Weber's Health Assessment in Nursing Chapter 2 Prep U

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

Between the examiner and the client, so all parties can make the necessary observations

In a corner of the room, so as to provide minimal distraction to the interview

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

A priority is for the examiner is to have a good view of the client and to avoid having to look back and forth between client and interpreter. The nurse should remember to use short simple phrases while speaking directly to the client and ask the client to repeat back what he or she understands.

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

cardiovascular

musculoskeletal

peripheral vascular

neurologic

Because the client states numbness of the hands, this information should be included under the neurologic system. Even though the symptom affects the hands, it should not be documented under musculoskeletal. This symptom is not a cardiovascular problem. Peripheral vascular is not a category within the review of systems.

Which statements provide information about a client's health maintenance? Select all that apply.

A child received immunizations based on the recommended schedule.

A female client had a mammogram 2 weeks ago.

A client recently a had lab test for liver function.

A client was hospitalized for dehydration 2 years ago.

A client had a circumcision at birth.

A child received immunizations based on the recommended schedule.

A female client had a mammogram 2 weeks ago.

A client recently a had lab test for liver function.

Immunizations, screening tests, safety measures, and any lifestyle-related risk factors all provide information about a client's health maintenance. Past hospitalizations and surgical procedures do not provide information about health maintenance as this information does not capture ongoing health factors that impact the client's overall quality of health.

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

allow the client time to calm down.

avoid discussing sensitive issues.

set time limits with the client.

explain the role and purpose of the nurse.

explain the role and purpose of the nurse.

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.

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

using open-ended questions.

rephrasing the client's statements.

inferring information.

using closed-ended questions.

using closed-ended questions.

Use closed-ended questions to obtain facts and to focus on specific information. Closed-ended questions are useful in keeping the interview on course.

The nurse is interviewing a client. The client describes why he is visiting the clinic. The nurse then briefly summarizes the main points of what the client has just said. What type of communication is the nurse using?

Reflection

Elaboration

Restatement

Silence

reflection

Reflection is similar to restatement; however, instead of simply restating comments, the nurse summarizes the main themes of communication. Elaboration is encouraging the client to say more. Creating silence allows clients to gather their thoughts.

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.

Summarize findings.

Build rapport.

Provide a comfortable environment.

Explain the purpose of the interview.

Ensure confidentiality.

During the introductory phase of the interview, it is essential that the nurse gain the client's trust and build rapport, provide a comfortable physical and emotional environment, explain the purpose of the interview, and ensure information will remain confidential as per HIPAA (Health Insurance Portability and Accountability Act) guidelines. Summarizing findings occurs during the summary and closing phase of the interview.

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?

self-concept

mental health

family violence

role-relationship

family violence

The family violence portion of the comprehensive health history focuses on personal safety. Self-concept and role-relationship are health patterns. The mental health portion of the comprehensive health history focuses on emotional and mental health.

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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?

"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."

"The care team needs to cross-reference your diagnostic testing with your medical history."

"We don't want to focus solely on the medical problem that brought you here."

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

Taking a health history should begin with an explanation to the client of why the information is being requested; for example, "so that I will be able to plan individualized nursing care with you." The other listed statements are not inaccurate, but none directly describes the rationale for the nursing health history.

Alexandra, 28 years old, presents to the clinic. She has abdominal pain that she describes as a dull ache, located in the right upper quadrant, and that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago; it lasts for 2 to 3 hours at a time, comes and goes, and seems to be worse a few hours after eating. The client has noticed that the pain starts after eating greasy foods, so she has cut down on this as much as she can. Initially the pain occurred once a week, but now it happens every other day. Nothing makes it better. From this description, which of the attributes of a symptom has been omitted?

Setting in which the symptom occurs

Associated symptoms and signs

Quality

Timing

Associated symptoms and signs

The interviewer has not recorded whether nausea, vomiting, fever, chills, weight loss, and so on have accompanied the pain. Associated manifestations are additional symptoms that may accompany the initial chief complaint and that help the examiner to start refining his or her differential diagnosis.

