jensen chapter 2

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?" "When did the sleep problem begin?" "How would you rate your sleep on a scale from 1 to 10?" "What have you tried to help with your sleep?"

"Can you tell me about your sleep problem from when it started until now?"

During a health history, a client asks why family information is requested. Which response should the nurse make to the client? -"It is used to predict your longevity." -"It helps determine your response to prescribed medications." -"It can help identify any illnesses that you might be at risk for developing." -"It helps determine what health problems you might be experiencing now."

"It can help identify any illnesses that you might be at risk for developing."

The nurse suspects that a client is experiencing alcohol abuse. When completing the CAGE questionnaire, the nurse can confirm the client is having guilty feelings when she makes which statement? -"In the past I've considered drinking a little less." -"My husband should stop nagging me about my drinking." -"I was worried about myself when I needed a glass of wine at 9 o'clock in the morning" -"My family doesn't deserve my bad behavior."

"My family doesn't deserve my bad behavior."

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

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

When the nurse is assessing the value-belief health patterns of a client with a poor prognosis for a diagnosis of pancreatic cancer, which question would be most appropriate to ask? "Where do you find your strength and hope?" "How have your regular routines changed?" "How well do you think you can manage your care?" "Do you feel rested after a night of sleep?'

"Where do you find your strength and hope?"

Which observation would cause the nurse to suspect an abusive situation? Select all that apply. -A pre-schooler rubs her perineum and complains of it hurting. -The explanation of an injury seems appropriate. -A caregiver of a cognitively intact older adult dominates the interview. -A parent allows the adolescent to speak privately with the nurse. -A child is persistent in trying to please a parent.

-A child is persistent in trying to please a parent. -A caregiver of a cognitively intact older adult dominates the interview. -A pre-schooler rubs her perineum and complains of it hurting.

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. -Use slang -Speak clearly -Avoid jargon -Show respect -Use simple terms

-Speak clearly -Avoid jargon -Show respect -Use simple terms

While discussing family history with a patient who is healthy except for a current UTI requiring IV antibiotics, the patient tells the nurse that he has three sisters and two brothers. Two of his sisters have died and one brother is in a nursing home after a stroke. The nurse would include the sibling group in a genogram in what manner? -3 circles and 3 squares with lines through 2 circles -3 circles and 3 squares with lines through 2 squares -3 circles and 3 squares with broken lines connecting 2 of the circles -3 circles and 3 squares with two diagonal slashed lines through lines connecting the 2 deceased siblings

3 circles and 3 squares with lines through 2 circles

Which statements provide information about a client's health maintenance? Select all that apply. -A child received immunizations based on the recommended schedule. -A female client had a mammogram 2 weeks ago. -A client recently a had lab test for liver function. -A client was hospitalized for dehydration 2 years ago. -A client had a circumcision at birth.

A child received immunizations based on the recommended schedule. A female client had a mammogram 2 weeks ago. A client recently a had lab test for liver function.

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 -Restatement -Reflection -Encouraging elaboration (facilitation)

Active listening

During an interview with a client with a language barrier, what action does the nurse take first to assure mutual understanding? -Request that a trained interpreter be available during the interview. -The interview should consist of short and simple sentences. -Ask the client to repeat back in his or her own words what was asked. -Allow extra time to develop the nurse-client relationship.

Ask the client to repeat back in his or her own words what was asked.

The nurse is assessing a female client's reproductive area during the review of systems. Which information should the nurse document within this section? (Select all answer choices that apply) Polyuria Hematuria Dysmenorrhea Age at menarche Age at menopause

Dysmenorrhea Age at menarche Age at menopause

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? Explain that you will find out the information for the client. Change the subject and return to this topic later. Teach the client to only take prescribed medications. Encourage the client to ask the pharmacist or primary care provider.

Explain that you will find out the information for the client.

