HA - Chapter 2 - Collecting Subjective Data : The Interview & Health History
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?" In order to open the interview, the nurse should start with an open-ended question and then identify missing data. Asking when the sleep problem began is assessing for the onset of the problem. Asking the client to rate the sleep problem from 1 to 10 is part of assessing characteristic symptoms. Asking the client what has been tried to help with the sleep is assessing for treatments.
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. "When does the pain occur?" "What makes the pain better or worse?" "Have you had any recent laboratory tests?" "How would you describe the pain?" "Could you show me where the pain is exactly?"
"How would you describe the pain?" "When does the pain occur?" "What makes the pain better or worse?" "Could you show me where the pain is exactly?" Pain is subjective, and many clients may not demonstrate objective signs and symptoms of pain. The nurse should use COLDSPA (character, onset, location, duration, severity, pattern, associated factors) to better understand the origin of the pain. The nurse determines onset by asking when the pain occurs, pattern when asking what makes the pain better or worse, and character when asking how the client would describe the pain. The COLDSPA approach does not include laboratory values or tests.
During a health history interview the client states, "I have been short of breath." What is the priority action of the nurse? Document the finding. Ask the client if they currently feel short of breath. Move to the next system. Ask the client what exacerbates their shortness of breath.
Ask the client if they currently feel short of breath. If a client reports difficulty breathing or chest pain, the nurse should determine if they are currently experiencing these symptoms and intervene appropriately. Because pain and shortness of breath are subjective, the client may not be exhibiting outward (objective) signs and symptoms. The nurse would document these findings, but this is not the priority action. The nurse needs to address the client's report of shortness of breath before moving onto the next system. Even though the nurse would ask what exacerbates the shortness of breath, this is not the priority action.
When interviewing, the nurse should logically move from specific to open-ended questions. True False
False
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? Knock and announce self before entering the client's room Loudly announce self when approaching the client. Approach the client on the unaffected side and announce self. Turn lights on when entering the room and announce self.
Knock and announce self before entering the client's room The nurse should always announce self at the door before entering a client's room. This is especially important if the client has a sensory deficit such as vision or hearing. If the nurse enters the room unannounced it might startle the client. There is no need to speak loudly while approaching a client with a visual deficit. The nurse should approach the client on their unaffected side but should have announced self before entering the room. Turning the lights on is not necessary in this situation; however, if the client has a hearing deficit, good lighting would be needed for the client to read the nurse's lips.
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 Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client's birth date, Social Security Number, medical record number, or similar identifying data may be included in the biographic data section. The client's culture, ethnicity, and subculture may begin to be determined by collecting data about date and place of birth; nationality or ethnicity; marital status; religious or spiritual practices; and primary and secondary languages spoken, written, and read. Gathering information about the client's educational level, occupation, and working status at this point in the health history assists the examiner to tailor questions to the client's level of understanding. The information regarding the client's mother, including the date and cause of death, would appear in the family health history section. The information on the head and neck would appear in the review of systems section.
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 A priority is for the examiner is to have a good view of the client and to avoid having to look back and forth between client and interpreter. The nurse should remember to use short simple phrases while speaking directly to the client and ask the client to repeat back what he or she understands.
What occurs during the termination phase of an interview? Planning for follow-up care Addressing topics that have not yet been addressed Assessing the client's mental status Letting the client know you understood all he or she has told you
Planning for follow-up care The main activity that takes place during the termination phase is planning for follow-up and closing the interview.
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 introductory. ongoing. working. closure.
Working During the working phase, the nurse elicits the client's comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level. The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client. The nurse and client collaborate to identify the client's problems and goals.
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 The client's inability to sleep is being caused by anxiety which would be addressed within the coping-stress-tolerance category of the health pattern review. The client's anxiety is causing an issue within the category of sleep-rest. The client's anxiety would not be addressed within the activity-exercise or self-perception/self-concept categories within the health pattern review.
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? well-placed phrasing close-ended questioning rephrasing active listening
rephrasing The nurse is using a communication technique referred to as rephrasing to better understand subjective data. Rephrasing helps to clarify information. Well-placed phrases such as "uh-huh, go ahead, I see" are useful in keeping a conversation going and letting the client know that the nurse is listening. Closed-ended questions limit the client's response to one or two words, for example, either yes or no or something specific such as a date of birth. Active listening is used to demonstrate that the nurse is interested in what the client is saying.
