PrepU ch. 2

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

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

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 interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication?

Using a moderate amount of eye contact

While discussing family history with a client who is healthy except for a current UTI requiring IV antibiotics, the client 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

Which statements provide information about a client's health maintenance? Select all that apply.

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

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?

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

The nurse is preparing to conduct an interview with a hospitalized client. What nursing intervention can best ensure a confidential and comfortable environment for the client?

Asking permission to draw the client's privacy curtain.

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

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 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?

Explain 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

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

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

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

Learning about the effects 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

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

Past health history Reason for seeking care History of present illness

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

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 a health history interview, a nurse asks a client about childhood illnesses, past surgeries, and allergies. The nurse knows that this information will be charted in what section of the initial comprehensive assessment database?

Personal health history

What occurs during the termination phase of an interview?

Planning for follow-up care

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.

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

Quote the client's words

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?

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

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?

Report it to the nurse's supervisor

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

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

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

A client reports having scarlet fever when in the 2nd grade. In which area of the comprehensive health history should the nurse document this information?

past history

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 diseases did you have as a child?"

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?"

A nurse is running late after a quarterly quality improvement meeting at the hospital and has just been paged from the nurses' station. A client's relative wants to talk as soon as possible about the client's care. The nurse has clinic duty this afternoon and is about to see the first client. The first appointment time slot is double-booked, and three other clients have arrived, all of whom are sitting in the waiting room. Which of the following demeanors is consistent with skilled interviewing when the nurse walks into the examination room to speak with the first client at the clinic?

calm

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 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

The nurse identifies characteristics of the client including age, gender, and occupation. What aspect of assessment is being performed to gather this information?

interviewing

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

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.

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 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 thought of hurting yourself?"

During the interview, the client states, "Is today the 12th? My wife died 2 months ago today." Which of the following responses would be most appropriate?

"How does that make you feel right now?"

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 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 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

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

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?

Laundry list

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?

Pre-interaction

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

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 identify genetic family trends for which the client is at risk To provide counseling and health teaching in high-risk areas To help identify those diseases for which the client may be at risk

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

True

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?

Using a moderate amount of eye contact

A client comes to the office for evaluation of fatigue. He has come to the office many times in the past with various injuries, and the nurse suspects that the client has a problem with alcohol. Which of the following questions will be most helpful in diagnosing this problem?

When was your last drink?

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

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.

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

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

past medical history

A client 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

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

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?"

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.

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

general

The nurse is asking a client to describe the history of the present illness. On which areas should the nurse focus at this time? (Select all answer choices that apply)

self treatment risk factors review of system information

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?"

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?"

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 provides care in a rural hospital that serves a community that has few minority residents. When interviewing a client from a minority culture, the nurse has enlisted the assistance of a "culture broker." How can this individual best facilitate the client's care?

By interpreting the client's language and culture

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

Health perception-health management