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

Family history

Learning about the effects of the illness does what for the nurse and the patient? -Gives them the basis to establish a trusting relationship -Gives them each a better understanding of the other -Gives them the ability to communicate better -Gives them the opportunity to create a complete and congruent picture of the problem

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

As the nurse completes a review of systems, what is it important to ask the client regarding the review of the area of the thorax and lungs. Select all that apply. History of emphysema History of asthma Last chest x-ray Any difficulty swallowing History of tinnitus

History of emphysema History of asthma Last chest x-ray

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? -C -D -L -O

L

What occurs during the termination phase of an interview? Planning for follow-up care Addressing topics that have not yet been addressed Assessing the patient's mental status Letting the patient know you understood all he or she has told you

Planning for follow-up care

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: -Call social services. -Call the police. -Report the findings to a supervisor. -Confront the patient.

Report the findings to a 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: Report the findings to a supervisor. Call social services. Call the police. Confront the patient.

Report the findings to a supervisor.

While assessing health patterns, the nurse asks the question "If you could change anything about yourself, what would you change?" Which pattern is the nurse focusing on at this time? Value-belief Activity-exercise Role-relationship Self-perception/self-concept

Self-perception/self-concept

What information aids the nurse in assessing possible biases in the data collected in the health history? Ethnicity of patient Gender of patient Source of information Socioeconomic status of the patient

Source of information

Your new patient becomes visibly anxious during the nursing interview. You respond by telling her, "Don't worry, everything will be okay." What might this premature reassurance cause? A feeling of closeness between the patient and the nurse The nurse to shorten the interview process The blockage of further disclosures by the patient A noticeable lessening of the patient's anxiety

The blockage of further disclosures by the patient

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 client's general intelligence The presence of any phobias The client's judgment and insight

The client's sensory abilities

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 promote objectivity -To summarize the conversation -To clarify -To restate what the patient has said

To clarify

When performing an admission assessment, the nurse knows to ask about both first- and second-order relatives. Why does the nurse do this? To see how many living relatives the patient has To identify the cause of death of any aunts or uncles To identify the ages of great-grandparents To identify diseases that may be genetic

To identify diseases that may be genetic

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

Using a moderate amount of eye contact

A nurse who may be shy in social situations may exhibit excellent therapeutic communication by what? Select all that apply. Using silence Giving advice Using touch Discussing alternative treatment options Communicating nonverbally through facial expression

Using silence Using touch Communicating nonverbally through facial expression

During a health history, a client states "I want to know why my feet are swelling" whereas the primary diagnosis is arthritis. What should the nurse do with the client's statement? Write is as the chief complaint Identify it as referral information Document it within health history Designate it as a health promotion goal

Write is as the chief complaint

Which client situation would require a focused health history? a client has who has recently been diagnosed with a chronic illness a client with gastrointestinal disease with acute abdominal pain a client who just confirmed she is pregnant a client for who makes frequent hospital visits reporting the same symptom

a client with gastrointestinal disease with acute abdominal pain

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? -Restatement -Reflection -Active listening -Encouraging elaboration (facilitation)

active listening

A client reports pain as being 7 on a scale from 1 to 10. In which area of the symptom should the nurse document this information? -Onset -Location -Duration -Characteristic

characteristic

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

coping stress tolerance

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

create a genogram

The patient presents to the clinic reporting chest pain and shortness of breath. Which type of health history would the nurse would conduct? -Emergency -Comprehensive -Focused -Review of systems

emergency

A client with hypertension seeks medical attention for a new onset of a nosebleed. Which type of assessment should the nurse complete with this client? -Emergent -Follow-up -Comprehensive -Focused

focused

A client reports experiencing chest pain after eating. Which category within the review of systems should the nurse document this information? neurologic cardiovascular gastrointestinal musculoskeletal

gastrointestinal

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 -personal and social history -review of systems -physical examination

health maintenance

The nurse is completing a comprehensive assessment with a newly admitted client. In which area should the nurse document the client's list of immunizations? health patterns review of systems health maintenance past medical history

health maintenance

A client plays doubles tennis every Saturday and golfs on Wednesday afternoons. In which part of the comprehensive health history is this information utilized? -health patterns -review of systems -health maintenance -history of present illness

health patterns

A client states, "My wife died two months ago today." Which of the following responses would be most appropriate? -"What did she die of?" -"How does that make you feel?" -"You probably must be sad." -"Are you feeling sad, depressed, angry, or upset?"