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?

Introductory

Summary

Analysis

Working

Summary

During the summary and closing, the nurse summarizes information obtained during the working phase and validates problems and goals with the client. In the introductory phase, the nurse meets the client and explains the purpose of the interview, discusses what type of questions will be asked, explains reasons for taking notes, and assures the client that confidential information will remain confidential. Analysis is not a phase of the interview process. The working phase is when data collection occurs.

When assessing the gastrointestinal system, the nurse correctly asks, "Do you have any trouble swallowing?"

true

false

true

A nurse is eliciting a client's health history and the client asks, "Can I take the herb ginkgo biloba with my other medications?" What action would be best if the nurse is unsure of the answer?

Explain that you will find out the information for the client.

Change the subject and return to this topic later.

Teach the client to only take prescribed medications.

Encourage the client to ask the pharmacist or primary care provider.

Explain that you will find out the information for the client.

The nurse should address all questions asked by a client as best as possible and should make every effort to find unknown answers. Ignoring the question and telling the client to ask the pharmacist interferes with trust and does not ensure adequate follow-up. Telling the client to take only prescribed medication ignores the client's feelings and may not be accurate.

A client with acute onset of shoulder pain is answering questions during a health history. The nurse is utilizing a mnemonic specific to the attributes of a symptom. The nurse first asks about the onset of symptoms followed by

relieving/exacerbating factors

characteristic symptoms

associated manifestations

location

duration

treatment

location

duration

characteristic symptoms

associated manifestations

relieving/exacerbating factors

treatment

This is an example of using the "OLDCARTS" mnemonic to understand a symptom.

Jason, a 41-year-old electrician, presents to the clinic for evaluation of shortness of breath, which occurs with exertion and improves with rest. The shortness of breath has been occurring for several months. Initially, it happened only a few times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than 12 times a day. The shortness of breath lasts for fewer than 5 minutes at a time. The client has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. Which of the following symptom attributes was not addressed in this description?

Severity

Setting in which the symptom occurs

Timing

Associated symptoms and signs

Severity

The interviewer did not record the severity of the symptom, so we have no understanding as to how bad the symptom is for this client. The client could have been asked to rate his pain on a 0 to 10 scale or according to one of the other standardized pain scales available. This allows the comparison of pain intensity before and after an intervention.

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

offering a "laundry list" of descriptors.

rephrasing the client's statements.

repeating verbatim what the client has said.

inferring what the client's statements mean.

rephrasing the client's statements.

Rephrasing information the client has provided is an effective way to communicate during the interview. This technique helps you to clarify information the client has stated; it also enables you and the client to reflect on what was said.

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

Using silence

Giving advice

Using touch

Discussing alternative treatment options

Communicating nonverbally through facial expression

Using silence

Using touch

Communicating nonverbally through facial expression

Because of the nurse-client relationship, the nurse in the professional role listens more than talks. Those who might be shy in social situations may exhibit excellent therapeutic communication not by talking but by communicating nonverbally through presence, facial expression, or touch. This makes giving advice and discussing alternative treatment options incorrect answers.

The nurse documents that a client completed a 4-year college program and speaks English. How will this information be used?

Determine health literacy

Validate the client's stated age

Understand choice of occupation

Analyze the client's lifestyle patterns

Determine health literacy

Knowledge of the client's education level and primary language will help assess the client's health literacy level which is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Education level and primary language are not used to validate the client's age, understand the choice of occupation, or to analyze the client's lifestyle patterns.

The nurse would document driving with car seatbelt fastened, bicycling with properly-fitted helmet, and installing a smoke detector in a vacation home in the client's health history under which of the following?

Identifying data

Reliability

Review of systems

Personal and social history

Personal and social history

Health-maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety are components of the client's personal and social history.

