Chapter 2- Collecting Subjective Data: The Interview and Health History

A nurse receives report on a client admitted for new onset of lung cancer and reviews the initial comprehensive assessment. The nurse recognizes that which information is subjective and needs validation by further data collection?

Client denies any feelings of anxiety or distress over the diagnosis

The client admitted to the health care facility for new onset of a domino pain expresses 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

The 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 his client?

Provide simple and organize information

A client reports chest pain that occurs with exercise but subsides with rest. The nurse recognizes this as what type of data?

Subjective

A nurse assesses a client who reports the onset of severe headache. During which phase of the nursing interview should the nurse asked the client about the history of the present health concern and the reasons for seeking care?

Working

A nurse is conducting a review of systems with the client is asking about his ears. The nurse asks,"do you have any problems with yours or your hearing?" The client stares blankly at the nurse a moment and then says, "I'm sorry could you repeat that?" The nurse repeats the question, to which the client replies, "no" the nurse then ask, do you ever experienced any trouble hearing or any ringing, buzzing or earaches?" The clown responds,"No." What should the nurse record under "years" in the review of systems section of the clients health history?

"Denies any trouble hearing or any ringing, buzzing, or earaches."

Client presents to the health care clinic with reports of sleeplessness and loss of appetite. The client tells the nurse that his wife is seriously ill in the hospital and he's not been able to visit her much because of the transportation problems. Which open ended question should the nurse asked the client to obtain more information about presenting symptoms?

"Do you think your wife is getting better?"

A nurse is interviewing the client was recently been diagnosed with a terminal disease. In covering his lifestyle and health practices profile, the nurse asks him, "Are you close any extended family members in the area?" The client objects to the question and asks why the nurse needs to know that. Which of the following is the best rationale for the nurse posing this question?

"I just wanted to see what kind of social support you might have to help care for you during your illness."

AA nurse is discussing with the client the clients 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?"

Which interview question by the nurse demonstrates a bias or prejudice attitude?

"You're not homosexual, are you?"

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

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

As many maternal and paternal relatives as the client can recall

The nurse draws a genogram to help organize it illustrate the clients family history. Which shape is a standard format for representing the deceased female relative?

Circle with a cross

A nurse is collecting subjective data from a client as part of the assessment process. Which behavior is most appropriate for the nurse to display in this situation?

Explaining the reason for taking down notes

A nurse is gathering biographical 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 biographics section of the clients help history?

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

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

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 client's chief complain, 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 question represent?

Onset

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

Personal health history

A nurse is interviewing a client who seems anxious. Which nonverbal communication by the nurse helps to facilitate a relaxed environment for the client during the interview process?

Portraying a neutral and friendly expression

When gathering information about medical use, the nurse should ask the client about which type of drugs?

Prescription and over-the-counter (OTC) medications

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

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

The client is admitted to the healthcare facility with new onset of abdominal pain. The client becomes angry with the nurse when questions about personal information. How should the nurse proceed with the interview?

Remain in control and allow the client to ventilate feelings

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 prescribe medications

What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking?

Suggest methods and provide resources to assist with smoking cessation

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?

Termination

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 the component "associated factors"?

What other symptoms occurred during the spell?

An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, or being interviewed by the nurse to update the client help us through. The nurse also has the client electronic health record on her tablet computer. Earlier in the day, the nurse had spoke with the clients primary care physician, would relate some concerns to the nurse regarding the progression of the clients disease. Which source of biographic information should the nurse do you as primary ?

The client

A nurse is interviewing a man complaining of 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 nurses seen similar cases and 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 interviewing a 16-year-old girl regarding her health history. When inquiring about her chief complaint, the girl lowers her voice and says, "I've been with a guy recently, and I'm worried that I might have caught something from him." Nurse responds by saying, "so, you're concerned that you may have a sexually transmitted infection?" Which verbal communication technique is the nurse using here?

Rephrasing

An elderly female client was accompanied by her daughter and a visit to the healthcare facility. The nurse observes that the client is doing quite well, except for the use of a hearing aid. How can the nurse best facilitate the interview process with this client?

Speak slowly and clearly, using straightforward language