chapter 2 prep u questions
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 reports feeling depressed for several months since being fired from a long-term job. Which question should the nurse include when assessing this client?
"Have you thought of hurting yourself?"
The nurse has just asked a client how he feels about his emphysema. He becomes silent, folds his arms across his chest, and leans back in his chair. Then the client replies "It is what it is." How should the nurse respond?
"You seem bothered by this question."
Which observation would cause the nurse to suspect an abusive situation? Select all that apply.
A pre-schooler rubs her perineum and complains of it hurting. A caregiver of a cognitively intact older adult dominates the interview. A child is persistent in trying to please a parent.
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
The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use?
After assessing for cigarette use
On a very busy day in the office, Mrs. Donelan, 81 years old, comes for her usual visit to check her blood pressure. She has been on a low-dose diuretic for many years and denies any side effects. Today, her blood pressure is 118/78 today, which is well-controlled. The client mentions that it is hard not having her husband Bill around anymore. What would the nurse do next?
Ask why Bill is not there.
A client reports pain as being 7 on a scale from 1 to 10. In which area of the symptom should the nurse document this information?
Characteristic
A nurse is creating a genogram of a client's family health history. The nurse should use which of the following symbols to denote the client's female relatives?
Circle
The nurse is focusing an interview on a patient's respiratory status. Which question should the nurse ask first to begin this interview?
Describe how you breathe for me?
A patient arrives at the Emergency Department reporting shortness of breath. She is cyanotic with bilateral wheezing. The patient begins to gasp for air and cannot speak. The nurse begins to gather information so that interventions can resolve the immediate breathing problem. Her assessment and interventions are concurrent. The nurse is performing what type of health history?
Emergency
During a health history, a client reports drinking bloody Mary's several mornings a week before going to work. In which part of the CAGE questionnaire should the nurse document this information?
Eye-openers
The nurse asks the patient about whether other family members have been diagnosed with diabetes. Which component of the comprehensive health history is the nurse addressing?
Family history
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
Which should the nurse assess when conducting a health history of the pregnant woman? Select all that apply.
Gynecological history Obstetrical history History of abuse
Which action should a nurse implement when assessing a non-native client to facilitate collection of subjective data?
Maintain a professional distance during assessment
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
A client admitted to the health care facility for new onset of abdominal pain expresses to nurse that they were treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?
Past health 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
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?
Preinteraction
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.
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.
What is a key element of the history of present illness?
Self-treatment
An older client arrives for an appointment in the community clinic. Which approach should the nurse use when communicating with this client? Select all that apply.
Speak clearly Use simple terms Show respect
A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask the patient next. What is a useful interview technique for the student to use at this point?
Summarization
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
You are taking a health history on a new patient. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the significance of this information to the health history?
The patient may be at risk for developing diabetes.
While interviewing a patient, the nurse asks, "What happens when you have low blood glucose?" This type of response to the patient is used for what purpose
To clarify
A nurse is interviewing a client with a different cultural background. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?
Using a moderate amount of eye contact
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 is preparing to interview a client with a history of sexual abuse. What technique should the nurse use when conducting this interview?
be nonjudgmental
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
The nurse prepares a genogram after collecting health history information from a client. For which part of the history is this diagram beneficial?
family history
A client comes to the community clinic seeking help for acute low back pain. Which type of assessment should the nurse complete for this client?
focused
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
The nurse uses the mnemonic OLD CART when assessing a client's symptoms. Which letter represents the area of the symptom and if it radiates?
l
A client says that food is not important and meals are not enjoyable. Where should the nurse document this information?
nutrition health pattern
During a comprehensive health history, a client reports smoking cigarettes for 20 years. The nurse will document this information in which of the following sections?
past history
An older adult client is brought to the ED. The client tells the nurse, "I feel like something really heavy is sitting on my chest." The nurse then says to the client, "You feel as if something heavy is sitting on your chest?" Of what type of nurse-client communication is this an example?
restatement
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
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
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?
"Do you perform any sustained or continually repetitive motions with that arm?"
During the interview, the client states, "Is today the 12th? My wife died 2 months ago today." Which of the following responses would be most appropriate?
"How does that make you feel right now?"
A client states, "My wife died two months ago today." Which of the following responses would be most appropriate?
"How does that make you feel?"
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?"
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?"
The principle of confidentiality is of paramount importance in the nurse-patient relationship. When should you inform the patient of with whom his or her information will be shared?
At the beginning of the interview
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.
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
A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize?
Establishing a trusting relationship
When describing the purpose for obtaining a comprehensive health history to a client, which of the following would the nurse include as primary?
Provides a focus for the physical exam.
When recording the patient's reason for seeking care (chief concerns) during the health history, it is recommended that the interviewer:
Quote the patient's words
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
A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication?
Using a moderate amount of eye contact
A middle-aged client has an appointment for a routine physical. Which type of assessment is the most appropriate for the nurse to complete?
comprehensive
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
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
Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the patient's quality of life. When assessing ADLs, the nurse asks if the patient can grasp small objects and open jars. This is an example of assessing the patient's:
mobility
The nurse conducts a health history with a client who reports having a dull headache over the past month. The client tells the nurse that using aromatherapy scents have helped manage the pain sometimes. This information is belongs to which attribute of a symptom?
treatment
