Chapter 2: Collecting Subjective Data: The interview and Health History
A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status?
"Do you live alone or with someone?"
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?"
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?"
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?"
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."
Prior to conducting an initial interview with a new client, the nurse reviews the client's chart and learns that the client has a history of presbycusis (hearing loss that occurs in older adults). What is the best action(s) of the nurse to improve communication with this client during an initial interview?
-Face the client and use low tones. -Reduce environmental noise.
Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients? Select all that apply.
-Make sure that dress and appearance are professional -Do not use facial expressions such as rolling the eyes or looking bored or disgusted -Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally
A nurse who may be shy in social situations may exhibit excellent therapeutic communication by what? Select all that apply.
-Using silence -Using touch -Communicating nonverbally through facial expression
A nurse is running late after a quarterly quality improvement meeting at the hospital and has just been paged from the nurses' station. A client's relative wants to talk as soon as possible about the client's care. The nurse has clinic duty this afternoon and is about to see the first client. The first appointment time slot is double-booked, and three other clients have arrived, all of whom are sitting in the waiting room. Which of the following demeanors is consistent with skilled interviewing when the nurse walks into the examination room to speak with the first client at the clinic?
Calm
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
A nurse receives a report on a client admitted for the onset of lung cancer and reviews the data collected during the initial comprehensive assessment. Which information does the nurse recognize as requiring further data collection to validate?
Client denies any feelings of anxiety or distress over the diagnosis.
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.
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
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?
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.
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
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.
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.
During an interview, the client begins to talk about the frequency of being abused by a spouse. What can the nurse do at this time to acknowledge the sensitivity of the information the client is providing?
Stop documenting in order to maintain eye contact with the client.
While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose?
To clarify
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?
During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?
Working
While conducting a comprehensive health history the client says a few sentences about the current problem but then explains how her deceased mother used to have the same problem because of having diabetes. What action should the nurse take?
begin drawing the genogram
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
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
The nurse is interviewing a client in the clinic for the first time. When the client tells the nurse that he smokes "about two packs of cigarettes a day," the nurse should
encourage the client to quit smoking.
The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should
explain the role and purpose of the nurse.
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
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
The nurse has interviewed a Hispanic client with limited English skills for the first time. The nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. The nurse should
indicate acceptance of the client's cultural differences.
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.
During an initial health history, a client states, "I haven't slept in weeks." The nurse asks, "You are saying that you have not had any sleep in weeks?" What communication technique is the nurse using to obtain accurate subjective data from the client?
rephrasing
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
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.
