Chapter 2: Health History and Interview

A client states, "My wife died two months ago today." Which of the following responses would be most appropriate?

"How does that make you feel?" Rationale: The client's statement about his wife's death provides the nurse with an opportunity to gather information about the client's current state. Asking the open-ended question, "How does that make you feel?" would be most appropriate to obtain key information. Asking what the wife died from is a closed-ended question that ignores the client's feelings. Telling the client that he probably feels sad is imposing the nurse's personal values on the client. Asking the client the laundry list of feelings would be demeaning and doesn't allow the client to put his feelings into his own words.

Which observation would cause the nurse to suspect an abusive situation? Select all that apply.

A child is persistent in trying to please a parent. A caregiver of a cognitively intact older adult dominates the interview. A preschooler rubs her perineum and complains of it hurting. Rationale: Observations suggestive of possible abuse include a caregiver of a cognitively intact older adult dominating the interview, a child being persistent in trying to please a parent, and a preschooler rubbing her perineum and complaining of it hurting. Observations not suggestive of abuse include a parent allowing an adolescent to speak privately with the nurse and an explanation that is appropriate for an injury.

An older client arrives for an appointment in the community clinic. Which approach should the nurse use when communicating with this client? Select all that apply.

Speak clearly Avoid jargon Show respect Use simple terms Rationale: When communicating with an older client the nurse should speak clearly, avoid jargon, show respect, and use simple terms. The use of slang should be avoided.

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 Rationale: 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.

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?

"Do you perform any sustained or continually repetitive motions with that arm?" Rationale: Inferring information from what the client tells you and what you observe in the client's behavior may elicit more data or verify existing data. Be careful not to lead the client to answers that are not true. The question, "Do you perform any sustained or continually repetitive motions with that arm?" is open enough to not lead the client to an expected answer but narrow enough for the nurse to help elicit more information from the client about probable causes of his pain. Recommending that the client change his posture while working at the computer is premature, as the nurse has not confirmed that the computer work is the culprit. Likewise, "You work at a computer a lot, don't you?" is a leading question, as it encourages the client to answer in the affirmative. The question, "When did the pain start?" is a close-ended question; it will elicit more information from the client but is not an example of inferring.

A nurse completes an initial assessment and discusses findings with the client. What is the next best action of the nurse?

Develop a plan of care with the client. Rationale: Once the assessment has been completed, the nurse discusses the findings, validates problems, determines goals, and develops a plan of care with the client. The review of systems, validation of biographical data, and discussion of lifestyle and health practices occur during the working phase of the interview.

When beginning the collection of the client data base, which of the following would be most important for the nurse to do?

Establish a trusting relationship Rationale: 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.

The nurse uses the mnemonic OLD CART when assessing a client's symptoms. Which letter represents the area of the symptom and if it radiates?

L Rationale: The letter L represents the location of the symptom and if it radiates to another body area. The C represents the characteristic symptoms that are occurring. The D represents the duration of the symptom. The O represents the onset of the symptom.

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 Rationale: 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.

When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following?

Quote the client's words. Rationale: When recording the client's chief concern, it is preferable to quote the client's exact words whenever possible.

Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the client's quality of life. When assessing ADLs, the nurse asks if the client can grasp small objects and open jars. This is an example of assessing the client's:

mobility Rationale: This is an example of assessing the client's mobility. Self-perception is how the client 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.

A nurse conducts a health history on a new client and documents the following findings: ● Age: 45 ● Sex: male ● Allergies: penicillin (PCN), peanuts ● Medications at home: daily multi-vitamin, MDI inhalers ● PMH: chronic obstructive pulmonary disease, past smoker Based on the client's history, which of the following orders would the nurse question?

penicillin IVPB every 6 hours Rationale: The nurse would question the order for penicillin (PCN) because the client has allergies to PCN. There is no reason to question intravenous fluids at 50 mL/hr, acetaminophen for pain as needed, and nebulizer treatments.

After teaching a group of students about verbal communication techniques, the instructor determines that the teaching was successful when the students identify which of the following as an example of a closed-ended question/statement?

