Chapter 2: The Health History and Interview

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 of the following questions would be most important for the nurse to 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?"

Which observation would cause the nurse to suspect an abusive situation? Select all that apply

A child is persistent in trying to please a parent A caregiver of a cognitively intact older adult dominates the interview A preschooler rubs her perineum and complains of it hurting

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 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

A client states that the reason he has come into the clinic is for a routine annual physical. In what section of the health history would you document this information?

Chief complaint

The nurse is preparing to obtain a health history on a client who recently migrated from Asia. What is the first action of the nurse?

Determine if an interpreter is needed

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

Learning about the effects of the illness does what for the nurse and the client?

Gives them the opportunity to create a complete and congruent picture of the problem

The nurse is teaching the client how to self-administer insulin. Which functional health pattern does this nursing intervention address?

Health perception-health management

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 assessing an olde adult focuses the health history on

Sensory deficits, illness history, and lifestyle factors

A patient says that they are having throbbing pain that they rate as 6 on a 10-point scale. This is referred to as

Subjective primary data

The nurse prepares to complete the review of systems with a client. On which area should the nurse focus when completing this part of the assessment?

Symptoms

A nurse receives a new order for intravenous fluids (IVF) for a client. The nurse reviews the client's health history prior to administration. For which of the following findings should the nurse clarify this order?

The client has a long history of congestive heart failure and fluid overload

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 performs patient teaching after assessing that the nutritional history reveals that the patient generally consumes a high-fat, high-calorie diet. This critical thinking

Uses subjective data to analyze findings and intervene

A nurse assesses a client who reports the onset of a severe headache. During which phase of the nursing interview should the nurse ask the client about the history of the present health concern and the reasons for seeking care?

Working

A client reports the health status of living parents, sibling, 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

The nurse has completed collecting primary data and is finishing a health history for a newly admitted client on the medical-surgical unit. Which statement best reflects primary data?

information exclusively provided by the client

During which of the following phrases of the interview process will the nurse assure the client that all personal data the client discusses with the nurse will be kept confidential?

introductory

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

A client comes to the ED complaining of chest pain. This would be considered

subjective primary data

A male older adult client reports a 2-week history of sleep disruption due to frequently waking up to void in the middle of the night. Where in the review of systems should the nurse document this symptom?

urinary

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 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?"

To assess self-perception, the nurse asks

"How would you describe yourself?"

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"

The mother of an infant with severe asthma is extremely anxious. The nurse is treating the patient in the emergency room. When collecting the history, the best response of the nurse is

"You seem worried, but I need to ask a few questions"

The nurse who asks about feeding, bathing, toileting, dressing, grooming, mobility, home maintenance, shopping, and cooking is assessing

ADLs

In the closing phase of the interview process, the nurse analyzes the data collected for what priority reason?

Identifying the primary problems or patterns of concern

When gathering the family history, the nurse draws a genogram

Inserting lines between parents to show marriage

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

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 comprehensive health history includes which components? Select all that apply

Reason for seeking care History of present illness Past health history

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 client. While performing your assessment, the client informs you that her mother has type 1 diabetes. What is the significance of this information to the health history?

The client may be at risk for developing diabetes

The nurse asks, "What are the most important things to you in life?" to assess the functional pattern related to

Values

The nurse is gathering the health history data before performing the physical assessment. This phase of the interview process is the

Working phase

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

A client comes to the community clinic seeking help for acute low back pain. What assessment should the nurse complete for this client?

focused

A client with a long history of back pain is scheduled for back surgery. The nurse obtains the client's health history. Which of the following statements by the client requires further investigation?

"I take medication to thin my blood"

The patient is crying after being given a diagnosis with a poor prognosis. The best response from the nurse is

"I'll stay with you" (gets a tissue)

The nurse suspects that a female client has an alcohol use disorder. When completing the AUDIT-C screening tool, which response requires further follow-up by the nurse?

On the weekends I will go out and have about six to seven drinks with friends

The nurse is completing a comprehensive assessment with a client experiencing a lung infection. Which information is essential to document within risk factors?

tobacco use