chapter 3

A client's spouse answers the interview questions and will not leave the examination room. What should the nurse suspect be occurring with the client? a.) cultural b.) physical abuse c.) patient is shy c.) depression

Physical abuse should be considered if the partner tries to dominate the interview and will not leave the room. The spouse's behavior does not suggest low self-esteem or a cognitive or mental health disorder.

Which action should a nurse implement when assessing a non-native client to facilitate collection of subjective data? Speak to the client using local slang Maintain a professional distance during assessment Ask one of the client's significant others to interpret Avoid any eye contact with the client

Maintain a professional distance during assessment

The nurse is conducting a client interview and responds to the client in a way that encourages the client to more completely describe his or her problems. What is this called? Restatement Promoting elaboration Focusing Clarification

Promoting elaboration Explanation: Encouraging elaboration (facilitation) is a technique that assists clients to more completely describe difficulties. You use responses that encourage clients to say more and continue the conversation. This shows clients that you are interested

Your new client becomes visibly anxious during the nursing interview. You respond by telling her, "Don't worry, everything will be okay." What might this premature reassurance cause? A feeling of closeness between the client and the nurse The nurse to shorten the interview process A noticeable lessening of the client's anxiety The blockage of further disclosures by the client

The blockage of further disclosures by the client

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 self-concept role-relationship mental health

family violence

The nurse is completing a comprehensive assessment with a newly admitted client. In which area should the nurse document the client's list of immunizations? review of systems health maintenance past medical history health patterns

health maintenance

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should? ask leading questions throughout the interview. maintain eye contact while asking the questions from the form.

maintain eye contact while asking the questions from the form. Explanation: Establish eye contact when the client is speaking to you but look down at your notes from time to time.

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 introductory. closure. ongoing. working.

working

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? a.) I'm sorry... b) none of the following c.) that's a good way to look at it d) You seem bothered by this question. e.) everything will be okay

"You seem bothered by this question.

A victim of a house fire is admitted for possible inhalation injuries. During the admission process, which type of assessment should the nurse complete? comprehensive emergency follow-up focused

emergency

While assessing a client, the nurse is asking questions that help the nurse perceive and communicate an understanding of what the client is feeling. What is this called? Caring Empathy Sympathy Therapeutic communication

empathy

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. avoid discussing sensitive issues. allow the client time to calm down. set time limits with the client.

explain the role and purpose of the nurse. Explanation: When interacting with an anxious client provide the client with simple, organized information in a structured format and explain who you are, along with your role and purpose

A client with abdominal pain says that the last time it the pain occurred, over-the-counter laxatives helped. In which part of the assessment should the nurse document this information? past health history review of symptoms chief complaint history of present illness

history of present illness

A student nurse is conducting her first client interview. The student suddenly draws a blank on what to ask the client next. What is a useful interview technique for the student to use at this point? Transition Reassurance Termination Summarization

summarization

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? a.) to clarify b.) validates the information c.) helps nurses understand what is happening with the patient d.) all of the above

to clarify

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 Closing Introductory Summary

working

What occurs during the termination phase of an interview? Letting the client know you understood all he or she has told you Planning for follow-up care Assessing the client's mental status Addressing topics that have not yet been addressed SUBMIT ANSWER

planning follow up care

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is "Is stress a problem in your life?" "How do you manage your stress?" "Do you feel stress at work?" "How often do you feel stressed?"

"How do you manage your stress?"

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information? consider using it when planning care include in the past medical history document it in a narrative note create a genogram

create a genogram

When interviewing, the nurse should logically move from specific to open-ended questions. True False

false because Use focused questions to elicit information that the patient has not already offered. In general, an interview moves back and forth from open-ended questions to increasingly focused questions and then on to another open-ended question, returning the lead in the interview to the patient.

The nurse assesses an assigned client after receiving morning report to evaluate level of pain. Which type of assessment is the nurse completing? follow-up focused emergency comprehensive

A follow-up assessment -evaluates a specific problem after treatment. A focused assessment gathers information about the current health problem. An emergency assessment focuses on data to quickly resolve the immediate health problem. A comprehensive assessment includes demographic data, a full description of the reason for seeking care, individual health history, family history, functional status, and a history in all physical and psychosocial areas.

A client plays doubles tennis every Saturday and golfs on Wednesday afternoons. In which part of the comprehensive health history is this information utilized? a.) family history b.) review of systems c.) health patterns d.) risk factors

Activity-exercise is a category within the health patterns section of the comprehensive health history. Physical activity is not a part of the review of systems. Health maintenance focuses on immunizations, safety and risk factors. The client's activity is not a part of the history of the present illness.

