Test 4 chapter 2

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?"

"How many steps can you climb before you get short of breath?" is an example of what kind of question?

A question that elicits a graded response

During one of your clinical placements you encounter a patient who becomes silent during the nursing interview. What would be appropriate for you to do? (Mark all that apply.)

Appear attentive Give brief encouragement to the patient Watch the patient closely for nonverbal cues

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?

Circle with a cross

When gathering information about medication use, a nurse should ask a client about which types of drugs?

Prescription and OTC medications

Which of the following questions is most useful in the assessment of a client's diabetes management?

What is your routine for checking your blood sugar these days?

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

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information?

past medical history

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

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.

A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?

"Can you tell me about your sleep problem from when it started until now?"

A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status?

"Do you live alone or with someone?"

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?"

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

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?"

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 client with a terminal diagnosis has asked the nurse about the purpose of a durable power of attorney for health care. What explanation will best answer the client's question?

A proxy is identified to make healthcare decisions when the client is no longer able to do so.

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

A nurse collects data about a client's family health history. Which family member's health problems should the nurse include when documenting this information in the database?

As many maternal and paternal relatives as the client can recall

The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?

Ask the client to repeat the statement or question.

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

When conducting the health assessment, the nurse interacts with the client in a caring manner. How would the nurse demonstrate caring to the client? Select all that apply.

Being nonjudgmental Showing respect to the client Valuing the client unconditionally

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?

How would the nursing instructor explain the goal of guided questioning to his or her students?

Facilitating the patient's fullest communication

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

False

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

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

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

The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview?

Have you ever had a problem with mental or emotional illness?

The nurse should respond to a client's request to "keep what I'm about to tell you a secret" with which statement?

I have to share the information if it reveals something that could hurt you

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? Select all that apply.

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

Which action should a nurse implement when assessing a nonnative 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

When using an interpreter to facilitate an interview, where should the interpreter be positioned?

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

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

What occurs during the termination phase of an interview?

Planning for follow-up care

When interacting with a client, what conveys the extent of interest, attention, acceptance, and understanding of the nurse? (Select all that apply.)

Posture Gestures Tone of voice Eye contact

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.

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 vent feelings

During an interview, the patient begins to talk about the frequency of being abused by a spouse. What can the nurse do at this time to acknowledge the sensitivity of the information the patient is providing?

Stop documenting in order to maintain eye contact with the patient.

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

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 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 client may not want the sister to know their private information

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 who may be shy in social situations may exhibit excellent therapeutic communication by what? Select all that apply.

Using silence Using touch Communicating nonverbally through facial expression

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

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.

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

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?

chief complaint

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 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

expressing interest in a neutral manner.

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

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

gastrointestinal

The nurse is beginning the review of systems with a client. Which approach would ensure that all major body systems are included in this assessment?

head to toe

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

A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?

health maintenance

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?

history of present illness

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have

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

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should

maintain eye contact while asking the questions from the form.

During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information?

neurologic

Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms and to generate and test diagnostic hypotheses?

open-ended questions to encourage the client to tell his or her story

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?

physical abuse

During the interview of an adult client, the nurse should

provide the client with information as questions arise.

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

During an interview with an adult client for the first time, the nurse can clarify the client's statements by

rephrasing the client's statements.

During an interview with an adult client, the nurse can keep the interview from going off course by

using closed-ended questions.

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?

value-belief

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.