Chapter 2- Collecting Subjective Data

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?"

Which statement made by the nurse demonstrates an understanding of the termination phase of the interviewing process?

"Let me stress the importance of being medication adherent."

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?"

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

-Provide the client with a laundry list of words to choose from A laundry list of descriptive terms can assist the client to describe symptoms, conditions, or feelings. The laundry list will assist the nurse to obtain specific answers & reduce the likelihood of the client perceiving or providing an expected answer. Restating the question would be useful if the client does not understand the questions being asked.

During an interview with an adult client, the nurse can keep the interview from going off course by

-closed ended questions

During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved?

-this is where you collect data

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.

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? -Hospital interpreters may not always be the best choice because they are unfamiliar with the client -Using children in the family, other relatives, or close friends as interpreters does not violate privacy laws -Friends and family who are unfamiliar with medical terminology may misinterpret information -Interpreters do not understand cultural health beliefs and practices, so they are unable to help bridge the gap

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?

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. -if someone is anxious this is the response they should get -if aggressive, approach in an in control manner

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

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? -What other symptoms occurred during the spell? -How long did the spell last? -where is the numbness/tingling?

What other symptoms occurred during the spell?... what else is related to it, what caused it?

leading questions

a question that prompts or encourages the desired answer... AVOID

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

create a genogram

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

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?

family violence The family violence portion of the comprehensive health history focuses on personal safety. Self-concept and role-relationship are health patterns. The mental health portion of the comprehensive health history focuses on emotional and mental health.

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 matinence

An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?

last surgery date validated by adult daughter

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. -temp -height -weight

perception of pain.

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

personal healthy history

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

relaxed

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

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

start with open ended questions so you can get the full story (later you can get specific on certain details and symptoms)

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

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 -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 is considered the primary source and all others (including the client's medical record) are secondary sources. In some cases, the client's immediate family or caregiver may be a more accurate source of information than the client. An example would be an older adult client's wife who has kept the client's medical records for years or the legal guardian of a mentally compromised client. In any event, validation of the information by a secondary source may be helpful.

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.

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

working