A 60-year-old woman with a bunion will undergo surgery later today. The client tells the nurse in the surgical daycare admitting department, "I'm sure I've been asked these questions before. Can't we just focus on my foot and not all these other topics?" How should the nurse best explain the rationale for obtaining a health history? "We don't want to focus solely on the medical problem that brought you here." "The care team needs to cross-reference your diagnostic testing with your medical history." "We want to make sure your nursing care matches your needs as closely as possible." "In general, it's necessary for us to gather as much information about each client as possible."

We want to make sure your nursing care matches your needs as closely as possible

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? a.) circle b.) square C.) rectangle D.) triangle

circle When creating a genogram, female relatives are usually indicated by a circle and male relatives by a square. Triangles and rectangles are generally not used

During an interview with an adult client, the nurse can keep the interview from going off course by rephrasing the client's statements. inferring information. using open-ended questions. using closed-ended questions.

close ended questions

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 intro pre- intro termination

working

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 your congestive heart failure been affecting your activities of daily living recently?" "Do you ever find yourself SOB when you're carrying out your daily routines?" "Has this been having an effect on your ability to carry out your routines and get around your home?" "Has your heart failure been causing you any dyspnea lately?"

"Has this been having an effect on your ability to carry out your routines and get around your home?"

A client complains of knee pain on the nurse's arrival in the room. What should the nurse's first sentence be after greeting the client? "When did this happen?" "How much pain are you having?" "Have you injured this in the past?" "Could you please describe what happened?"

Could you please describe what happened? When looking into a complaint, it is best opened with an invitation for the client to tell the nurse in his or her own words. The nurse should use more specific questions later in the interview to fill in any gaps.

Learning about the effects of the illness does what for the nurse and the client a.) helps with coping b.) gives the nurse a refresher on the info C.) this allows for the relationship between the nurse and patient to be stronger d.) Gives them the opportunity to create a complete and congruent picture of the problem

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

A client is admitted to the health care facility with new onset of abdominal pain. The client becomes angry with the nurse when questions about personal information are asked. How should the nurse proceed with the interview? Encourage the client to use a more appropriate method to cope with feelings Remain in control and allow the client to vent feelings Remind the client that this information must be obtained to provide proper care Touch the client lightly on the shoulder to dissipate the anger

Remain in control and allow the client to vent feelings

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? a.) don't document b.) last surgery date c.)last surgery date validated by adult daughter d.) wait to validate record later

last surgery date validated by adult daughter The client's memory was cloudy but the adult daughter was able to provide the exact date based upon a life event that can be validated. This interaction does not indicate that the adult daughter is controlling the interview. The client was unable to recall the exact date of the surgery but with the daughter's help, the date was provided. The exact information about the surgical date and the person who provided the information should be documented. The client may have been confused, but that is not what needs to be documented.

A nurse is teaching a recent nursing graduate about the significance of verbal and nonverbal communication during client care. The new graduate demonstrates an understanding of these techniques by citing what example of verbal communication? Maintaining an open and encouraging facial expression Providing a laundry list of descriptors when needed Using silence appropriately Maintaining an open attitude

providing a laundry list of descriptors when needed Explanation: Laundry list is an example of a verbal communication technique. Attitude, silence, and facial expression are examples of nonverbal communication.

A nurse is conducting a review of systems with a client and is asking about his ears. The nurse asks, "Do you have any problems with your ears or your hearing?" The client stares blankly at the nurse a moment and then says, "I'm sorry—could you repeat that?" The nurse repeats the question, to which the client replies, "No." The nurse then asks, "Do you ever experience any trouble hearing or any ringing, buzzing, or earaches?" The client responds, "No." What should the nurse record under "Ears" in the review of systems section of the client's health history? "client is indenial of his problems" "Client denies any problems but had trouble hearing me when I asked him a question." "Denies any trouble hearing or any ringing, buzzing, or earaches." "no problems"

"Denies any trouble hearing or any ringing, buzzing, or earaches."

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? a.) Asking what the wife died from b.) You must be very sad c.)How does that make you feel right now? d.) I am very sorry to hear that

"How does that make you feel" The client's statement about his wife's death provides the nurse with an opportunity to gather information about the client's current state. Asking an open-ended question such as "How does that make you feel?" would be most appropriate to obtain key information. Asking what the wife died from is a closed-ended question that ignores the client's feelings. Telling the client that he probably feels sad is imposing the nurse's personal values on the client. Asking the client the laundry list of feelings would be demeaning and doesn't allow the client to put his feelings into his own words.

