Health Assessment Ch.2

The nurse is preparing to assess a female client's activities related to health promotion and maintenance. Which question would provide the most objective and thorough data? a) "Could you describe how you perform self-breast exams?" b) "Do you use condoms with each sexual encounter?" c) "Do you always wear your seatbelt when driving?" d) "How much beer, wine, or alcohol do you drink?"

"Could you describe how you perform self-breast exams?"

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?"

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

"How does that make you feel?"

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 do you usually eat in a typical day?" "Are both of your parents still living?" "How do you feel about having to seek health care?" "What diseases did you have as a child?"

"What diseases did you have as a child?"

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? a) Refer the client to a spiritual guide. b) Mirror the client's feelings. c) Approach the client in an in-control manner. d) Provide simple and organized information.

: Provide simple and organized information.

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? A. Follow-up B. Comprehensive C. Problem-oriented D. Focused

A. Follow-up EXPLANATION: 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.

When the nurse is conducting the health history, when would be the most natural time to ask the client about alcohol use? A. after asking about cigarette smoking B. after discussing reactions to allergens C. after asking about previous surgeries D. after reviewing current medications

A. after asking about cigarette smoking

A nurse is interviewing an adult client who had a miscarriage 3 weeks ago. The woman is crying and is having difficulty talking. The nurse moves closer and places a hand on the woman's hand. What type of communication is this? Encouraging elaboration (facilitation) Active listening Reflection Restatement

Active listening

An elderly female client is accompanied by her daughter on a visit to the health care facility. The nurse observes that the client is doing quite well, except for the use of a hearing aid. How can the nurse best facilitate the interview process with this client? A. Ask the client's daughter to be present during the interview B. Speak slowly and clearly, using straightforward language C. Occupy a position close to the client and speak softly D. Direct the questions to the daughter to enhance communication

B. Speak slowly and clearly, using straightforward language EXPLANATION: The nurse should speak slowly and clearly, using straightforward language, keeping the language as simple as possible for easy understanding. The nurse should not occupy a position close to the client and speak softly, as the client has hearing loss; in such cases, the nurse should face the client at all times and speak loudly.

A client comes to the ED complaining of chest pain. This would be considered A. objective primary data B. subjective primary data C. objective secondary data D. subjective secondary data

B. subjective primary data

A male older adult client reports a 2-week history of sleep disruption due to frequently waking up to void in the middle of the night. Where in the review of systems should the nurse document this symptom? A. NEUROLOGIC B. PSYCHOTIC C. URINARY

C. URINARY

A nurse, conducting a functional assessment on an adult client, assesses overall psychosocial well-being by assessing what? Sleep/dreaming Coping/stress tolerance Past history/genetic influence Family/friends

Coping/stress tolerance EXPLANATION: 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.

The nurse is focusing an interview on a patient's respiratory status. Which question should the nurse ask first to begin this interview?

Describe how you breath for me?

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

The nurse is in the introductory phase of the client interview. Which of the following activities would be appropriate? a) Determining the client's reason for seeking care b) Obtaining family health history data c) Explaining the purpose of the interview d) Collaborating with the client to identify problems

Explaining the purpose of the interview

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? a) Maintaining eye contact with the client at all times b) Remaining standing during the interview c) Explaining the reason for taking down notes d) Reading questions from the history form

Explaining the reason for taking down notes

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

The nurse is teaching the patient how to self-administer insulin. Which functional health pattern does this nursing intervention address? a) Role-relationship b) Cognition-perception c) Coping/stress tolerance d) Health perception-health management

Health perception-health management

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? O C L D

L- Location

A group of students is reviewing for a quiz on verbal and nonverbal communication. The students demonstrate a need for additional studying when they identify which of the following as an example of nonverbal communication? a) Laundry list b) Attitude c) Facial expression d) Silence

Laundry List --Laundry list is an example of a verbal communication technique.

A client has been admitted following an unexplained weight loss of 15 pounds over the past 3 months. How should the nurse best assess the subjective component of the client's nutritional status? a) Ask about the contents of one typical meal. b) Ask the client to explain MyPlate. c) Obtain a 24-hour diet recall. d) Elicit the client's favorite foods.

Obtain a 24-hour diet recall.