how does that make you feel

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? -Silence -Facial expression -Laundry list -Attitude

laundry list

A patient with acute onset of shoulder pain is answering questions during a health history. The nurse is utilizing a mnemonic specific to the attributes of a symptom. The nurse first asks about the onset of symptoms followed by location treatment associated manifestations characteristic symptoms duration relieving/exacerbating factors

location duration characteristic symptoms associated manifestations relieving/exacerbating factors treatment

During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information? neurologic cardiovascular musculoskeletal peripheral vascular

neurologic

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? -Identifying data -Reliability -Review of systems -Personal and social history

personal and social 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: -pattern and relationship of illnesses -religious and spiritual factors -self-perception and stress tolerance -pregnancy, birth, and perinatal histories

pregnancy, birth, and perinatal histories

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? -puzzling -concerning -questionable -reliable

reliable

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. -inferring what the client's statements mean. -repeating verbatim what the client has said. -offering a "laundry list" of descriptors.

rephrasing the client's statements.

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? -Call the police -Counsel the client -Do not pursue the situation unless the client asks for help -Report it to the nurse's supervisor

report it to the nurses supervisor

During the review of systems, a client reports having difficulty with urination and with establishing an erection. Which additional information should the nurse recognize as the highest priority to assess at this time? -Lifestyle -Substance use -Sexual history -Alcohol and tobacco

sexual history

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? -Transition -Summarization -Reassurance -Termination

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's wife -The physician -The client's medical record -The client

the client

When teaching students how to perform an assessment, the nurse informs the students that the reason this information needs to be accurate and complete is: to allow for the patient to focus on the illness to develop a plan with interventions that promote health to allow for the patient to spend more time with the nurse to allow the nurse more time to know the patient

to develop a plan with interventions that promote health

When assessing the gastrointestinal system, the nurse correctly asks, "Do you have any trouble swallowing?" True False

true

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

unable to go to the gym since having back surgery

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? -psychiatric -neurologic -urinary -gastrointestinal

urinary

During an interview with an adult client, the nurse can keep the interview from going off course by using open-ended questions. rephrasing the client's statements. inferring information. using closed-ended questions.

using closed-ended questions.

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

what diseases did you have as a child

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. -ongoing. -introductory. -closure.

working

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

Maintain a professional distance during assessment

When using an interpreter to facilitate an interview, where should the interpreter be positioned? -Behind the examiner, so the interpreter can pick up the movements of the lips of the client and the client's nonverbal cues -Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client -Between the examiner and the client, so all parties can make the necessary observations -In a corner of the room, so as to provide minimal distraction to the interview

Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client

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? Identifying data Reliability Review of systems Personal and social history

Personal and social history

A nursing instructor is demonstrating to a student during clinical how to do a review of systems. When demonstrating this, the instructor will include which of the following? Check all that apply. Questions about all body systems Questions about health-promotion practices A list of all medications Teaching about areas of concern A comprehensive abuse evaluation

Questions about all body systems Questions about health-promotion practices Teaching about areas of concern

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

Reason for seeking care History of present illness Past health history

Jason, a 41-year-old electrician, presents to the clinic for evaluation of shortness of breath, which occurs with exertion and improves with rest. The shortness of breath has been occurring for several months. Initially, it happened only a few times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than 12 times a day. The shortness of breath lasts for fewer than 5 minutes at a time. The client has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. Which of the following symptom attributes was not addressed in this description? Severity Setting in which the symptom occurs Timing Associated symptoms and signs

Severity

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? -empathy -empowering -summarizing -active listening

active listening

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 -summarizing -active listening