A nurse knocks and enters a client room, makes introductions to the client and visitors, and explains to the client that she would like to conduct an interview so a plan of care can be completed. Which statement by the nurse would be most appropriate? a.)"Barbara, I am going to conduct an interview so I would like to ask your visitors to leave so we can have some privacy." Correct response: b.)"Mrs. Smith, I would like to conduct an interview with you but I see you have visitors. I will come back in about 30 minutes so you can visit before you and I sit privately to talk c.) "Hi, Mr. John, I will be conducting an interview right now" d.) "Sandra let me know when you are ready for me to conduct an interview with you."

"Mrs. Smith, I would like to conduct an interview with you but I see you have visitors. I will come back in about 30 minutes so you can visit before you and I sit privately to talk Recognizing visitors but setting a time for returning to discuss privately gives everyone time to talk and visit but does not cause a long delay for the important interview.

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? "Did you bring all your medications with you?" "What is your major health concern at this time?" "Do you have adequate health insurance coverage?" "Are you generally fairly healthy?"

"What is your major health concern at this time?" Explanation: Asking the question about the client's major health concern assists the client to focus on the most significant issues and answers the nurse's question "why are you here?" or "how can I help you?" The nurse may inquire later on about the client's health insurance, but not if it is adequate. Asking if the client is fairly healthy is a closed-ended question that doesn't allow the client to verbalize concerns. Asking about medications would be appropriate later on during the interview when discussing the medications that the client takes

During the nurse's assessment of the client's exercise and activity habits, the client laughs and then states, "Unless you're including channel surfing, I don't really do much of anything." What would the nurse do next? Briefly describe some of the potential benefits of regular exercise. Tell the client to exercise 30 minutes at least 3 days a week. Document the client's current activity level as minimal. Ask the client if he understands the risk factors for heart disease and diabetes

Briefly describe some of the potential benefits of regular exercise Explaining the benefits of exercise would be an appropriate follow-up to the client's statement. Focusing on negatives (such as lack of exercise as a risk factor for disease) or stating ideal levels of exercise is less likely to prompt change. The nursing diagnosis may or may not apply, and documentation would not take place immediately following the client's statement.

How does giving false reassurance to a client hurt the nurse-client relationship? Select all that apply. It enhances anxiety, which can increase a client's urge to seek further reassurance It diminishes his or her trust It validates client concerns It indicates to a client that his or her concerns are not worth discussing It tells the client that the nurse will be there to provide a therapeutic relationship

It indicates to a client that his or her concerns are not worth discussing It enhances anxiety, which can increase a client's urge to seek further reassurance It diminishes his or her trust

When using an interpreter to facilitate an interview, where should the interpreter be positioned? Behind the examiner, so the interpreter can pick up the movements of the lips of the client and the client's nonverbal cues Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client in the corner, so the interpreter is not a distraction.

Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client

A way to use nonverbal communication is through silence. The purposeful use of silence during the interview allows clients to what? Provide accurate answers Talk about their feelings Rest and improve health Communicate verbal concern

Provide accurate answers nurse uses silence purposefully during the interview to allow clients time to gather their thoughts and provide accurate answers. The nurse also uses silence therapeutically to communicate nonverbal concern. Silence also gives clients a chance to decide how much information to disclose. Silence is not used to rest and improve the client's health, have the client talk about their feelings, or communicate verbal concern.

Which behavior is appropriate for a nurse to display when collecting subjective data as part of the assessment process? Remain standing during the interview Read questions from the history form Maintain eye contact with the client at all times Explain the reason for taking down notes

explain the reasoning for taking down notes

A client reports experiencing chest pain after eating. Which category within the review of systems should the nurse document this information? cardiovascular gastrointestinal neurologic musculoskeletal

gastrointestinal

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have experience in dealing with these types of clients. knowledge of his or her own thoughts and feelings about these issues. personal experiences with death, dying, and sexuality. advanced preparation in this area.

knowledge of his or her own thoughts and feelings about these issues.

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? a.) family history b.) mini mental health assessment c.) personal health history d.) initial health assessment

personal health history The chief complaint is the abdominal pain. Any associated symptoms would be a part of the history of present illness. The information provided by the client about a past illness would be part of the personal health history. Review of systems provides specific questions about past illnesses that might still be impacting the client.

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

relaxed

The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document? experiences panic attacks several times a week unable to go to the gym since having back surgery misses seeing friends who used to go for walks together gained 15 lbs. over the last 6 month

unable to go to to gym because of surgery The client's inability to go to the gym after having back surgery is affecting the activity-exercise health pattern. Gaining weight affects the nutrition health pattern. Panic attacks affects coping-stress-tolerance health pattern. Missing friends affects the role-relationship health pattern.

A nurse is interpreting and validating information from the client. The nurse is in which phase of the interview? a. working b. intro c. self-reflection d. termination

working During the working phase, the nurse elicits the client's comments about major biographical data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level. Throughout this phase, the nurse listens, observes cues, and uses critical thinking to interpret and validate information received from the client.