NUR 3066C: Health Assessment Chapter 2: The Health History and Interview

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?"

During an interview, how can the nurse best assist the client as the client tells their story?

Avoid interrupting the client

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 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

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

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

To assess the client's self-concept and self-care responsibilities, the nurse will ask which of the following question(s)?

The nurse is aware that how clients perceive themselves, their self-concept and self-care, includes an investigation of all behaviors attempted by the client to promote health. Questions about family problems and what gives the family hope during times of trouble are not directly related to the client's perception of self or what actions the client takes to promote health.

During a health history, a client states "I want to know why my feet are swelling" whereas the primary diagnosis is arthritis. What should the nurse do with the client's statement?

Write is as the chief complaint

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 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 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 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?

rephrasing

The nurse is conducting an initial health history with a client. The nurse asks about the client's history of neurological, respiratory, cardiovascular, and musculoskeletal problems. Which part of the subjective health assessment is the nurse performing?

review of the systems In asking about the client's history of neurological, respiratory, cardiovascular, and musculoskeletal problems, the nurse is conducting a review of the systems. Health and lifestyle practices focuses on lifestyle practices that place the client at risk for certain diseases. Biological information includes name, religion, and occupation. Family history provides information about diseases that may be genetic and predispose the client.

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

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.

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 considering the attributes of a symptom and the OLD CART mnemonic, which questions will the nurse ask a client who is reporting pain in the left knee? Select all that apply.

The OLD CART mnemonic includes questions concerning the symptom's Onset, Location, Associated manifestations, and Relieving factors. While it may not be inappropriate to ask the client his or her opinion of the cause of the symptom, such a question is not associated with OLD CART or the assessment of the attributes of a symptom.

A client is providing information about the history of a present illness. What should the nurse keep in mind when documenting this information?

The history of present illness is where each symptom is described. This area includes the client's thoughts and feelings about the illness. It also includes medications, smoking and alcohol intake if these actions contributed to the development of the illness. Childhood illnesses are a part of the client's past medical history.

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; 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.

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 client.

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; It is essential for the nurse to develop trust and rapport with the client to elicit accurate and meaningful information. This trust is the focus of the interview and must be developed in the initial phase of the interview. Determining the client's strengths, identifying health problems, and making inferences occur during the working phase of the interview.

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.

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?

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.

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 Before meeting with the client, the nurse collects data from the medical record, including the previous history of medical illnesses or surgeries, current medication list, and problem list. The nurse uses this information to conduct an interview, already knowing about some of the past problems and responses to treatments. The beginning phase of the interview process is when introductions are exchanged and the nurse explains the purpose of the interview process. The working phase of the interview process is when data is collected from the client, either in subjective or objective form. The closing phase of the interview process is when the nurse summarizes the interview, assessing for any issues or concerns that need to be addressed either at that time, or in the future.

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

Prior to meeting with the client, the nurse should first review the client's chart, in particular the client's past medical history. After reviewing the client's chart, the nurse should introduce themselves and let the client know their role and what to expect during the interview and assessment. Conducting a comprehensive phone interview would not be appropriate unless the client was unable to attend the clinic and arrangements for a phone or video appointment were agreed upon. Requesting that blood tests be performed prior to the appointment is premature, and would require a health care provider prescription. Speaking to family members regarding the client's visit would violate the Health Insurance Portability and Accountability Act (HIPAA). The client's past medical history is included in the client's medical record. The nurse should have already read the client's past medical history when they reviewed the client's medical record. After introducing themselves, the nurse may clarify any questions they may have about the client's past medical history.

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 client's chief concern, it is preferable to quote the client's exact words whenever possible.

The nurse is preparing to assess the mental status of an older adult client. Which of the following would the nurse need to assess first?

Sensory abilities The nurse needs to assess the older adult's sensory capabilities, such as vision and hearing. Impaired vision can interfere with the older client's ability to read information requested. Assessing hearing acuity is very important when interviewing older adult clients because hearing loss normally occurs with age and undetected hearing loss is often misinterpreted as mental slowness or confusion.

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

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

Usually the nurse collects demographical data first and then elicits from clients a complete description of their reason for seeking care, because that information usually is most important. The nurse collects information about the present illness by beginning with open-ended questions and having clients explain symptoms. A complete description of the present illness is essential to an accurate diagnosis. Reason for seeking care History of present illness Past health history

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?"

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?

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.

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?

the working phase, the nurse collects data by asking specific questions. Two types of questions are closed-ended and open-ended questions. Each type has a purpose; the nurse chooses which type will help solicit the appropriate information. Pre-interaction, beginning, and closing are all phases in the interview process. The pre-interaction phase is prior to meeting the client, when the nurse collects data from the medical record. The information gathered from the medical record is used to conduct the client interview. The beginning phase is when introductions are exchanged, privacy is ensured, and actions are made by the nurse to relax the client. The closing phase is when a review of the interview is conducting, summarizing areas of concerns or importance, allowing the client to ask any closing questions.

When interviewing a client who does not speak English, the nurse enlists the assistance of a "culture broker," based on the understanding of what as this person's primary function?

to interpret the language and culture If misunderstanding or difficulty in communicating is evident, the nurse will seek help from an expert who is thoroughly familiar not only with the client's language, culture, and related health care practices but also with the health care setting and system of the dominant culture, often called a culture broker. The role of a culture broker is not to evaluate the client's health practices, teach the client about health care, or make the client feel comfortable and safe.

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

value-belief The value-belief health pattern describes patterns of values, beliefs or goals that guide choices or decisions. The self-perception-self-concept pattern describes body image, feeling state, self-esteem, personal identity, and social identity. The role-relationship pattern describes patterns of role interactions and relationships including family functioning and problems, and work and neighborhood environment. The coping-stress-tolerance pattern describes general coping pattern and its effectiveness in terms of stress tolerance.