Chapter 2 PrepU

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

unable to go to the gym since having back surgery

The nurse is reviewing a new client's chart prior to the initial interview. The chart reveals the client has a visual impairment. What actions should the nurse take to ensure a successful interview? Turn lights on when entering the room and announce self. Loudly announce self when approaching the client. Knock and announce self before entering the client's room. Approach the client on the unaffected side and announce self.

Knock and announce self before entering the client's room.

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 sleep-rest self-perception/self-concept activity-exercise

coping-stress-tolerance

During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client's perception of pain. temperature. height. weight.

perception of pain.

When focusing on the client's perspective of a symptom or problem, the nurse will ask which questions? Select all that apply. "Do you have any idea concerning why you are experiencing these headaches?" "Can you tell me when the headaches first began?" "Do you have any fears about the headaches you experience?" "What do you do to make the headaches go away?" "Do the headaches negatively impact your day-to-day life?"

"Do you have any idea concerning why you are experiencing these headaches?" "Do the headaches negatively impact your day-to-day life?" "Do you have any fears about the headaches you experience?"

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?" "When was the last time you talked with a psychiatrist?" "What medication do you take for your depression?" "Have you considered counseling for your mental problems?

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

The nurse is preparing to meet Mr. James Smith, a 70-year-old client. How should the nurse greet this client? "So nice to meet you Jim!" "Hello Mr. Smith." "Hi dear! Have a seat!" "How are you doing today Mr. Jim?"

"Hello Mr. Smith."

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 do you usually eat in a typical day?" "Are both of your parents still living?" "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?"

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

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

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?" "How bad was the tingling and numbness?" "How long did the spell last?" "Where did the numbness and tingling occur?"

"What other symptoms occurred during the spell?"

The nurse performs a focused assessment on a client who is reporting joint pain. To gain a better understanding of the client's pain, the nurse uses COLDSPA. Which question(s) should the nurse ask the client to determine the origin of the pain? Select all that apply. "Have you had any recent laboratory tests?" "Could you show me where the pain is exactly?" "When does the pain occur?" "How would you describe the pain?" "What makes the pain better or worse?"

"When does the pain occur?" "What makes the pain better or worse?" "How would you describe the pain?" "What makes the pain better or worse?"

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 Encouraging elaboration (facilitation) Reflection Active listening

Active listening

During an interview, how can the nurse best assist the client as the client tells their story? Avoid interrupting the client. Use a focused questioning format. Correct the client when the client makes erroneous statements. Suggest information the client has appeared to have forgotten.

Avoid interrupting the client.

The nurse has been assigned to a group of clients on a medical surgical unit. What is the best action of the nurse prior to receiving a report on these clients? Validate problems and goals with the clients. Conduct a brief review of the client's charts. Provide a brief introduction to the clients. Perform a quick assessment on all the clients.

Conduct a brief review of the client's charts.

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

Describe how you breathe for me?

A nurse completes an initial assessment and discusses findings with the client. What is the next best action of the nurse? Develop a plan of care with the client. Perform a review of systems. Validate the client's biographical data. Discuss lifestyle and health practices with the client.

Develop a plan of care with the client.

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

Establishing a trusting relationship

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? Determine the client's vital signs. Obtain family health history data. Explain the purpose of the interview. Collaborate with the client to identify problems.

Explain the purpose of the interview.

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? Maintaining eye contact with the client at all times Reading questions from the history form Explaining the reason for taking down notes Remaining standing during the interview

Explaining the reason for taking down notes

How would the nursing instructor explain the goal of guided questioning to his or her students? Providing the most plausible answer to the client Developing a basis for accurate health promotion activities Creating an opportunity for the early generation of a plan Facilitating the client's fullest communication

Facilitating the client's fullest communication

How would the nursing instructor explain the goal of guided questioning to his or her students? Providing the most plausible answer to the client Facilitating the client's fullest communication Developing a basis for accurate health promotion activities Creating an opportunity for the early generation of a plan

Facilitating the client's fullest communication

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. Occupation: Brick mason Head and neck: sore throat and enlarged lymph nodes Lamar P. Thompson Caucasian Mother: Sugar L. Thompson, died 7/14/2006 from heart attack 1212 South Maple St., Sylvan, VA 23236

Lamar P. Thompson 1212 South Maple St., Sylvan, VA 23236 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? History of present health concern Lifestyle and health practices profile Personal health history Family health history

Lifestyle and health practices profile

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

Maintain a professional distance during assessment.

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

Personal health history

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? Mirror the client's feelings. Refer the client to a spiritual guide. Approach the client in an in-control manner. Provide simple and organized information.

Provide simple and organized information.

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." The 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? Well-placed phrase Rephrasing Open-ended question Laundry list

Rephrasing

A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned? Leaning on the nightstand at eye level with the client Seated in a chair at eye level with the client Standing beside the bed, looking down at the client Sitting on the side of the bed, looking down at the client

Seated in a chair at eye level with the client

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

The client

A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client? The sister may not tell the client exactly what the nurse says The client's sister may not understand medical terminology The sister may not be there every time the nurse needs to talk to the client The client may not want the sister to know their private information

The client may not want the sister to know their private information

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 summarize the conversation To promote objectivity To restate what the client has said To clarify

To clarify

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? Closing Beginning Working Pre-interaction

Working

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

allow the client to verbalize his or her feelings.

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

chief complaint

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

create a genogram

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

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 chief complaint history of present illness family history

identifying data

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should ask the client to complete the form. read the questions verbatim from 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.

Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms? specific questions to secure a description of every symptom yes-or-no questions to determine relevant areas of the physical examination pertinent positive and negative questions to determine relevant details open-ended questions to allow full freedom of response

open-ended questions to allow full freedom of response

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information? past medical history health patterns health maintenance review of systems

past medical history

During an initial health history, a client states, "I haven't slept in weeks." The nurse asks, "You are saying that you have not had any sleep in weeks?" What communication technique is the nurse using to obtain accurate subjective data from the client? close-ended questioning well-placed phrasing active listening rephrasing

rephrasing

During an interview with an adult client for the first time, the nurse can clarify the client's statements by repeating verbatim what the client has said. offering a "laundry list" of descriptors. rephrasing the client's statements. inferring what the client's statements mean.

rephrasing the client's statements.

An initial review of the client's chart and brief interview reveals the following: ● Labs: Albumin 1.5 g/dL (3.5-5.0 g/dL), AST 185 U/L, ALT 200 U/L ● Client states: "I've gained so much weight in the last month." ● Client states: "My stomach feels distended." ● Client states: "I drink about 1 bottle of wine every day." ● Client's weight is 150 lb. (68 kg) ● 4+ pitting edema lower extremities Which subjective finding will the nurse document? Select all that apply. increased hematocrit and hemoglobin pedal edema report of abdominal distention report of weight gain decreased albumin

report of weight gain report of abdominal distention

A nurse in a clinic is preparing to meet with a new, 35-year-old male client. Complete the following sentence by choosing from the lists of options. Prior to meeting the new client, the nurse should first (Select...review the client's medical record, request blood tests be performed, conduct a comprehensive phone interview) and then (Select...explain the purpose of the interview, speak to family members, ask the client about their past medical history)

review the client's medical record explain the purpose of the interview