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.

read the questions verbatim from the form.

ask the client to complete the form.

ask leading questions throughout the interview.

maintain eye contact while asking the questions from the form.

Establish eye contact when the client is speaking to you but look down at your notes from time to time.

The nurse is in the introductory phase of the client interview. Which of the following activities would be appropriate?

Collaborating with the client to identify problems

Explaining the purpose of the interview

Determining the client's reason for seeking care

Obtaining family health history data

Explaining the purpose of the interview

During the introductory phase, the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client about the confidentiality of the information. Collaborating to identify problems, determining the reason for seeking care, and obtaining family health history data are components of the working phase.

The client presents to the clinic reporting chest pain and shortness of breath. Which type of health history would the nurse would conduct?

Emergency

Comprehensive

Focused

Review of systems

Emergency

Reports of chest pain and shortness of breath can indicate a life-threatening situation, such as myocardial infarction. The nurse needs to quickly collect information regarding the presenting problem and act to stabilize the client. A comprehensive health history would not be appropriate at this time, because information about demographics, family history, functional and psychosocial status, and review of systems is not a priority. A focused assessment is not appropriate for the client presenting with a potential life-threatening situation.

A nurse has admitted a client to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe?

"This helps us to complete your health record accurately."

"This helps us to establish a trusting interpersonal relationship."

"This helps us to evaluate the seriousness of your risk factors for disease."

"This helps us have an appropriate focus for the physical examination."

"This helps us have an appropriate focus for the physical examination."

The information gained in a comprehensive health history lays the groundwork for identifying client health problems that need further exploration and validation during the physical exam. It is one aspect of the client's health record and helps to provide some indication about possible risk factors for the client. Trust is necessary, but this is not the central purpose.

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The nurse is using the COLDSPA mnemonic to assess a client's history of chest pain. What interview question addresses the "A" in this assessment model?

"Do you have any other symptoms together with your chest pain, such as nausea, sweating?"

"In your experience, what kinds of activities tend to cause your chest pain?"

"Would you describe your chest pain as being acute, or is it chronic?"

"What changes do you have to make in order to accommodate your chest pain?"

"Do you have any other symptoms together with your chest pain, such as nausea, sweating?"

The "A" in COLDSPA addresses associated factors, such as dyspnea, diaphoresis, pale clammy skin, nausea, and vomiting.

The nurse prepares to complete a past medical history with a client. Which areas should the nurse include in this history? (Select all answer choices that apply)

Location

Allergies

Medications

Adult illnesses

Exacerbating factors

Allergies

Medications

Adult illnesses

Key elements of the past history include allergies, medications, and adult illnesses. Location and exacerbating factors are a part of the history of present illness.

A teenage girl comes to the clinic with abdominal pain. She is accompanied by her mother. During the interview, the nurse gets the impression that the client wants to talk but is afraid to with her mother in the room. What action by the nurse would best facilitate communication with the adolescent client?

Politely ask the mother to wait in the waiting room

Try to coax the information from the client without asking the mother to leave

Ask the client to write her answers down so that the nurse can read them after the girl and her mother leave

Ask the mother to get the information at home and call it in to the clinic

Politely ask the mother to wait in the waiting room

Adolescent concerns may involve sensitive issues such as sexuality, drugs, and alcohol. Privacy for this client is especially important; adolescents need an opportunity to discuss health-related issues without parents present. The nurse asks parents for time alone with clients and conveys an attitude of respect toward teens by being honest and treating them maturely. The nurse would never try to coax information from the client without asking the mother to leave; having the client write down the answers so that the nurse can read them later could potentially anger a mother who would not leave the room and give her child some privacy with the nurse. Asking the mother to get the information at home is violating the trust of the client.

The nurse is assessing a client's sexual history. Which question should be included regardless of the presenting problem?

