chapter 2- weber

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

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

A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent errors?

Ask the other nurse to read back what first nurse reported

A nurse is conducting a review of systems with a client and is asking about his ears. The nurse asks, "Do you have any problems with your ears or your hearing?" The client stares blankly at the nurse a moment and then says, "I'm sorry—could you repeat that?" The nurse repeats the question, to which the client replies, "No." The nurse then asks, "Do you ever experience any trouble hearing or any ringing, buzzing, or earaches?" The client responds, "No." What should the nurse record under "Ears" in the review of systems section of the client's health history?

"Denies any trouble hearing or any ringing, buzzing or earaches"

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 with motions with that arm?"

During one of your clinical placements you encounter a patient who becomes silent during the nursing interview. What would be appropriate for you to do? (Mark all that apply.)

-Appear attentive -Give brief encouragement to the patient -Watch the patient closely for nonverbal cues

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 -Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally

a nurse is collecting data from a client during an interview (subjective data)

-clients occupation -clients family history of cancer -clients weight lifting routine

After a patient describes abdominal pain to the nurse, which questions can the nurse use to help the patient provide more information about the pain? (Select all that apply.)

-what other symptoms do you have with the pain? -where does the pain travel? -where do you feel the pain? -what makes the pain less or worse?

When interviewing a patient with a language barrier, it is best to use a family member to help interpret so the patient has a level of comfort with the process.

False

Which action should a nurse implement when assessing a non-native client to facilitate collection of subjective data?

Maintain a professional distance during assessment

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

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

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

A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client?

The client may not want her sister to know her private information

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

"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

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?

client states pain began 2 weeks ago, worse with eating, improves after a bowl movement, rates 7/10

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 nurse is collecting subjective data from a client as part of the assessment process. Which behavior is most appropriate for the nurse to display in this situation?

explaining the reason for taking down notes

How would the nursing instructor explain the goal of guided questioning to his or her students

facilitating the patients fullest communication

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?

focused

Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?

meaningful use of electronic health records

A clinic nurse is caring for a newborn and the newborn's parents. Observing parental behavior is an important nursing function during this child's well-baby visit. What would the nurse expect during observation?

parents encouraging the baby's happy behaviors

The nurse is planning to interview a client who has demonstrated manipulative behaviors during past clinic visits. During the interview process, the nurse should plan to

provide structure and set limits with the client

while interviewing an adult about her nutrition habits, the nurse should

review the choosemyplate information with the client

A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask the patient next. What is a useful interview technique for the student to use at this point?

summarization

To make legal entry into medical record, the nurse must document what

time of the assessment

a nurse has just discussed with a client the quality, severity, and location of the clients back pain. Which of the following an appropriate guideline for the nurse to follow when documenting these findings?

use phrases instead of sentences to record data

When a client reports never having had surgery, yet physical examination reveals a 10-cm abdominal scar, the nurse needs to:

validate the data

A nurse assesses a client who reports the onset of a severe headache. During which phase of the nursing interview should the nurse ask the client about the history of the present health concern and the reasons for seeking care?

working

A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered?

• A description of a large bruise on the client's thigh • The client's weight • The presence of a lump in the client's breast discovered on palpation

A nurse is gathering biographic data from a new client who is visiting the office for the first time. Which of the following pieces of data would likely be included in the biographic section of the client's health history? Select all that apply

• Lamar P. Thompson • 1212 South Maple St., Sylvan, VA 23236 • Caucasian • Occupation: Brick mason

Which of the following examples of documentation best exemplifies sound clinical documentation practices?

Non-blancing reddened area noted on medial aspects of left great toe, 1 cm of diameter