During an interview with an adult client for the first time, the nurse can clarify the client's statements by offering a "laundry list" of descriptors. rephrasing the client's statements. repeating verbatim what the client has said. inferring what the client's statements mean.
rephrasing the client's statements. Rephrasing information the client has provided is an effective way to communicate during the interview. This technique helps you to clarify information the client has stated; it also enables you and the client to reflect on what was said.
A nurse is conducting a review of systems with a client and is asking about his ears. The nurse asks, "Do you have any problems with your ears 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 asks, "Do you ever experience any trouble hearing or any ringing, buzzing, or earaches?" The client responds, "No." What should the nurse record under "Ears" in the review of systems section of the client's health history? "No problems." Nothing—it should be left blank "Denies any trouble hearing or any ringing, buzzing, or earaches." "Client denies any problems but had trouble hearing me when I asked him a question."
"Denies any trouble hearing or any ringing, buzzing, or earaches." During the review of body systems, document the client's descriptions of her health status for each body system and note the client's denial of signs, symptoms, diseases, or problems that the nurse asks about but are not experienced by the client. If the lone entry "no problems" is entered on the health history form, other health care professionals reviewing the history cannot ascertain what specific questions had been asked, if any. Care must be taken in this section to include only the client's subjective information and not the examiner's observations. Thus, the nurse should not include the observation about the client having trouble hearing the nurse, especially because the client may have simply misunderstood the question when the nurse posed it the first time.
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? "I recommend that you change your posture while working at the computer." "You work at a computer a lot, don't you?" "When did the pain start?" "Do you perform any sustained or continually repetitive motions with that arm?"
"Do you perform any sustained or continually repetitive motions with that arm?" Inferring information from what the client tells you and what you observe in the client's behavior may elicit more data or verify existing data. Be careful not to lead the client to answers that are not true. The question, "Do you perform any sustained or continually repetitive motions with that arm?" is open enough to not lead the client to an expected answer but narrow enough for the nurse to help elicit more information from the client about probable causes of his pain. Recommending that the client change his posture while working at the computer is premature, as the nurse has not confirmed that the computer work is the culprit. Likewise, "You work at a computer a lot, don't you?" is a leading question, as it encourages the client to answer in the affirmative. The question, "When did the pain start?" is a close-ended question; it will elicit more information from the client but is not an example of inferring.
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?" When initiating an interview, it is important to use language that is understandable and appropriate to the client. "Dyspnea," "SOB," and "activities of daily living" are potentially unclear to a client and reflect clinical language rather than clear communication.
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? "What medication do you take for your depression?" "When was the last time you talked with a psychiatrist?" "Have you considered counseling for your mental problems? "Have you ever had a problem with mental or emotional illness?"
"Have you ever had a problem with mental or emotional illness?" The nurse should begin by asking a non-threatening, open-ended question such as "Have you ever had a problem with mental or emotional illness?" Even though the nurse has information about this topic in the documentation, asking the question opens a dialogue with the client in which the client can share as feels comfortable. The question may elicit important information about the client's prior experiences seeking care for mental illness, for example. Asking specifically about medication for depression assumes the client has a history of depression. Asking about talking with a psychiatrist or counseling may cause the client to become defensive.
A client will require an extended period of intense physical therapy after having a compound fracture of the femur surgically repaired. What question should the nurse ask when assessing the client's perception of the injury and recovery plan? (Select all that apply.) "How does experiencing such a trauma make you feel?" "What did the pain feel like when you broke your femur?" "How do you plan to support yourself financially while you recover?" "What frustrations are you experiencing since your accident?" "What do you expect from the physical therapy you will have?"
"How does experiencing such a trauma make you feel?" "How do you plan to support yourself financially while you recover?" "What frustrations are you experiencing since your accident?" "What do you expect from the physical therapy you will have?" It is important for the nurse to understand how the client perceives/views the illness they have experienced. Their perception helps the nurse identify their needs and so directs their plan of care. The client's feelings about the injury as well as their expectations about recovery are relevant and should be a focus on the nurse's questions. It is also important to understand the client's viewpoint regarding how the situation affects their ability to function daily and the types of frustrations they are experiencing. A question about the sensation of pain when the injury occurred does not provide an understanding of the client's perspective on an illness.