"Are you allergic to any medications?" Rationale: Closed-ended questions ask for specific information that can be answered with one or two words. Asking about the relationship, what the client eats in a normal day, and what the client's typical day is like are examples of open-ended questions that elicit information about the client's feelings and perceptions.

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." Rationale: 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 receives a new order for intravenous fluids (IVF) for a client. The nurse reviews the client's health history prior to administration. For which of the following findings should the nurse clarify this order?

The client has a long history of congestive heart failure and fluid overload. Rationale: A client receiving continuous intravenous fluids is at risk for fluid overload. A client with a history of congestive heart failure is at high risk for fluid overload. The nurse should clarify this order. The other options—having allergies to shellfish and iodine, family history of cardiac disease, and client's last admission date—do not affect the nurse's decision as to whether or not to administer the IVF.

A client comes to the community clinic seeking help for acute low back pain. Which type of assessment should the nurse complete for this client?

focused Rationale: A focused assessment gathers information about the current health problem. A follow-up assessment evaluates a specific problem after treatment. An emergency assessment focuses on data to quickly resolve the immediate health problem. A comprehensive assessment includes demographic data, a full description of the reason for seeking care, individual health history, family history, functional status, and a history in all physical and psychosocial areas.

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 Rationale: 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.

A client comes to the emergency department with severe abdominal pain. When performing a complete assessment, the nurse would focus on which of the following areas when covering past health history?

previous medical and surgical problems Rationale: The past health history includes asking about previous medical and surgical problems along with their dates. Aggravating factors, duration, and intensity of the pain are all part of the history of present illness.

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 Rationale: 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.

A nurse is about to obtain a health history on a client of Southeastern Asian descent who recently moved to the United States 6 months ago. Which of the following is the most important consideration the nurse must take into account when obtaining a health history?

the client's cultural norms Rationale: When obtaining a health history, especially on clients from cultures that differ from the dominant culture, the nurse needs to consider cultural norms, family, and community, because these all affect health status. Being aware of the client in context can improve client outcomes. Although the nurse would take the client's developmental or educational level into consideration when explaining procedures, these are not most important considerations. The color of the client's skin should not be a factor, except for assessment reasons; for example, darker-skinned clients may present with different signs and symptoms, such as in anemia, which is more difficult to visually detect in mucosa than in a Caucasian client.

The nurse is nearing the end of the interview. Which question(s) about the client's extracurricular activities will the nurse ask to determine the client's level of social development? Select all that apply.

"Are you involved in any community groups?" "How do you feel about your community?" "What do you do for fun and relaxation?" Rationale: Asking about involvement in community groups, how the client feels about the community, and what the client does for fun and relaxation are inquiries about social activities that assist the nurse in determining the client's level of social development. Asking about whether the client has had any major changes in the past year and the things the client does to stay healthy are not related the client's level of social development but may have been asked by the nurse when completing the health history for the client.

A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?

"Can you tell me about your sleep problem from when it started until now?" Rationale: In order to open the interview, the nurse should start with an open-ended question and then identify missing data. Asking when the sleep problem began is assessing for the onset of the problem. Asking the client to rate the sleep problem from 1 to 10 is part of assessing characteristic symptoms. Asking the client what has been tried to help with the sleep is assessing for treatments.

A client reports feeling depressed for several months since being fired from a long-term job. Which question should the nurse include when assessing this client?

"Have you thought of hurting yourself?" Rationale: If the client seems depressed, ask about thoughts of suicide: "Have you ever thought about hurting yourself or ending your life?" The severity of the depression needs to be assessed since it could be lethal. Asking about a job search or finances are not appropriate questions when a client is depressed.

A client with a long history of back pain is scheduled for back surgery. The nurse obtains the client's health history. Which of the following statements by the client requires further investigation?

"I take medication to thin my blood." Rationale: The nurse would want to find out more about the medication the client takes to thin their blood because this can cause complications during surgery, for example, excessive bleeding. Exercising every day and eating a well-balanced diet are healthy habits. The client confirming that they have had back pain for years does not need further investigation.

A client with a foot wound returns to the outpatient wound clinic for a weekly appointment and treatment. Which type of assessment should the nurse complete with this client?

