Health Assessment Prep U Chapter 2

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?"

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

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

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

As many maternal and paternal relatives as the client can recall

One technique of therapeutic communication is silence. What does silence allow the client to do?

Decide how much information to disclose.

Learning about the effect of the illness does what for the nurse and the client?

Gives them the opportunity to create a complete and congruent picture of the problem.

During a comprehensive assessment the client reports having a college education , is employed as a human resource director, and is 45 years old. Which part of the assessment should the nurse document this information?

Identifying data

A nurse assesses a client with regard to nutritional habits, use of substances, education, work, and stress levels. The nurse recognizes this as what type of information?

Lifestyle and health practices profile

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

Maintain a professional distance during assessment.

A nurse is collecting data on a licent's chief complaint, which is pain in the heel of his foot. The nurse asks the client, "When did this pain start?" Which component of symptom analysis does this questions represent?

onset

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

rephrasing the client's statements.

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.

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?"

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 nurse is discussing with a client the client's personal health history. What would be an appropriate question to ask at this time?

"What disease did you have as a child?"

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.

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

What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?

Closing the door may help to limit background noise.

During the introduction phase of the interview, the client begins to talk nonstop about health problems, family issues, and fears related to illness. What can the nurse do to control the interview process?

Courteously interrupt the client to clarify some information.

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

Create a genogram

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

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

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 client has a 10-year history of being treated for hypertension. Where should the nurse document this information?

Past medical history

A client's spouse answers the interview questions and will not leave the examination room. What should the nurse suspect be be occurring with the client?

Physical abuse

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

What is the best action by a nurse when a client has difficulty describing the chief complaint?

Provide the client with a laundry list of words to choose from

During a health history a client recalls the date when being first diagnosed with hypertension. Which term should the nurse use to categorize the quality of the client's data?

Reliable

In interviewing a client about substance use, a nurse asks her whether she takes any herbal substances. Which of the following is the best rationale for asking this question?

Some herbal supplements may interact with prescribed medications.

A student nurse is conducting her first client interview. The student suddenly draws a blank on what to ask the client 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?

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 verbalize his or her feelings

During the client interview, the nurse uses nonverbal expression appropriately when the nurse

avoids excessive eye contact with the client.

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.

The nurse is planning to interview a client who is being treated for depression. When the nurse enters the examination room, the client is sitting on the table with shoulders slumped. The nurse should plan to approach this client by

expressing interest in a neutral manner.

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.

Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients?

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

A 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

During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relived when you rested?" In what phase of the interview is the nurse involved?

Working

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

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

Describe how you breathe for me?

What type of question is asked FIRST by the nurse in order to attain a full description of the client's symptoms and to generate and test diagnostic hypotheses?

Open-ended questions to encourage the client to tell his or her story

The nurse is preparing to interview a client with a documented history of mental illness. What question should the nurse use to begin this interview?

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

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?

Active listening

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

Facilitating the client's fullest communication

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

A nurse has completed assessment of a client and is now validating the information gathered and reviewing goals with the client. Which phase of the interview process is this?

Summary

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 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 have back surgery

A client who speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room the 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 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?"

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.

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?"

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.

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

value-belief

During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed

working.

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 hear about this client many time 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.