NUR 207 Jensen PrepU Chapter 2

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?"

The review of systems component of the health history is best described as a

A focus on symptoms related to each of the different body systems

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

As many genetic relatives as the client can recall

The nurse 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

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

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

The nurse is in the introductory phase of the client interview. Which of the following activities would be appropriate?

Explaining the purpose of the interview

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

Facilitating the client's fullest communication

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

When caring for any patient, what is important in conducting a conversation?

Keep the conversation at the knowledge level of the patient

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

Maintain a professional distance during assessment

A 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 disease did you have as a child

The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use?

after assessing for cigarette use

Which observation would cause the nurse to suspect an abusive situation? Select all that apply.

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

The client is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the client, the nurse is obtaining what other type of data from the client?

primary

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

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

value-belief

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?

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

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?

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."

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?"

The nurse is teaching the patient how to self-administer insulin. Which functional health pattern does this nursing intervention address?

Health perception-health management.

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

Lifestyle and health practices profile

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.

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

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?

active listening

When the nurse is conducting the health history, when would be the most natural time to ask the client about alcohol use?

after asking about cigarette smoking

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 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?

characteristics

A nurse is creating a genogram of a client's family health history. The nurse should use which of the following symbols to denote the client's female relatives?

circle

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 client presents to the clinic reporting chest pain and shortness of breath. Which type of health history would the nurse would conduct?

emergency

The nurse is preparing to interview a newly admitted client. What should be done prior to hearing the client's story?

establish an agenda for the interview

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?

eyeopeners

A client comes to the community clinic seeking help for acute low back pain. Which type of assessment should the nurse complete for this client?

focused

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?

follow up

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

gastrointestinal

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

general

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

past medical 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?

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?

preinteraction

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?

promoting elaboration

A client 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 client always explains having fallen and tripped. The nurse suspects abuse. The next step should be to

report finding to 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?

sexual history

A nurse is interviewing a client with a different cultural background. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?

sing a moderate amount of eye contact

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

The review of systems component of the health history is best described as a:

• Limitations in English are not a reflection of intellectual functioning• Written information in the native language supports verbal communication

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 provide counseling and health teaching in high-risk areas• To identify genetic family trends for which the client is at risk

The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data?

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

A client reports a ten pound weight loss in the past month. In which areas of the review of systems will the nurse note this information? (Select all that apply.)

A. EndocrineC. GastrointestinalD. GeneralE. Psychiatric

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?

Associated symptoms and signs

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?

Circle with a cross

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?

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?

L

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?

LAUNDR LIST

A comprehensive health history includes which components? Select all that apply.

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

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

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

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 patient.

The nurse is taking a comprehensive health history on a new client. Why would it be essential for the nurse to obtain a complete description of the present illness?

To establish an accurate diagnosis

A 60-year-old woman with a bunion will undergo surgery later today. The client tells the nurse in the surgical daycare admitting department, "I'm sure I've been asked these questions before. Can't we just focus on my foot and not all these other topics?" How should the nurse best explain the rationale for obtaining a health history?

We want to make sure your nursing care matches your needs as closely as possible."

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?

What is your major health concern at this time?"

The nurse is performing a health history on a client with mild chest pain who came to the Emergency Department. When asked about his allergies, the client states that he is allergic to codeine for pain. The nurse asks if that is the only allergy and then proceeds with the rest of the assessment. What other information should the nurse obtain when a client states an allergy?

What type of reaction did the patient experience?

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

comprehensive

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

A nurse, conducting a functional assessment on an adult client, assesses overall psychosocial well-being by assessing what?

coping/stress tolerance

A client reports feeling depressed for several months since being fired from a long-term job. Which question should the nurse include when assessing this client?

have you taught of hurting yourself

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?

health maintenance

A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?

heath maintenance

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?

history of present 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

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

location duration characteristic symptom associated manifestations relieving/exacerbating factors treatment

Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the client's quality of life. When assessing ADLs, the nurse asks if the client can grasp small objects and open jars. This is an example of assessing the client's:

mobility

Which 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

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?

past health history

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

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

true

The 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 having back surgery

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

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