Health Assessment Chapter 2 Practice Questions

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?

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

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 should respond to a client's request to "keep what I'm about to tell you a secret" with which statement?

"I have to share the information if it reveals something that could hurt you."

Which of the following questions is most useful in the assessment of a client's diabetes management?

"What is your routine for checking your blood sugar these days?"

"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

During one of your clinical placements you encounter a client 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 client Watch the client closely for nonverbal cues

A nurse collects data about a client's family health history. Which family member's health problems should the nurse include when documenting this information in the database?

As many genetic relatives as the client can recall

The principle of confidentiality is of paramount importance in the nurse-client relationship. When should you inform the client of with whom his or her information will be shared?

At the beginning of the interview

During an interview, the nurse remains silent and nods the head periodically while the client is talking. The therapeutic communication technique the nurse is using would be:

Continuers

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

Describe how you breathe for me?

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

When interviewing, the nurse should logically move from specific to open-ended questions.

FALSE

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

Maintain a professional distance during assessment.

When using an interpreter to facilitate an interview, where should the interpreter be positioned?

Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client- A priority is for the examiner is to have a good view of the client and to avoid having to look back and forth between client and interpreter. The nurse should remember to use short simple phrases while speaking directly to the client and ask the client to repeat back what he or she understands.

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 client is being admitted for elective surgery. What should the nurse instruct the client to do to ensure that the medication history is complete?

bring all medications and preparations used to the hospital

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?

create a genogram Explanation: A genogram is a diagram of the family history. It provides a visual record that allows the provider to quickly identify disease patterns within the family. The family history does not need to be documented in a narrative note. This information is not part of the client's past medical history. It is not typically used when planning care.

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 a newly admitted client. What should be done prior to hearing the client's story?

establish the agenda for the interview

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.

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should

maintain eye contact while asking the questions from the form.

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

During an interview with an adult client for the first time, the nurse can clarify the client's statements by

rephrasing the client's statements.

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?

value-belief

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

The nurse is performing a follow-up assessment and interview of a 72-year-old woman with a history of congestive heart failure. The nurse asks the client, "Have you been experiencing any activity intolerance since I last saw you?" What would be a more appropriate way for the nurse to elicit this information?

"Has this been having an effect on your ability to carry out your routines and get around your home?"

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?" Examples of questions related to associated factors include the following: "What other symptoms occur with it? How does it affect you? What do you think caused it to start? Do you have any other problems that seem related to it? How does it affect your life and daily activities?" The question, "How bad was the tingling and numbness?" relates to severity. The question, "How long did the spell last?" relates to duration. The question, "Where did the numbness and tingling occur?" relates to location.

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 the sister to know their private information

A client with abdominal pain says that the last time it the pain occurred, over-the-counter laxatives helped. In which part of the assessment should the nurse document this information?

history of present illness

During a client interview, the nurse asks questions about the client's past health history. The primary purpose of asking about past health problems is to

identify risk factors to the client and his or her significant others

During an interview with an adult client, the nurse can keep the interview from going off course by

using closed-ended questions Use closed-ended questions to obtain facts and to focus on specific information. Closed-ended questions are useful in keeping the interview on course.

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