considered the primary source and all others (including the client's medical record) are secondary sources. In some cases, the client's immediate family or caregiver may be a more accurate source of information than the client. An example would be an older adult client's wife who has kept the client's medical records for years or the legal guardian of a mentally compromised client. In any event, validation of the information by a secondary source may be helpful. (less)
A nurse is interviewing a 22-year-old client of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?
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
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 ventilate 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.
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.
decubitus on left heelThe only example of objective data is the decubitus. Subjective data are the feelings, perceptions, signs, and symptoms of the patient that an observer cannot perceive.
Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the patient's quality of life. When assessing ADLs, the nurse asks if the patient can grasp small objects and open jars. This is an example of assessing the patient's:
mobilaty This is an example of assessing the patient's mobility. Self-perception is how the patient views himself or herself. Home maintenance includes such things as housekeeping chores, cooking, shopping, and driving. Values and beliefs guide a person's choices or decisions.
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:
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. (less)
"Tell me about your pain" is an example of an open-ended question. true or false
true
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?
working During the working phase, the nurse collects data by asking specific questions. Two types of questions are closed-ended and open-ended. Each type has a purpose; the nurse chooses which type will help solicit the appropriate information. The pre-interaction phase is prior to meeting with the client. The nurse review the client's medical records to collect important data. The beginning phase is the phase when introductions are exchanged and the purpose of the interaction is explained to the client. The closing phase is a time for summarizing information shared with the client and assessing any learning deficits.