A client admitted to the health care facility for new onset of abdominal pain expresses to nurse that they were treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

Past health history

The nurse would document driving with car seatbelt fastened, bicycling with properly-fitted helmet, and installing a smoke detector in a vacation home in the client's health history under which of the following? a) Reliability b) Identifying data c) Personal and social history d) Review of systems

Personal and social history

Prior to a client interview, the nurse collects information from the client's medical record, such as prior surgeries, home medications, allergies, and past treatments. What phase of the interview process is this? a) Preinteraction b) Beginning c) Closing d) Working

Preinteraction

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? a) Rephrasing b) Well-placed phrase c) Open-ended question d) Laundry list

Rephrasing

A nurse in the ED is assessing an adult client who, the nurse suspects, has been beaten by her husband. What is the nurse's legal obligation in this situation? a) Do not pursue the situation unless the client asks for help b) Counsel the client c) Call the police d) Report it to the nurse's supervisor

Report it to the nurse's supervisor

A patient has come to the physician's office several times in the last month with a black eye, bruises, and lacerations on the lower extremities. The patient always explains having fallen and tripped. The nurse suspects abuse. The next step should be to: a) Call social services. b) Confront the patient. c) Report the findings to a supervisor. d) Call the police.

Report the findings to a supervisor.

The nurse is assessing an older adult client a hospice unit. The client cannot speak or communicate, but the client's daughter is there and answers all the questions as best as she can. What type of data source is the daughter? Secondary Subjective Primary Tertiary

Secondary

What is a key element of the history of present illness?

Self-treatment

During an interview, the patient 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 patient is providing?

Stop documenting in order to maintain eye contact with the patient.

A client reports chest pain that occurs with exercise but subsides with rest. The nurse recognizes this as what type of data? Objective Reflective Introspective Subjective

Subjective Explanation: Subjective data includes the following: sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information collected from the client. This information can be elicited and verified only by the client. Introspection and reflection are not types of data collection but ways in which a nurse can assist a client to work towards changing behaviors. Objective data are obtained by the nurse through observation using the four physical assessment techniques.

You are taking a health history on a new patient. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the significance of this information to the health history?

The patient may be at risk for developing diabetes.

While interviewing a patient, the nurse asks, "What happens when you have low blood glucose?" This type of response to the patient is used for what purpose?

To clarify

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? a) Sitting across the room from the client b) Using a moderate amount of eye contact c) Standing while the client is seated d) Minimizing facial expressions

Using a moderate amount of eye contact

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 of an interview the nurse encourages the client to continue and expand on the health issues. What technique is the nurse using? empowering empathy active listening summarizing

active listening

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.

During an interview with an adult client for the first time, the nurse can clarify the client's statements by a- offering a "laundry list" of descriptions b- rephrasing the client's statements c- repeating verbatim what the client has said d- inferring what the client's statements mean

b- 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.

A nurse in the ED is assessing an adult client who, the nurse suspects, has been beaten by her husband. What is the nurse's legal obligation in this situation? a) Do not pursue the situation unless the client asks for help b) Counsel the client c) Call the police d) Report it to the nurse's supervisor

d) Report it to the nurse's supervisor

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 a- allow the client time to calm down b- avoid discussing sensitive issues c- set time limits with the client d- explain the role and purpose of the nurse

d- explain the role and purpose of the nurse

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 heel

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: A. mobility B. self-perception C. home maintenance D. values and beliefs

mobility

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information? review of systems health maintenance health patterns past medical history

past medical history

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

A patient 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

Which factor influences the nurse's ability to individualize the health assessment? Select all that apply.

• Cultural factors • Sensory deficits • Age of individual

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. a) 1212 South Maple St., Sylvan, VA 23236 b) Lamar P. Thompson c) Caucasian d) Head and neck: sore throat and enlarged lymph nodes e) Occupation: Brick mason f) Mother: Sugar L. Thompson, died 7/14/2006 from heart attack

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

Which item would be included in a review of the neurological system? Select all that apply.

• Numbness • Loss of coordination • Memory loss

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. a) To elicit negative family history b) To provide counseling and health teaching in high-risk areas c) To help the client feel at ease and not worry about being sick d) To help identify those diseases for which the client may be at risk e) To identify genetic family trends for which the client is at risk

• 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

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? a) Those with illnesses that resulted in death or disablement b) Those with diseases that are known to have a genetic link c) Only the members with health problems that relate to the client's gender d) As many genetic relatives as the client can recall

As many genetic relatives as the client can recall

**Alexandra, 28 years old, presents to the clinic. She has abdominal pain that she describes as a dull ache, located in the right upper quadrant, and that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago; it lasts for 2 to 3 hours at a time, comes and goes, and seems to be worse a few hours after eating. The client has noticed that the pain starts after eating greasy foods, so she has cut down on this as much as she can. Initially the pain occurred once a week, but now it happens every other day. Nothing makes it better. From this description, which of the attributes of a symptom has been omitted? Timing Quality Setting in which the symptom occurs Associated symptoms and signs

Associated symptoms and signs Explanation: The interviewer has not recorded whether nausea, vomiting, fever, chills, weight loss, and so on have accompanied the pain

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

When describing the purpose for obtaining a comprehensive health history to a client, which of the following would the nurse include as primary?

