HA CH 2
Client presents to the health care clinic with reports of sleeplessness and loss of appetite. The client tells the nurse that his wife is seriously ill in the hospital and he's not been able to visit her much because of the transportation problems. Which open ended question should the nurse asked the client to obtain more information about presenting symptoms?
"Do you think your wife is getting any better?"
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 the component associated factors?
"What other symptoms occurred during the spell?"
Which interview question by the nurse demonstrates a biased or prejudiced attitude?
"You're not homosexual, are you?"
A nurse collects data about a client's family health history. Which family members' health problems should the nurse include when documenting this information in the database?
As many maternal and paternal relatives as the client can recall
A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative?
Circle with a cross
A nurse receives report on a client admitted for new onset of lung cancer and reviews the initial comprehensive assessment. The nurse recognizes that which information is subjective and needs to be validated by further data collection?
Client denies any feelings of anxiety or distress over distress the diagnosis
A nurse is collecting subjective data from a client as part of the assessment process. Which behavior is most appropriate for the nurse to display in this situation?
Explaining the reason for taking down notes The nurse should explain the reason for taking notes during the interview and ensure that it will remain confidential; this will help the client to provide all the required information during the interview.
A nurse is gathering biographic data from a new client who is visiting the office for the first time. Which of the following pieces of data would likely be included in the biographic section of the client's health history?
Lamar P. Thompson 1212 South Maple St., Sylvan, VA 23236 Caucasian Occupation: Brick mason
A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information?
Lifestyle and health practices profile
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
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
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 health history
A nurse is interviewing a client who seems anxious. Which nonverbal communication by the nurse helps to facilitate a relaxed environment for the client during the interview process?
Portraying a neutral and friendly expression
When gathering information about medication use, a nurse should ask a client about which types of drugs?
Prescription and OTC medications It is important to ask a client about prescription, OTC, vitamin & herbal supplements, as well as information about substance use/abuse. Many OTC and herbal supplements can interfere with the action of prescription drugs or cause untoward side effects.
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 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?
Remain in control and allow the client to ventilate feelings An angry client should be approached in a calm, reassuring, in-control manner by the nurse. Allow the client to ventilate his feelings, as this may help to diffuse the anger.
A nurse is interviewing a 16-year-old girl regarding her health history. When inquiring about her chief complaint, the girl lowers her voice and says, "I've been with a guy recently, and I'm worried that I might have caught something from him." The nurse responds by saying, "So, you're concerned that you may have a sexually transmitted infection?" Which verbal communication technique is the nurse using here?
Rephrasing
In interviewing a client about substance use, a nurse asks her whether she takes any herbal supplements. Which of the following is the best rationale for asking this question?
Some herbal supplements may interact with prescribed medications.
An elderly female client is accompanied by her daughter on a visit to the health care facility. The nurse observes that the client is doing quite well, except for the use of a hearing aid. How can the nurse best facilitate the interview process with this client?
Speak slowly and clearly, using straightforward language
A client reports chest pain that occurs with exercise but subsides with rest. The nurse recognizes this as what type of data?
Subjective
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
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 During the working phase, the nurse asks the client about the history of the present health concern and the reasons for seeking care.
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?
termination/Closing
A nurse is interviewing a client who has recently been diagnosed with terminal disease. In covering his lifestyle and health practices profile, the nurse asks the client, "Are you close to any extended family members in the area?" The man objects to the question and asks why the nurse needs to know that. Which of the following is the best rationale for the nurse posing this question?
"I just wanted to see what kind of social support you might have to help care for you during your illness." Ask clients to describe the composition of the family into which they were born and about past and current relationships with these family members. In this way, you can assess problems and potential support from the client's family of origin.
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?
"Denies any trouble hearing or any ringing, buzzing, or earaches."
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?" Inferring information from what the client tells you and what you observe in the client's behavior may elicit more data or verify existing data. Be careful not to lead the client to answers that are not true. The question, "Do you perform any sustained or continually repetitive motions with that arm?" is open enough to not lead the client to an expected answer but narrow enough for the nurse to help elicit more information from the client about probable causes of his pain.
Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data?
Maintain a professional distance during assessment. When assessing a nonnative client, the nurse should maintain a professional distance during assessment; the size of personal space affects one's comfortable interpersonal distance.
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. The nurse should provide simple and organized information to reassure the client about the procedure and its expected outcomes.
What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking?
Suggest methods and provide resources to assist with smoking cessation The client will know that the nurse understands that it is hard to quit smoking if the nurse suggests methods available to help kick the smoking habit. The nurse should keep a neutral and friendly expression, and avoid any display of surprise or shock at the situation. A neutral, friendly expression will help the client to open up and explain to the nurse his efforts at breaking free from the habit. The nurse need not tell the client that excessive smoking could cause cancer, as the client will likely be well aware of the dangers of smoking.