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?" "What is your routine for checking your blood sugar these days?" is an open-ended question designed to elicit as much information as possible about how the client is monitoring blood sugar. The other choices are leading questions that clearly signal a "right" answer; the client might feel reluctant to respond "incorrectly." These questions also elicit yes-no responses; closed-ended questions such as these are appropriately used to clarify or obtain more accurate information about issues disclosed in response to open-ended questions.
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? "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?"
"What other symptoms occurred during the spell?" Examples of questions related to associated factors include the following: "What other symptoms occur with it? How does it affect you? What do you think caused it to start? Do you have any other problems that seem related to it? How does it affect your life and daily activities?" The question, "How bad was the tingling and numbness?" relates to severity. The question, "How long did the spell last?" relates to duration. The question, "Where did the numbness and tingling occur?" relates to location.
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 Active listening is the ability to focus on the client and their perspectives. It requires the nurse to constantly decode messages including thoughts, words, opinions, and emotions. For example, if a client is sad, it is appropriate for a nurse to place a hand over the client's and to show a facial expression of compassion. The purpose of restatement is to have the client elaborate on what was originally stated by the client. Reflection uses summarizing by the nurse to find the true meaning of a client's words. Encouraging elaboration encourages the client to explain or go into more detail in the client's responses.
The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action? Change the subject to put the client at ease. Turn the television on for distraction. Ask the client to repeat the statement or question. Refer all questions to the client's family member in room.
Ask the client to repeat the statement or question. The nurse should ask clients to repeat questions or statements if the nurse is unable to understand what the client said. The nurse can also paraphrase client responses to verify understanding.
Nurses weave the individualization of the client interview through all aspects of the encounter. The nurse should avoid assuming that clients follow cultural beliefs. In place of making this assumption, what should a nurse do? Assess the degree to which the client perceives the cultural beliefs Assess how acculturated the client is Know the mores of the culture Know his or her own cultural beliefs
Assess the degree to which the client perceives the cultural beliefs The nurse should avoid assuming clients follow cultural beliefs and assess the degree to which each individual perceives those beliefs. Knowing the mores of the culture and the nurse's own cultural beliefs are important, but do not answer the question at hand. The nurse would have difficulty assessing how acculturated the client is within the client's cultural beliefs.
Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client did not want to wait. The nurse has heard about this client many times from colleagues and is aware that she is very talkative. Which of the following is a helpful technique to improve the quality of the interview for both provider and client? Allow the client to speak uninterrupted for the duration of the appointment. Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed. Set the time limit at the beginning of the interview and stick with it, no matter what occurs in the course of the interview. Allow impatience to show so that the client picks up on nonverbal cues that the appointment needs to end.
Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed. The nurse can also say, "I want to make sure I take good care of this problem because it is very important. We may need to talk about the others at the next appointment. Is that OK with you?" This is a helpful technique that can help the nurse to change the subject, but at the same time, validate the client's concerns; this can provide more structure to the interview.
The nurse is conducting an initial interview with a client. During the introductory phase, it is essential that the nurse perform which of the following actions? Select all that apply. Build rapport. Provide a comfortable environment. Explain the purpose of the interview. Ensure confidentiality. Summarize findings.
Build rapport. Provide a comfortable environment. Explain the purpose of the interview. Ensure confidentiality. During the introductory phase of the interview, it is essential that the nurse gain the client's trust and build rapport, provide a comfortable physical and emotional environment, explain the purpose of the interview, and ensure information will remain confidential as per HIPAA (Health Insurance Portability and Accountability Act) guidelines. Summarizing findings occurs during the summary and closing phase of the interview.
A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format of representing a deceased female relative? Simple circle Simple square Circle with a cross Square with a cross
Circle with a cross The standard format of representing a deceased female relative in a genogram is using a circle with a cross. A simple circle indicates a living female relative. A simple square indicates a living male relative. A square with a cross indicates a deceased male relative.
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
Communicating nonverbally through facial expression Using touch Because of the nurse-client relationship, the nurse in the professional role listens more than talks. Those who might be shy in social situations may exhibit excellent therapeutic communication not by talking but by communicating nonverbally through presence, facial expression, or touch. This makes giving advice and discussing alternative treatment options incorrect answers.