Provides a focus for the physical exam.

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 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."

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? a) "What is your major health concern at this time?" b) "Are you generally fairly healthy?" c) "Did you bring all your medications with you?" d) "Do you have adequate health insurance coverage?"

"What is your major health concern at this time?"

Which of the following questions would be most important for the nurse to ask first when obtaining the health history?

"What is your major health concern at this time?"

Upon entering an exam room, the client states, "Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!" Which response by the nurse would be most appropriate? a) "You're certainly justified in being upset, but I am ready to begin your exam now." b) "No one is forcing you to be here, and you are free to leave at any time." c) "Our schedule is very busy also. We got to you as soon as we could." d) "Would you like to report your complaints to someone with power?"

"You're certainly justified in being upset, but I am ready to begin your exam now."

When interviewing a Hispanic client, the nurse enlists the assistance of a "culture broker," based on the understanding that this person's primary function is to: A) Interpret the language and culture. B) Evaluate the client's health practices. C) Teach the client about health care. D) Make the client feel comfortable and safe.

A) Interpret the language and culture.

Which of the following are aspects of the comprehensive health history? (Mark all that apply.) A. Creates platform for health promotion through education and counseling B. Obtains data to evaluate the outcomes of the plan of care C. Provides baselines for future assessments D. Strengthens the nurse-client relationship C. Is appropriate for established clients

A. Creates platform for health promotion through education and counseling C. Provides baselines for future assessments D. Strengthens the nurse-client relationship

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. A. Do not use facial expressions such as rolling the eyes or looking bored or disgusted B. Laugh a lot, which puts the client at ease C. Do not look the client in the eye D. Make sure that dress and appearance are professional E. Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally

A. Do not use facial expressions such as rolling the eyes or looking bored or disgusted D. Make sure that dress and appearance are professional E. Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally

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? A. Establishing a trusting relationship B. Determining the client's strengths C. Identifying potential health problems D. Making clinical inferences

A. 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.

The nurse prepares a genogram after collecting health history information from a client. For which part of the history is this diagram beneficial? A. Family history B. Current problem C. Social concerns D. Past medical problems

A. Family history

The nurse is completing the past medical history information with a client. Which part of the health maintenance information can the nurse assess during the review of systems? A. Screening tests B. Risk factors C. Immunizations D. Safety measures

A. Screening tests Screening tests include those for tuberculin, cholesterol, occult blood, Pap smears, and mammograms. These screening tests may be assessed during and documented in the review of systems. Risk factors, immunizations, and safety measures are assessed and documented within the past medical history information.

The nurse is caring for a client following left hip replacement. Which response by the client is appropriate when the nurse asks the client to identify a pain management goal related to the client's left hip pain? A) "I think about sitting on the beach." B) "I want to be able to sleep on my left side." C) "Climbing stairs makes my pain worse." D) "My pain is a 7 all the time."

B) "I want to be able to sleep on my left side." A functional goal reflects a specific activity or task the client would like to accomplish. The client wanting to sleep on the left side is an example of a functional goal. A pain rating of 7 describes the intensity of the client's pain. Climbing stairs is an aggravating factor. An example of an alleviating factor is the client thinking about sitting on the beach.

Which action should a nurse implement when assessing a non-native client to facilitate collection of subjective data? A) Avoid any eye contact with the client. B) Maintain a professional distance during assessment. C) Ask one of the client's children to interpret. D) Speak to the client using local slang.

B) Maintain a professional distance during assessment

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. A. "What things do you do to stay healthy?" B. "What do you do for fun and relaxation?" C. "Are you involved in any community groups?" D. "How do you feel about your community?" E. "Have you had any major changes in the past year?"

B. "What do you do for fun and relaxation?" C. "Are you involved in any community groups?" D. "How do you feel about your community?"

A nurse is eliciting a client's health history and the client asks, "Can I take the herb ginkgo biloba with my other medications?" What action would be best if the nurse is unsure of the answer? A. Change the subject and return to this topic later. B. Explain that you will find out the information for the client. C. Teach the client to only take prescribed medications. D. Encourage the client to ask the pharmacist or primary care provider.

B. Explain that you will find out the information for the client. Explanation: The nurse should address all questions asked by a client as best as possible and should make every effort to find unknown answers. Ignoring the question and telling the client to ask the pharmacist interferes with trust and does not ensure adequate follow-up. Telling the client to take only prescribed medication ignores the client's feelings and may not be accurate.