Use of birth control

Last sexual experience

Concerns about HIV or AIDS

Partner preference for intercourse

Concerns about HIV or AIDS

It is important to ask all clients, "Do you have any concerns about HIV infection or AIDS?" even if no explicit risk factors are evident. Questions may be asked about birth control, last sexual experience, and partner preference according to the situation.

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?

Maintaining eye contact with the client at all times

Explaining the reason for taking down notes

Remaining standing during the interview

Reading questions from the history form

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. Some clients may be very uncomfortable with too much eye contact, while others may believe that the nurse is hiding something from them if eye contact is avoided. Therefore, the nurse should maintain only a moderate amount of eye contact and not maintain eye contact with the client at all times. The nurse should not remain standing while taking down notes, as it could indicate being in a hurry to complete the interview; it could also indicate that the nurse is expressing superiority over the client. The nurse should not read questions from the history form, as this deflects attention from the client and results in an impersonal interview process.

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

Avoid any eye contact with the client

Ask one of the client's significant others to interpret

Maintain a professional distance during assessment

When assessing a non-native client, the nurse should maintain a professional distance during assessment; the size of personal space affects one's comfortable interpersonal distance. The nurse should not speak to the client using local slang because, if the client finds it difficult to learn the proper language, slang would be much more difficult to understand. The nurse need not avoid any eye contact with the client, but should maintain eye contact with the client as required, without giving the client reason to think that the nurse is being rude. Asking one of the client's significant others to interpret during the interview may actually impair the assessment process. In addition, health care institutions often have specific policies regarding interpreters that you must be aware of prior to using an interpreter.

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?"

"When did the sleep problem begin?"

"How would you rate your sleep on a scale from 1 to 10?"

"What have you tried to help with your sleep?"

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

In order to open the interview, the nurse should start with an open-ended question and then identify missing data. Asking when the sleep problem began is assessing for the onset of the problem. Asking the client to rate the sleep problem from 1 to 10 is part of assessing characteristic symptoms. Asking the client what has been tried to help with the sleep is assessing for treatments.

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.

ongoing.

working.

closure.

working

During the working phase, the nurse elicits the client's comments about major biographic 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. The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client. The nurse and client collaborate to identify the client's problems and goals.

The nurse assesses an assigned client after receiving morning report to evaluate level of pain. Which type of assessment is the nurse completing?

focused

follow-up

emergency

comprehensive

follow-up

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.

The nurse understands that health promotion is a very important part of nursing care. When performing the health history, there are many different opportunities for the nurse to teach healthy behaviors. One way the nurse can do this is by focusing on which of the following topics:

gender

spirituality

culture

sexual history and pattern

sexual history and pattern

There are many opportunities for the nurse to promote healthy behaviors. When assessing high-risk clients with multiple partners, the nurse can seize this opportunity to provide information that can prevent disease and illness. Gender, culture, and spirituality are not generally factors in teaching about health promotion.

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?

History of present health concern

Personal health history

Family health history

Lifestyle and health practices profile

Lifestyle and health practices profile

By assessing the client with regard to nutritional habits, use of substances, education, and work and stress levels, the nurse expects to obtain a lifestyle and health practices profile. To determine the history of present health concerns, the nurse should ask questions relating to the onset, duration, and treatments, if any have been conducted on the client, for the present health concern. The questions related to personal health history assist the nurse in identifying risk factors that stem from previous health problems. Family health history helps the nurse to identify potential risk factors for the client.

During the interview of an adult client, the nurse should

use leading questions for valid responses.

provide the client with information as questions arise.

read each question carefully from the history form.

complete the interview as quickly as possible.

provide the client with information as questions arise.

If a client reports difficulty breathing or chest pain, the nurse should determine if they are currently experiencing these symptoms and intervene appropriately. Because pain and shortness of breath are subjective, the client may not be exhibiting outward (objective) signs and symptoms. The nurse would document these findings, but this is not the priority action. The nurse needs to address the client's report of shortness of breath before moving onto the next system. Even though the nurse would ask what exacerbates the shortness of breath, this is not the priority action.

