TTT Exam 1 Chapter 2: Collecting Subjective Data: The Interview and Health History - ML8
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?"
Which statement made by the nurse demonstrates an understanding of the termination phase of the interviewing process?
"Let me stress the importance of being medication adherent."
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?"
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."
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 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.
During an interview, how can the nurse best assist the client as the client tells their story?
Avoid interrupting the client.
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.
What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?
Closing the door may help to limit background noise.
The nurse is focusing an interview on a client's respiratory status. Which question should the nurse ask first to begin this interview?
Describe how you breathe for me?
A nurse completes an initial assessment and discusses findings with the client. What is the next best action of the nurse?
Develop a plan of care with the client.
A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client's data, which of the following actions should the nurse prioritize?
Establishing a trusting relationship
Prior to conducting an initial interview with a new client, the nurse reviews the client's chart and learns that the client has a history of presbycusis (hearing loss that occurs in older adults). What is the best action(s) of the nurse to improve communication with this client during an initial interview? Select all that apply.
Face the client and use low tones. Reduce environmental noise.
How would the nursing instructor explain the goal of guided questioning to his or her students?
Facilitating the client's fullest communication
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
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
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 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
A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned?
Seated in a chair at eye level with the client
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.
During an interview, the client 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 client is providing?
Stop documenting in order to maintain eye contact with the client.
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 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
During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?
Working
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
When interviewing, the nurse should logically move from specific to open-ended questions.
false
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 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?c
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
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.
A client has a 10-year history of being treated for hypertension. Where should the nurse document this information?
past medical history
During an initial health history, a client states, "I haven't slept in weeks." The nurse asks, "You are saying that you have not had any sleep in weeks?" What communication technique is the nurse using to obtain accurate subjective data from the client?
rephrasing
While interviewing an adult client about her nutrition habits, the nurse should
review the ChooseMyPlate information with the client.
A nurse in a clinic is preparing to meet with a new, 35-year-old male client. Complete the following sentence by choosing from the lists of options. Prior to meeting the new client, the nurse should first.... and then....
review the client's medical record explain the purpose of the interview
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.
During an interview with an adult client, the nurse can keep the interview from going off course by
using closed-ended questions.
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
The review of systems is to be completed next while conducting a comprehensive assessment. Which type of question should the nurse use for this review?
yes or no
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?"
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
The nurse performs a focused assessment on a client who is reporting joint pain. To gain a better understanding of the client's pain, the nurse uses COLDSPA. Which question(s) should the nurse ask the client to determine the origin of the pain? Select all that apply.
"When does the pain occur?" "What makes the pain better or worse?" "How would you describe the pain?" "Could you show me where the pain is exactly?"
During a comprehensive assessment the client reports having a college education, is employed as a human resource director, and is 45 years old. Which part of the assessment should the nurse document this information?
identifying data
During the interview of an adult client, the nurse should
provide the client with information as questions arise.
A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?
create a genogram
During a health history, the nurse recommends using a genogram. The client asks the nurse to explain the purpose of a genogram. How should the nurse respond?
"It helps the nurse organize data on the client's family history."
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
A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?
Explain the purpose of the interview.f
A client's spouse answers the interview questions and will not leave the examination room. What should the nurse suspect may be occurring with the client?
intimate partner violence
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
An initial review of the client's chart and brief interview reveals the following: ● Labs: Albumin 1.5 g/dL (3.5-5.0 g/dL), AST 185 U/L, ALT 200 U/L ● Client states: "I've gained so much weight in the last month." ● Client states: "My stomach feels distended." ● Client states: "I drink about 1 bottle of wine every day." ● Client's weight is 150 lb. (68 kg) ● 4+ pitting edema lower extremities Which subjective finding will the nurse document? Select all that apply.
report of weight gain report of abdominal distention