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 verbalize his or her feelings. -offer reasons why the client should not feel angry. -provide structure during the interview. -refer the client to a different health care provider.

allow the client to verbalize his or her feelings

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." What would the nurse do next? -Briefly describe some of the potential benefits of regular exercise. -Ask the client if he understands the risk factors for heart disease and diabetes. -Tell the client to exercise 30 minutes at least 3 days a week. -Document the client's current activity level as minimal.

briefly describe some of the potential benefits of regular exercise

A victim of a house fire is admitted for possible inhalation injuries. During the admission process, which type of assessment should the nurse complete? -focused -follow-up -emergency -comprehensive

emergency

During a health history, a client reports drinking bloody Mary's several mornings a week before going to work. In which part of the CAGE questionnaire should the nurse document this information? -Annoyance -Eye-openers -Cutting down -Guilty feelings

eye openers

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 determine whether genetic conditions are present. summarize the family's health problems. evaluate how the client's current symptoms affect his or her lifestyle. identify risk factors to the client and his or her significant others.

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

A pregnant woman comes to the physician's office for her first prenatal visit. The nurse knows the importance of performing a comprehensive health history in this case and understands the following must be included (check all that apply): -information about current pregnancy -food preferences -previous pregnancies -obstetrical and gynecological history -family history

information about current pregnancy previous pregnancies obstetrical and gynecological history family history

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

maintain a professional distance during assessment

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. read the questions verbatim from the form. ask the client to complete the form. ask leading questions throughout the interview.

maintain eye contact while asking the questions from the form.

A client says that food is not important and meals are not enjoyable. Where should the nurse document this information? -past medical history -nutrition health pattern -history of present illness -gastrointestinal review of systems

nutrition health pattern

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? -History of present illness -Review of systems -Chief complaint -Personal health history

personal health 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? -Preinteraction -Beginning -Working -Closing

preinteraction

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: gender spirituality culture sexual history and pattern

sexual history and pattern

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 -have a family member present during the interview. -use standard medical terminology. -use very basic lay terminology. -show the client pictures of different symptoms, such as the "faces pain chart."

use very basic lay terminology.

A client who takes oral contraceptives states that she often experiences breast pain just before her menstrual cycle begins. When using the COLDSPA mnemonic to assess the client's pain, the nurse should begin by asking which of the following? -"Would you describe the pain as being constant or as intermittent?" -"Has the pain changed over time?" -"How would you describe your pain? Is it sharp? Is it an ache?" -"Is there anything that makes the pain worse or better?"

"How would you describe your pain? Is it sharp? Is it an ache?"

The nurse prepares to complete a past medical history with a client. Which areas should the nurse include in this history? (Select all answer choices that apply) Location Allergies Medications Adult illnesses Exacerbating factors

Allergies Medications Adult illnesses

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

As many genetic relatives as the client can recall

A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative? Simple circle Simple square Circle with a cross Square with a cross

Circle with a cross

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 your congestive heart failure been affecting your activities of daily living recently?" "Has this been having an effect on your ability to carry out your routines and get around your home?" "Do you ever find yourself SOB when you're carrying out your daily routines?" "Has your heart failure been causing you any dyspnea lately?"

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

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

Coping/stress tolerance

A client complains of knee pain on the nurse's arrival in the room. What should the nurse's first sentence be after greeting the client? "How much pain are you having?" "Have you injured this in the past?" "When did this happen?" "Could you please describe what happened?"

"Could you please describe what happened?"

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? "Our schedule is very busy also. We got to you as soon as we could." "No one is holding you captive, you are free to leave at any time." "Would you like to speak to the office manager about your complaint?" "You seem very angry. I am ready to begin your exam now."

"You seem very angry. I am ready to begin your exam now."

