Health Assessment Chapter 2
When interviewing a patient with a language barrier, it is best to use a family member to help interpret so the patient has a level of comfort with the process. True False
Flase Recruiting family members or friends to serve as interpreters can be hazardous—confidentiality and cultural norms may be violated, meanings may be distorted, and transmitted information may be incomplete. Untrained interpreters may try to speed up the interview by telescoping lengthy replies into a few words, losing much of what may be significant detail.
Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data? Speak to the client using local slang. Maintain a professional distance during assessment. Avoid any eye contact with the client. Ask one of the client's children to interpret.
Maintain a professional distance during assessment.
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 summarize the conversation To restate what the patient has said To promote objectivity To clarify
to clarify
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? Working Beginning Closing Preinteraction
working During the working phase, the nurse collects data by asking specific questions. Two types of questions are closed-ended and open-ended. Each type has a purpose; the nurse chooses which type will help solicit the appropriate information. The pre-interaction phase is prior to meeting with the client. The nurse review the client's medical records to collect important data. The beginning phase is the phase when introductions are exchanged and the purpose of the interaction is explained to the client. The closing phase is a time for summarizing information shared with the client and assessing any learning deficits.
How would the nursing instructor explain the goal of guided questioning to his or her students? Providing the most plausible answer to the patient Facilitating the patient's fullest communication Developing a basis for accurate health promotion activities Creating an opportunity for the early generation of a plan
The main goal of guided questioning is to facilitate the patient's fullest communication. The early generation of a plan is not a paramount goal and it is incorrect to suggest particular answers to the patient.
A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information? create a genogram document it in a narrative note include in the past medical history consider using it when planning care
create a genogram
A clinic nurse is caring for a newborn and the newborn's parents. Observing parental behavior is an important nursing function during this child's well-baby visit. What would the nurse expect during observation? Parents encouraging the baby's happy behaviors Parents feeding the baby every time the baby cries Parents ignoring the infant's fussy behavior Parents playing with an irritable infant
Parents encouraging the baby's happy behaviors
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? Transition Summarization Reassurance Termination
Summarization can be used at different points in the interview to structure the visit, especially at times of transition. This technique also allows the nurse to organize his or her clinical reasoning and to convey it to the patient, making the relationship more collaborative. It is also a useful technique for learners when they draw a blank on what to ask the patient next.
A client is experiencing a relapse of a urinary tract infection. Which additional information should the nurse collect when discussing this client's present health problem? sexual history family history past medical history health maintenance
sexual history Although questions about sexual behavior can be used at multiple points in an interview, if the chief complaint involves genitourinary symptoms, questions about sexual health can be included as part of expanding and clarifying the client's story. The issue of repeated urinary tract infections is not appropriate when collecting data about the client's family history, past medical history, or health maintenance.
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. Approach the client in an in-control manner. Refer the client to a spiritual guide. Mirror the client's feelings.
Provide simple and organized information. The nurse should provide simple and organized information to reassure the client about the procedure and its expected outcomes. The nurse approaches the aggressive, not anxious, client in an in-control manner. The nurse refers the dying client or client with spiritual concerns to a spiritual guide. The nurse should avoid expressing anxiety or becoming anxious like the client, as it would make the client more anxious.
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? Only the members with health problems that relate to the client's gender As many genetic relatives as the client can recall Those with diseases that are known to have a genetic link with illnesses that resulted in death or disablement
As many genetic relatives as the client can recall Both maternal and paternal genetic relatives are included in the family health history. Problems can arise in families that are not genetically based but are manifest by virtue of exposure to lifestyle practices. Parents, grandparents, aunts, uncles, and children are all included in this history. If the relative is deceased, the cause of death and age of death of the relative is recorded.
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? "I recommend that you change your posture while working at the computer." "You work at a computer a lot, don't you?" "When did the pain start?" "Do you perform any sustained or continually repetitive motions with that arm?"
"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. Recommending that the client change his posture while working at the computer is premature, as the nurse has not confirmed that the computer work is the culprit. Likewise, "You work at a computer a lot, don't you?" is a leading question, as it encourages the client to answer in the affirmative. The question, "When did the pain start?" is a close-ended question; it will elicit more information from the client but is not an example of inferring.
Which of the following questions is most useful in the assessment of a client's diabetes management? "You check your sugars before each meal, don't you?" "Are you still using your glucometer 4 times a day?" "Are you staying vigilant with your blood sugar monitoring?" "What is your routine for checking your blood sugar these days?"
"What is your routine for checking your blood sugar these days?" it's open-ended
A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format of representing a deceased female relative? Simple circle Simple square Circle with a cross Square with a cross
Circle with a cross The standard format of representing a deceased female relative in a genogram is using a circle with a cross. A simple circle indicates a living female relative. A simple square indicates a living male relative. A square with a cross indicates a deceased male relative.
A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client? The sister may not tell the client exactly what the nurse says The client's sister may not understand medical terminology The sister may not be there every time the nurse needs to talk to the client The client may not want her sister to know her private information
The client may not want her sister to know her private information Using children in the family, other relatives, or close friends as interpreters violates privacy laws, because clients may not want to share personal information with others. HIPAA guidelines address privacy issues such as this scenario. Even when the client gives permission for the family member to be present, an official interpreter should be present per facility policy. The other options could be true in some situations, but the priority answer addresses privacy, both the client's right to privacy, and the facility's handling of private information.
The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus? sleep-rest activity-exercise coping-stress-tolerance self-perception/self-concept
coping-stress-tolerance The client's inability to sleep is being caused by anxiety which would be addressed within the coping-stress-tolerance category of the health pattern review. The client's anxiety is causing an issue within the category of sleep-rest. The client's anxiety would not be addressed within the activity-exercise or self-perception/self-concept categories within the health pattern review.
The nurse is planning to interview a client who is being treated for depression. When the nurse enters the examination room, the client is sitting on the table with shoulders slumped. The nurse should plan to approach this client by providing the client with simple explanations. offering to hold the client's hand. using a highly structured interview process. expressing interest in a neutral manner.
expressing interest in a neutral manner. When interacting with a depressed client, express interest in and understanding of the client and respond in a neutral manner.
For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have advanced preparation in this area. 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.
knowledge of his or her own thoughts and feelings about these issues. Be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then recognize that these factors may affect the client's health and may need to be discussed with someone.
The nurse is planning to interview a client who has demonstrated manipulative behaviors during past clinic visits. During the interview process, the nurse should plan to give the client rules with which he must agree to comply. provide structure and set limits with the client. tell the client that the nurse is aware of his past behaviors. approach the client in an authoritative manner.
provide structure and set limits with the client.
During a health history a client recalls the date when being first diagnosed with hypertension. Which term should the nurse use to categorize the quality of the client's data? reliable puzzling concerning questionable
reliable
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 The client's wife The physician The client's medical record
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.