During a health history interview the client states, "I have been short of breath." What is the priority action of the nurse?

Document the finding.

Ask the client if they currently feel short of breath.

Move to the next system.

Ask the client what exacerbates their shortness of breath.

Ask the client if they currently feel short of breath.

If a client reports difficulty breathing or chest pain, the nurse should determine if they are currently experiencing these symptoms and intervene appropriately. Because pain and shortness of breath are subjective, the client may not be exhibiting outward (objective) signs and symptoms. The nurse would document these findings, but this is not the priority action. The nurse needs to address the client's report of shortness of breath before moving onto the next system. Even though the nurse would ask what exacerbates the shortness of breath, this is not the priority action.

The nurse is focusing an interview on a client's respiratory status. Which question should the nurse ask first to begin this interview?

Do you currently have a cough?

Do you have any difficulty producing sputum?

Describe how you breathe for me?

Do you experience any pain when you breathe?

Describe how you breathe for me?

During an interview, questions should proceed from general to specific. The question that is the most general is "describe your breathing." This provides the client with an opportunity to discuss the current breathing pattern with the nurse. The other questions are specific and will elicit a yes-no response.

A client is being admitted for elective surgery. What should the nurse instruct the client to do to ensure that the medication history is complete?

bring all medications and preparations used to the hospital

bring all discharge instructions from previous hospitalizations to the hospital

have the health care provider fax a copy of all current medications to the care area

provide the name and telephone number of the pharmacy that fills the prescriptions

bring all medications and preparations used to the hospital

To ensure that a thorough and correct medication history is completed, the nurse should instruct the client to bring all currently taking medications and preparations to the hospital. Asking for copies of previous discharge instructions is unrealistic. The client may not have the instructions or the client may never have been hospitalized. The medication history includes everything the client currently takes. The health care provider may not be aware of nutritional supplements or herbal preparations that the client routinely takes. The client may not use a pharmacy to fill nutritional supplements and herbal preparations. Without this information the medication history is incomplete.

The nurse is preparing to assess the mental status of an older adult client. Which of the following would the nurse need to assess first?

Sensory abilities

General intelligence

Severe phobias

Irrational cognition

Sensory abilities

The nurse needs to assess the older adult's sensory capabilities, such as vision and hearing. Impaired vision can interfere with the older client's ability to read information requested. Assessing hearing acuity is very important when interviewing older adult clients because hearing loss normally occurs with age and undetected hearing loss is often misinterpreted as mental slowness or confusion.

During an interview, how can the nurse best assist the client as the client tells their story?

Avoid interrupting the client.

Use a focused questioning format.

Correct the client when the client makes erroneous statements.

Suggest information the client has appeared to have forgotten.

Avoid interrupting the client.

Correcting the client when they make erroneous statements and suggesting information the client has appeared to have forgotten are both actions that bias the client's story. The nurse should avoid biasing the client's story with unnecessary interruptions, corrections, or suggestions about missing information. Detailed closed or focused questioning should be introduced after the client has finished sharing their story.

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?

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

Encourage the client to use a more appropriate method to cope with feelings

Remain in control and allow the client to vent feelings

An angry client should be approached in a calm, reassuring, in control manner by the nurse. Allow the client to ventilate their feelings may help to diffuse the anger. Telling the client that this information is necessary does not convey an understanding of feelings by the nurse. Touching or arguing with the client may escalate their anger. Encouraging the client to use other methods of coping may help when dealing with a seductive client.

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.

The nurse is preparing to conduct a health history on a client with a long history of drug addiction. What is the best first action of the nurse?

Examine the nurse's own feelings.

Assess the client just like everyone else.

Ask that security be present when interviewing.

Ask that the client be assigned to another nurse

Examine the nurse's own feelings.