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

Explaining the purpose of the interview

The nurse is preparing to interview a client with a history of sexual abuse. What technique should the nurse use when conducting this interview? -avoid eye contact -be nonjudgmental -ask direct questions -skip the sexual history

be nonjudgmental

The nurse is focusing an interview on a patient's respiratory status. Which question should the nurse ask first to begin this interview? -Do you currently have a cough? -Do you have any difficulty producing sputum? -Describe how you breathe for me? -Do you experience any pain when you breathe?

describe how you breathe for me

What information aids the nurse in assessing possible biases in the data collected in the health history? -Ethnicity of patient -Gender of patient -Source of information -Socioeconomic status of the patient

source of information

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? -Introductory -Working -Summary -Closing

working

"How many steps can you climb before you get short of breath?" is an example of what kind of question? -A question that offers multiple choices for answers -A question that is qualitative in focus -A question that elicits a graded response -A question that demands an imprecise response

A question that elicits a graded response

A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first? -Collaborate with the client to identify problems. -Explain the purpose of the interview. -Determine the client's vital signs. -Obtain family health history data.

Explain the purpose of the interview.

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? -health patterns -chief complaint -review of systems -history of present illness

chief complaint

The nurse is preparing to interview a newly admitted client. What should be done prior to hearing the client's story? review the attributes of a symptom establish the agenda for the interview review the client's issues in a chronologic order ask specific questions about the reason for admission

establish the agenda for the interview

The nurse is obtaining information about a client's past health history. Which client statement would best reflect this component of assessment? "My mom's still alive, but my dad died 10 years ago of heart failure." "I have a brother with leukemia and a sister with hypertension." "I had surgery 5 years ago to repair an inguinal hernia." "I have been having some pain when I urinate for the last several days."

"I had surgery 5 years ago to repair an inguinal hernia."

The nurse suspects that a client is experiencing alcohol abuse. When completing the CAGE questionnaire, the nurse can confirm the client is having guilty feelings when she makes which statement? "My family doesn't deserve my bad behavior." "In the past I've considered drinking a little less." "My husband should stop nagging me about my drinking." "I was worried about myself when I needed a glass of wine at 9 o'clock in the morning"

"My family doesn't deserve my bad behavior."

The nurse has just asked a client how he feels about his emphysema. He becomes silent, folds his arms across his chest, and leans back in his chair. Then the client replies "It is what it is." How should the nurse respond? -"You seem bothered by this question." -"Next, I would like to talk with you about your smoking habit." -"Okay, let's move on to your other problems." -"You have adopted a practical attitude toward your problem."

"You seem bothered by this question."

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 identify genetic family trends for which the client is at risk -To provide counseling and health teaching in high-risk areas -To help the client feel at ease and not worry about being sick -To elicit negative family history

-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

Which statements provide information about a client's health maintenance? Select all that apply. A child received immunizations based on the recommended schedule. A female client had a mammogram 2 weeks ago. A client recently a had lab test for liver function. A client was hospitalized for dehydration 2 years ago. A client had a circumcision at birth.

A child received immunizations based on the recommended schedule. A female client had a mammogram 2 weeks ago. A client recently a had lab test for liver function.

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. -pain rated 5 on scale of 1-10 -itching on lower left leg -nausea -decubitus on left heel

decubitus on left heel

An adult client is brought to the ED after falling 12 feet from a ladder. The client has an obvious deformity to his left lower leg. What kind of assessment is the nurse going to perform? Emergency Focused Comprehensive Head-to-toe

emergency

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? -self-concept -mental health -family violence -role-relationship

family violence

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

general

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should -read the questions verbatim from the form. -ask the client to complete the form. -ask leading questions throughout the interview. -maintain eye contact while asking the questions from the form.

maintain eye contact while asking the questions from the form.

The patient is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the patient, the nurse is obtaining what other type of data from the patient? -Secondary -Objective -Primary -Tertiary

primary

During the interview of an adult client, the nurse should -use leading questions for valid responses. -provide the client with information as questions arise. -read each question carefully from the history form. -complete the interview as quickly as possible.

provide the client with information as questions arise.