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? Conduct a brief review of the client's charts. Perform a quick assessment on all the clients. Provide a brief introduction to the clients. Validate problems and goals with the clients.
Conduct a brief review of the client's charts. During the pre-introductory phase of the interview, the nurse should review the client's chart. Information from the chart may assist the nurse with conducting the interview. Physical assessment is conducted during the working phase of the interview. The introduction is done during the introductory phase of the interview. Validating problems and goals is performed during the summary and closing phase of the interview.
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? 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? During an interview, questions should proceed from general to specific. The question that is the most general is "describe your breathing." This provides the client with an opportunity to discuss the current breathing pattern with the nurse. The other questions are specific and will elicit a yes-no response.
A nurse completes an initial assessment and discusses findings with the client. What is the next best action of the nurse? Perform a review of systems. Develop a plan of care with the client. Validate the client's biographical data. Discuss lifestyle and health practices with the client.
Develop a plan of care with the client. Once the assessment has been completed, the nurse discusses the findings, validates problems, determines goals, and develops a plan of care with the client. The review of systems, validation of biographical data, and discussion of lifestyle and health practices occur during the working phase of the interview.
Which action should a nurse implement when assessing a nonnative 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 children to interpret.
Maintain a professional distance during assessment. When assessing a nonnative client, the nurse should maintain a professional distance during assessment; the size of personal space affects one's comfortable interpersonal distance. The nurse should not speak to the client using local slang; if the client finds it difficult to learn the proper language, slang would be much more difficult to understand. The nurse need not avoid any eye contact with the client, but should maintain eye contact with the client as required, without giving the client reason to think that the nurse is being rude. Asking one of the client's children to interpret during the interview may actually impair the assessment process. In addition, health care institutions often have specific policies regarding interpreters that you must be aware of prior to using an interpreter.
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 The chief complaint is the abdominal pain. Any associated symptoms would be a part of the history of present illness. The information provided by the client about a past illness would be part of the personal health history. Review of systems provides specific questions about past illnesses that might still be impacting the client.
A client is admitted to the health care facility with new onset of abdominal pain. The client becomes angry with the nurse when questions about personal information are asked. How should the nurse proceed with the interview? Remind the client that this information must be obtained to provide proper care Touch the client lightly on the shoulder to dissipate the anger Remain in control and allow the client to vent feelings Encourage the client to use a more appropriate method to cope with feelings
Remain in control and allow the client to vent feelings An angry client should be approached in a calm, reassuring, in control manner by the nurse. Allow the client to ventilate their feelings may help to diffuse the anger. Telling the client that this information is necessary does not convey an understanding of feelings by the nurse. Touching or arguing with the client may escalate their anger. Encouraging the client to use other methods of coping may help when dealing with a seductive client.
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? Introductory Summary Analysis Working
Summary During the summary and closing, the nurse summarizes information obtained during the working phase and validates problems and goals with the client. In the introductory phase, the nurse meets the client and explains the purpose of the interview, discusses what type of questions will be asked, explains reasons for taking notes, and assures the client that confidential information will remain confidential. Analysis is not a phase of the interview process. The working phase is when data collection occurs.
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 restate what the client has said To promote objectivity To clarify
To clarify Another way to clarify is to ask, "What happens when you get low blood sugar?" Such questions prompt clients to identify other symptoms or give more information so that you can better understand the situation.
The nurse performs a comprehensive assessment on a new client. What is the next action of the nurse? Discuss findings with the health care provider. Instruct the client on what interventions need to be implemented. Validate problems and determine client's goals. Inform client of available treatments and procedures.
Validate problems and determine client's goals.
The nurse performs a comprehensive assessment on a new client. What is the next action of the nurse? Discuss findings with the health care provider. Instruct the client on what interventions need to be implemented. Validate problems and determine client's goals. Inform client of available treatments and procedures.
Validate problems and determine client's goals. Once objective and subjective data have been obtained through a comprehensive assessment of a client, the nurse discusses the findings with the client, validates problems, and determines the client's goals. The nurse would discuss findings with the health care provider after validating problems and determining client goals. Once problems are validated and goals determined, the nurse would inform the client of the various interventions, treatments, and procedures that may be available to resolve the problems and reach the client's goals.