After gathering basic data about the client, the nurse should reflect on any personal feelings in order to avoid biases. Even though the nurse should treat and assess the client like every other client, the nurse must overcome biases first. There is no need for a security guard. If the nurse cannot overcome personal biases and thinks it will prevent the nurse from providing quality nursing care, the nurse may ask that the client be assigned to another nurse.

A nurse is performing a client assessment in an urgent care clinic. The most likely tool being used is the

focused assessment

comprehensive health history

follow-up history

emergency history

focused assessment

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.

Ask the client if he understands the risk factors for heart disease and diabetes.

Tell the client to exercise 30 minutes at least 3 days a week.

Document the client's current activity level as minimal.

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.

What information aids the nurse in assessing possible biases in the data collected in the health history?

Ethnicity of client

Gender of client

Source of information

Socioeconomic status of the client

Source of information

Designating the source helps the nurse and reader assess the type of information provided and possible biases.

A 34-year-old man has come to the clinic to establish care. His chief complaint is that "my skin feels sour, so sour" and he fidgets continuously during the interview. How should the clinician best respond to this statement?

Initiate a focused integumentary assessment.

Tell the client that the clinician has concerns regarding the client's cognition and orientation.

Redirect the conversation to include components of a mental status examination.

Explain to the client that his complaint is phrased in an unusual way and that the clinician wants to assess for neurological health problems.

Redirect the conversation to include components of a mental status examination.

A bizarre description of a problem may prompt suspicions of a neurological or psychiatric health problem and is best addressed by steering the interview toward a mental status assessment.

A nurse completes an initial assessment and discusses findings with the client.

What is the next best action of the nurse?

Perform a review of systems.

Develop a plan of care with the client.

Validate the client's biographical data.

Discuss lifestyle and health practices with the client.

Develop a plan of care with the client.

Once the assessment has been completed, the nurse discusses the findings, validates problems, determines goals, and develops a plan of care with the client. The review of systems, validation of biographical data, and discussion of lifestyle and health practices occur during the working phase of the interview.

The review of systems component of the health history is best described as a:

Focus on diseases of the major body systems

Detailed investigation of questions about major body systems

Focus on common questions and issues related to each of the different body systems

Series of questions that start at the head and finish at the feet

Focus on common questions and issues related to each of the different body systems

The review of systems is a systematic method of addressing common questions, symptoms, and issues, rather than specific diseases, of the major body systems. As it is an overview, there should not be a large number or detailed investigation of questions about each system. Given the focus on identifying symptoms, it would be simplistic to describe it as simply a series of head-to-toe questions.

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 genogram is a diagram of the family history. It provides a visual record that allows the provider to quickly identify disease patterns within the family. The family history does not need to be documented in a narrative note. This information is not part of the client's past medical history. It is not typically used when planning care.

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?

adult daughter controlling the interview

unable to recall exact date of last surgery

last surgery date validated by adult daughter

confused regarding dates of surgical procedures

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 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?

Introductory

Working

Summary

Closing

working

During the working phase, the nurse asks the client about the history of the present health concern and the reasons for seeking care. In the introductory phase the nurse explains the purpose of the interview and assures the client that confidential information will remain confidential. During the summary phase or the closing phase, the nurse summarizes information obtained during the working phase and validates problems and goals with the client.

A client who takes oral contraceptives states that she often experiences breast pain just before her menstrual cycle begins. When using the COLDSPA mnemonic to assess the client's pain, the nurse should begin by asking which of the following?

"How would you describe your pain? Is it sharp? Is it an ache?"

"Has the pain changed over time?"

"Would you describe the pain as being constant or as intermittent?"

"Is there anything that makes the pain worse or better?"

"How would you describe your pain? Is it sharp? Is it an ache?"

The "C" in COLDSPA elicits the character of the client's pain. It does not address alleviating and aggravating factors or the timing.

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

Cultural reassurance

Eye contact

Gestures

Posture

Tone of voice

Eye contact

Gestures

Posture

Tone of voice

Consciously or not, the nurse sends messages through both words and behavior. Posture, gestures, eye contact, and tone of voice all convey the extent of interest, attention, acceptance, and understanding.