Follow-up Rationale: A follow-up history is a form of a focused assessment. The client is returning to have a problem evaluated after treatment. Data is gathered to evaluate if the treatment plan was successful. A focused or problem-oriented assessment focuses on the client's current problem. The client's symptoms, age, and this history will determine the extent of the physical examination to perform. A comprehensive assessment is completed when admitting a client to a facility.

The nurse includes an assessment of the developmental level of the individual in order to: (Select all that apply.)

Individualize nursing interventions for the individual's plan of care Determine the achievement of growth and development milestones Rationale: The nurse assesses the developmental level of the individual to determine the achievement of growth and development milestones and Individualize nursing interventions for the individual's plan of care. The nurse completes the genogram as part of the Family History. Assessment of past health problems and associated medial and surgical treatments are included in the Past Health History. The nurse collects information surrounding the present illness as part of the History of Present Illness.

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. Rationale: 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.

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 Rationale: The physical appearance of the nurse sends a message to the client. Thus, it is important for nurses to ensure that their dress and appearance are professional. Facial expressions should be relaxed, caring, and interested. Facial expressions common in social situations (e.g., rolling the eyes, looking bored or disgusted) reduce trust. The nurse uses gestures intentionally to illustrate points, especially for clients who cannot communicate verbally. The nurse may point with a finger or gesture an action, such as pretending to drink or pointing to the bathroom. Gestures are purposeful rather than distracting from the communication. Therefore, laughing a lot and not making eye contact are incorrect answers.

During a comprehensive health history, a client reports smoking cigarettes for 20 years. The nurse will document this information in which of the following sections?

Past history Rationale: Assessing for risk factors as a sub-category of health maintenance falls under the past history in the comprehensive health assessment. This is where the nurse will document the client's cigarette smoking history. Present illness elaborates on the chief complaint in that it describes how each symptom of the current illness developed. The chief complaint identifies the symptoms that caused the client to seek care. In the family history section, the presence or absence of specific illnesses within the family is recorded.

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. Rationale: 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 client with a history of diabetes arrives at the clinic. During the health history, the client reports being unable to manage blood sugars. The nurse performs a comprehensive assessment and analyzes the client's lab values, which reveal slightly elevated blood glucose. What action should the nurse take?

Recommend a referral to a specialist. Rationale: The nurse should recognize when a referral is needed. Because the client is reporting difficulty managing blood glucose at home, the nurse should recommend a referral to a specialist for assistance. The nurse has already clustered and prioritized client cues. An emergent assessment is not required. There are no outcomes to evaluate at this time.

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. Rationale: Whenever the client is talking about sensitive or disturbing information, the nurse should stop documenting or move away from the keyboard and maintain eye contact with the client. The nurse should not write down the information as the client is speaking and should not continue keying the information into the electronic medical record while the client is speaking. Avoiding eye contact minimizes the importance of the information that the client is providing and should not be done.

During the comprehensive health assessment, the nurse asks several questions relating to the client's family history of illnesses, such as diabetes and cancer. Why does the nurse do this? Select all that apply.

To help identify those diseases for which the client may be at risk To provide counseling and health teaching in high-risk areas To identify genetic family trends for which the client is at risk Rationale: The nurse asks the client about the health of close family members (i.e., parents, grandparents, siblings) to help identify those diseases for which the client may be at risk and to provide counseling and health teaching. Information concerning client and family history may be elicited to identify genetic family trends. The primary reasons are not to identify a negative family history or help the client feel at ease and not worry about being sick.

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 Rationale: 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.

The nurse asks a client "is there any time when you feel unsafe?" On which part of the comprehensive health history is the nurse focusing with this question?

family violence Rationale: The family violence portion of the comprehensive health history focuses on personal safety. Self-concept and role-relationship are health patterns. The mental health portion of the comprehensive health history focuses on emotional and mental health.

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:

pregnancy, birth, and perinatal histories Rationale: When doing a health history on children, the focus should be on the pregnancy, birth, and perinatal histories. Immunizations and growth and development are also special areas of attention. Patterns of illnesses are included for older adults, and self-perception and stress tolerance are reviewed to assess the client's well-being, especially if he or she has a history of psychosocial problems. Religious and spiritual belief systems play a role during the functional health screening related to values or beliefs.