During the nurse's assessment of the client's exercise and activity habits, the client laughs and then states, "Unless you're including channel surfing, I don't really do much of anything." How should the nurse best follow up this client's statement? a) Ask the client if he understands the risk factors for heart disease and diabetes. b) Briefly describe some of the potential benefits of regular exercise. c) Document the nursing diagnosis of Risk for Activity Intolerance related to sedentary lifestyle. d) Explain to the client that he should be performing aerobic exercise for 20 to 30 minutes at least three times a week.

Briefly describe some of the potential benefits of regular exercise.

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.

The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview? A. "When was the last time you talked with a psychiatrist?" B. "Have you considered counseling for your mental problems? C. "Have you ever had a problem with mental or emotional illness?" D. "What medication do you take for your depression?"

C. "Have you ever had a problem with mental or emotional illness?"

The nurse is collecting data for a comprehensive health history on a client new to the clinic. Under what component of the health history would the nurse place data on a chronic childhood illness? A. General information B. Health maintenance C. Past history D. Risk factors

C. Past history

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? A. Pre-interaction B. Beginning C. Working D. Closing

C. Working

The nurse is preparing to interview a client with a history of sexual abuse. What technique should the nurse use when conducting this interview? A. Skip the sexual history B. Ask direct questions C. Avoid eye contact D. Be nonjudgmental

D. Be nonjudgmental

While gathering data for the family history portion of the health history, what would you ask about? A. Injuries B. Liver disease C. Low bone density D. Coronary artery disease

D. Coronary artery disease

How would the nursing instructor explain the goal of guided questioning to his or her students? a) Developing a basis for accurate health promotion activities b) Creating an opportunity for the early generation of a plan c) Facilitating the patient's fullest communication d) Providing the most plausible answer to the patient

Facilitating the patient's fullest communication

A client reports a weight loss and fatigue during the review of systems. In which area should the nurse document this information? Appetite General Gastrointestinal Rest and sleep

General EXPLANATION: Information to document under the general area includes usual weight, recent weight change, any clothes that fit more tightly or loosely than before, weakness, fatigue, or fever. Information about weight and fatigue is not documented under the gastrointestinal system. Appetite and rest and sleep are not areas within the review of systems.

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information? a) Health patterns b) Review of systems c) Initial information d) History of present illness

History of present illness

A patient comes to the Emergency Department with bruises on her upper and lower body and appears to be withdrawn. The injuries do not appear consistent with the explanations for them. The patient's boyfriend refuses to leave the examination room and is overly protective of her. The nurse suspects: a) Inability of the patient to perform ADLs b) Human violence c) Anorexia nervosa d) Hypertension

Human violence

The nurse is conducting a patient interview and responds to the patient in a way that encourages the patient to more completely describe his or her problems. What is this called? a) Promoting elaboration b) Focusing c) Restatement d) Clarification

Promoting elaboration

Which of the following actions is most appropriate for the nurse to take after completing a comprehensive health history with a client who is new to an acute care unit?

Provide health promotion education.

When recording the patient's reason for seeking care (chief concerns) during the health history, it is recommended that the interviewer:

Quote the patient's words

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

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? a) The client's medical record b) The client's wife c) The physician d) The client

The client

The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first?

The client's sensory abilities

The nurse is taking a comprehensive health history on a new patient. Why would it be essential for the nurse to obtain a complete description of the present illness? a) To obtain demographic data b) To obtain primary data c) To establish an accurate diagnosis d) To assess if the patient is a reliable historian

To establish an accurate diagnosis

A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication? a) Using a moderate amount of eye contact b) Minimizing facial expressions c) Standing while the client is seated d) Sitting across the room from the client

Using a moderate amount of eye contact

The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document?a.gained 15 lbs. over the last 6 months b.experiences panic attacks several times a week c.unable to go to the gym since having back surgery d.misses seeing friends who used to go for walks together

c.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.

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus? self-perception/self-concept sleep-rest coping-stress-tolerance activity-exercise

coping-stress-tolerance

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information? consider using it when planning care create a genogram include in the past medical history document it in a narrative note

create a genogram

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? screening test risk factors health maintenance compliance with treatment

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.

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? active listening well-placed phrasing rephrasing close-ended questioning

rephrasing

*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: a) culture b) sexual history and pattern c) spirituality d) gender

sexual history and pattern

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing? coping-stress-tolerance value-belief self-perception-self-concept role-relationship pattern

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.

A comprehensive health history includes which components? Select all that apply. a) Income b) Past health history c) Reason for seeking care d) Employment history e) History of present illness

• Past health history • Reason for seeking care • History of present illness

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.

• Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally • Make sure that dress and appearance are professional • Do not use facial expressions such as rolling the eyes or looking bored or disgusted