A client with a long history of chronic renal failure is brought to the emergency room after missing a dialysis appointment. Once the client is stabilized and prior to discharge, what information should the nurse obtain from the client?

the name of the dialysis center

the frequency of the dialysis

if there are any caregivers at home

the reason for the missed dialysis appointment

the reason for the missed dialysis appointment

Once the emergency is resolved, the best action of the nurse would be to perform a focused health interview regarding the missed dialysis appointment that led to an emergency situation. The other options—the name of the dialysis center, frequency of the dialysis, and if there are caregivers at home—will not provide the information needed to prevent this occurrence from happening again.

Which of the following describes how the health history interview differs from a social conversation?

The interview is restricted to actual or potential illnesses.

The interview permits the clinician to express his or her needs and interests.

The interview focuses on the client's

needs to improve health and well-being.

The interview allows more time for the client to demonstrate self-awareness.

The interview focuses on the client's needs to improve health and well-being.

Unlike social conversations, in which participants can freely express their own needs and cand are responsible only for themselves, the primary goal of the nurse-client interview is to maximize the well-being of the client. The interview is not about the nurse's needs or interests, the well-being of the client may encompass more than the client's actual or potential illnesses, and the nurse will refocus the interview as needed to elicit the necessary information.

A comprehensive health history includes which components? Select all that apply.

Reason for seeking care

History of present illness

Past health history

Employment history

Income

Reason for seeking care

History of present illness

Past health history

Usually the nurse collects demographical data first and then elicits from clients a complete description of their reason for seeking care, because that information usually is most important. The nurse collects information about the present illness by beginning with open-ended questions and having clients explain symptoms. A complete description of the present illness is essential to an accurate diagnosis.

A nurse is obtaining subjective data from an adult client who is new to the clinic. The nurse has asked the client, "Where do you usually turn for help in a time of crisis?" What domain is this nurse assessing?

The client's family relationships

The client's current level of social and relational stability

The client's critical thinking and problem-solving abilities

The client's stress management and coping strategies

The client's stress management and coping strategies

This assessment question helps the nurse ascertain the client's strategies for coping and for managing stress. It does not directly assess social support or family relationships, although these may become apparent from the client's response. This question does not address critical thinking or problem solving.

A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview?

preintroductory

introductory

working

summary and closing

working

During the working phase, the nurse interprets and validates information about the client's chief concern, their recent functional decline, their feelings about this and how the decline is impacting their activities of daily living (ADLs). The preintroductory phase takes place prior to the nurse and client meeting when the nurse collects information from the medical record that will be beneficial during the introductory and working phase of the interview. During the summary and closing phase, the nurse summarizes the information obtained during the working phase, and identifies with the client health issues and goals for future care.

An adult client presents at the ED complaining of severe pain in the left upper quadrant. The nurse uses a mnemonic to remember the important elements to assess for the presenting symptom. What elements are represented by the mnemonic OLDCARTS? Select all that apply.

Other complaint

Dynamic

Timing

Character

Location

Timing

Character

Location

OLDCARTS (onset, location, duration, character, associated/aggravating factors, relieving factors, timing, severity)

While discussing family history with a client who is healthy except for a current UTI requiring IV antibiotics, the client tells the nurse that he has three sisters and two brothers. Two of his sisters have died and one brother is in a nursing home after a stroke. The nurse would include the sibling group in a genogram in what manner?

3 circles and 3 squares with lines through 2 circles

3 circles and 3 squares with lines through 2 squares

3 circles and 3 squares with broken lines connecting 2 of the circles

3 circles and 3 squares with two diagonal slashed lines through lines connecting the 2 deceased siblings

3 circles and 3 squares with lines through 2 circles

A client has come to the physician's office several times in the last month with a black eye, bruises, and lacerations on the lower extremities. The client always explains having fallen and tripped. The nurse suspects abuse. The next step should be to:

Report the findings to a supervisor.