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. -Summarize the client's words. -Paraphrase the client's words. -Describe the client's concerns and health goals.

quote the clients words

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: -gender -sexual history and pattern -culture -spirituality

sexual history and pattern

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: -gender -spirituality -culture -sexual history and pattern

sexual history and pattern

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. -have a family member present during the interview. -use standard medical terminology. -show the client pictures of different symptoms, such as the "faces pain chart."

use very basic lay terminology

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

value-belief

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

value-belief

Which of the following questions is most useful in the assessment of a client's diabetes management? -"You check your sugars before each meal, don't you?" -"Are you still using your glucometer 4 times a day?" -"Are you staying vigilant with your blood sugar monitoring?" -"What is your routine for checking your blood sugar these days?"

what is your routine for checking your blood sugar these days

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." What would the nurse do next? Briefly describe some of the potential benefits of regular exercise. Ask the client if he understands the risk factors for heart disease and diabetes. Tell the client to exercise 30 minutes at least 3 days a week. Document the client's current activity level as minimal.

Briefly describe some of the potential benefits of regular exercise.

The nurse is collecting information regarding the individual's medications. Which nursing activities does the nurse perform during this component of the health history? Select all that apply. -Differentiate among adverse versus allergic responses to medications -Validate names and dosages of medications currently being taken -Assess the individual's understanding of each medication's purpose -Document any adverse effect as an allergic response to protect the patient -Note the pharmaceutical company making the patient's medications

Differentiate among adverse versus allergic responses to medications Validate names and dosages of medications currently being taken Assess the individual's understanding of each medication's purpose

The review of systems component of the health history is best described as a: -Focus on diseases of the major body systems -Detailed investigation of questions about major body systems -Focus on common questions and issues related to each of the different body systems -Series of questions that start at the head and finish at the feet

Focus on common questions and issues related to each of the different body systems

The nurse is completing a past medical history with a 59-year-old client. Which immunization is the highest priority for the nurse to assess? Meningitis Hepatitis B Pneumonia Herpes zoster

Herpes zoster

During the review of systems within the comprehensive health history, the nurse notes that a client has multiple previous injuries and accidents. Which of the following issues is a priority in the nurse's assessment? Assess the client's gait and balance Investigate the possibility of physical abuse Inquire about the client's substance use Complete the Cage Questionnaire

Investigate the possibility of physical abuse

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 Mother: Sugar L. Thompson, died 7/14/2006 from heart attack Head and neck: sore throat and enlarged lymph nodes

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

The nurse is interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of guided questioning? -Use directed questioning: start with the general and proceed to the specific in a manner that does not make the client give a yes/no answer. -Reassure the client that the urinary symptoms are most often treated successfully. -Offer the client multiple choices to clarify the character of the urinary symptoms that she is experiencing. -Ask the client to tell you exactly what she means when she states that she has a urinary tract infection.

Reassure the client that the urinary symptoms are most often treated successfully.

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? -Setting in which the symptom occurs -Associated symptoms and signs -Quality -Timing

associated symptoms and signs

A middle-aged client has an appointment for a routine physical. Which type of assessment is the most appropriate for the nurse to complete? -focused -follow-up -emergency -comprehensive

comprehensive

A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? -Establishing a trusting relationship -Determining the client's strengths -Identifying potential health problems -Making clinical inferences

establishing a trusting relationship

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

explain the role and purpose of the nurse

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

false

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

false

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? -risk factors -health maintenance -screening test completion -compliance with treatment

health maintenance

In interviewing a client about substance use, a nurse asks her whether she takes any herbal supplements. Which of the following is the best rationale for asking this question? -Some herbal supplements may interact with prescribed medications. -Taking herbal supplements is an indicator that the client is concerned with maintaining her health. -Abuse of herbal supplements can result in cardiac dysfunction. -Taking herbal supplements may be the client's mechanism for coping with stress.

some herbal supplements may interact with prescribed medications