While conducting a comprehensive health history the client says a few sentences about the current problem but then explains how her deceased mother used to have the same problem because of having diabetes. What action should the nurse take? begin drawing the genogram refocus the client on the current problem express sympathy on the loss of her mother ask about the health of other family members
begin drawing the genogram The health history does not always proceed in a set pattern. As the client provides information, the nurse should fill in the different parts of the assessment. There is no need for the nurse to refocus the client on the current problem. Expressing sympathy on the loss of the client's mother would encourage the client to focus on areas that are not related to the health history. Asking about the health of other family members would take the focus completely off of the client's current problem.
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 chief complaint is the reason for the person seeking care. Health patterns focuses on the client's social history. The review of systems is where the presence or absence of common symptoms related to each major body system are reviewed and documented. The history of present illness describes how each symptom developed. It includes the client's thoughts and feelings about the illness, relevant parts of the review of systems, and medications, allergies, and lifestyle habits that impact the present illness.
A client has a 10-year history of being treated for hypertension. Where should the nurse document this information? health patterns review of systems health maintenance past medical history
past medical history An adult medical illness is documented as part of the past medical history. Health patterns identify the client's personal/social history and daily living routines that may influence health and illness. The review of systems focuses on the presence or absence of common symptoms related to each major body system. Health maintenance is a part of the past medical history and identifies actions taken to improve or maintain health.
The nurse is interviewing a client in the clinic for the first time. When the client tells the nurse that he smokes "about two packs of cigarettes a day," the nurse should look at the client with a frown. tell the client that he is spending a lot of money foolishly. provide the client with a list of dangers associated with smoking. encourage the client to quit smoking.
encourage the client to quit smoking. If you are interviewing a client who smokes, avoid lecturing condescendingly about the dangers of smoking. Also, avoid telling the client that he or she is foolish and avoid projecting an attitude of disgust. This will only harm the nurse-client relationship and will do nothing to improve the client's health. The client is, no doubt, already aware of the dangers of smoking. Forcing guilt on him is unhelpful. Accept the client, be understanding of the habit, and work together to improve the client's health. This does not mean you should not encourage the client to quit; it means that how you approach the situation makes a difference. Let the client know you understand that it is hard to quit smoking, support efforts to quit, and offer suggestions on the latest methods available to help kick the smoking habit.
A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information? physical examination health maintenance personal and social history review of systems
health maintenance Health maintenance includes any preventative diagnostics or health-promoting activities the client completed in the past. This is a subsection of the past history in the health assessment. The physical examination and review of systems capture the objective data that arises from the health assessment conducted by the nurse. Personal and social history capture client lifestyle factors such as family, employment, and habits.
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 One area within health maintenance is completion of vaccinations. If the client cannot recall when the last immunizations were received, this would impact health maintenance. Risk factors focus on tobacco use, environment, safety, and substance use. Screening tests are a subcategory within health maintenance. It is possible that the client is unaware of which vaccinations should be obtained. If this is the case, the client should not be labeled as not being compliant with treatment.
A client with abdominal pain says that the last time it the pain occurred, over-the-counter laxatives helped. In which part of the assessment should the nurse document this information? chief complaint past health history review of symptoms history of present illness
history of present illness The history of present illness describes how each symptom developed. It includes the client's thoughts and feelings about the illness, relevant parts of the review of systems, and medications, allergies, and lifestyle habits that impact the present illness. The history of present illness includes any attempts at self-treatment for the problem. The chief complaint is the reason for the person seeking care. The past history lists childhood illnesses, adult illnesses with dates, health maintenance practices, and risk factors. The review of systems is where the presence or absence of common symptoms related to each major body system are reviewed and documented.
The nurse has interviewed a Hispanic client with limited English skills for the first time. The nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. The nurse should indicate acceptance of the client's cultural differences. request a family member to interpret for the client. use slang terms to identify certain body parts. remain in a standing position during the interview.
indicate acceptance of the client's cultural differences. One of the most important nonverbal skills to develop as a health care professional is a nonjudgmental attitude. All clients should be accepted, regardless of beliefs, ethnicity, lifestyle, and health care practices.
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. Establish eye contact when the client is speaking to you but look down at your notes from time to time.
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 Because the client states numbness of the hands, this information should be included under the neurologic system. Even though the symptom affects the hands, it should not be documented under musculoskeletal. This symptom is not a cardiovascular problem. Peripheral vascular is not a category within the review of systems.
