NURS 235 Chapter 2

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?"

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 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?"

A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental?

"You must quit smoking because it affects others, not only you."

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

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

Avoid interrupting the client.

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?

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.

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?"

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?

Circle with a cross

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.

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

A graduate nurse working on a medical-surgical unit is admitting a client who does not speak English. No interpreters are available. The client's spouse is present and speaks English. What should the nurse remember about the use of interpreters when communicating with clients?

Friends and family who are unfamiliar with medical terminology may misinterpret information

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

How do you manage your stress?"

Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data?

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?

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?

Provide simple and organized information.

A nursing instructor is talking about nonverbal communication with the nursing class. The instructor explains that facial expressions should be what?

Relaxed

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?

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

allow the client to verbalize his or her feelings.

During a client interview, the nurse uses nonverbal expressions appropriately when the nurse

avoids excessive eye contact with the client.

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 reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?

create a genogram

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?

health maintenance

A nurse is collecting data on a client's chief complaint, 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

Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms?

open-ended questions to allow full freedom of response

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

The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to

use very basic lay terminology.

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.

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?

Establishing a trusting relationship

The nurse is planning to interview a client who has demonstrated manipulative behaviors during past clinic visits. During the interview process, the nurse should plan to

provide structure and set limits with the client.

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.

report of weight gain report of abdominal distention

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?

chief complaint

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?"

Which of the following questions is most useful in the assessment of a client's diabetes management?

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

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?" - "How would you describe the pain?" - "Could you show me where the pain is exactly?"

Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients? Select all that apply.

-Make sure that dress and appearance are professional -Do not use facial expressions such as rolling the eyes or looking bored or disgusted -Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally

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?

Ask the client to repeat the statement or question.

What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?

Closing the door may help to limit background noise.

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

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

The nurse is caring for a client in the health care provider's office. In reviewing the client's chart, the nurse recognizes the need for providing the client with additional education related to COVID-19 when noting which of the following about the client?

Works in the service industry

The nurse is beginning the review of systems with a client. Which approach would ensure that all major body systems are included in this assessment?

head to toe

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.

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

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

value-belief

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

past medical history

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

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should

explain the role and purpose of the nurse.