Call social services.

Call the police.

Confront the client.

Report the findings to a supervisor.

When abuse is suspected, nurses are obligated to report their concerns to a supervisor and obtain assistance from social services for further assessment. It is not in the nurse's scope of practice to call social services directly, and the nurse should never call the police independently. Also confronting the client will only isolate her and make her more uncomfortable.

The nurse is admitting a new client to the unit. While reviewing old records of the client, the nurse knows that the data being gathered are what kind of data?

Primary

Secondary

Subjective

Objective

Secondary

Charts and family members are considered secondary data sources. The client is the source of primary data. Subjective data are data provided to the nurse by the client; objective data are data that the nurse observes.

An older client arrives for an appointment in the community clinic. Which approach should the nurse use when communicating with this client? Select all that apply.

Use slang

Speak clearly

Avoid jargon

Show respect

Use simple terms

Speak clearly

Avoid jargon

Show respect

Use simple terms

When communicating with an older client the nurse should speak clearly, avoid jargon, show respect, and use simple terms. The use of slang should be avoided.

The nurse is reviewing a new client's chart prior to the initial interview. The chart reveals the client has a visual impairment. What actions should the nurse take to ensure a successful interview?

Knock and announce self before entering the client's room.

Loudly announce self when approaching the client.

Approach the client on the unaffected side and announce self.

Turn lights on when entering the room and announce self.

Knock and announce self before entering the client's room.

Reviewing a client's chart prior to an initial interview will provide the nurse with information that may improve their first encounter and build rapport; for example, if the nurse is aware of a visual deficit, interventions can be implemented from the start of the interview process to ensure a successful interview. The nurse should always announce self at the door before entering a client's room. This is especially important if the client has a sensory deficit such as vision or hearing. If the nurse enters the room unannounced it might startle the client. There is no need to speak loudly while approaching a client with a visual deficit. The nurse should approach the client on their unaffected side but should have announced self before entering the room. Turning the lights on is not necessary in this situation; however, if the client has a hearing deficit, good lighting would be needed for the client to read the nurse's lips.

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?

Initial information

Review of systems

Health patterns

History of present illness

History of present illness

The seven attributes of each principle symptom are documented within the history of present illness within the comprehensive health history. The initial information within the comprehensive health history includes date and time of history, identifying data, and reliability. The review of systems within the comprehensive health history includes the presence or absence of common symptoms related to each major body system. The health patterns section within the comprehensive health history includes personal and social history.

The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document?

gained 15 lbs. over the last 6 months

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

unable to go to the gym since having back 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.

An elderly client arrives in the Emergency Department with nonspecific symptoms. When the nurse attempts to take the health history, the client appears not to understand and does not answer the questions. The nurse realizes that this might be because of a common problem in the elderly, which is:

sensory deficits

anorexia

decubitus

altruism

sensory deficits

Sensory deficits, such as loss of vision or hearing, might alter the history taking. Anorexia is loss of appetite, decubitus is an ulcer, and altruism is a true concern for the welfare of others. Only sensory deficits is a term that explains why the older client cannot answer the questions during the health history.

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?

"How often do your adult children typically visit you?"

"Your husband's death must have been very difficult for you."

"You must quit smoking because it affects others, not only you."

"How would you describe your feelings about getting older?"

"You must quit smoking because it affects others, not only you."

Saying that smoking is harmful to others and telling the client that she must quit forces a sense of guilt on the client. The statement may be seen as "preaching," without focusing on assisting the client to attain optimal health. Asking how often the adult children visit or how the client feels about getting older focuses on information gathering. The statement about the husband's death being difficult is plausible and acknowledges the client's feelings.

During the comprehensive health assessment, the nurse asks several questions relating to the client's family history of illnesses, such as diabetes and cancer. Why does the nurse do this? Select all that apply.

To help identify those diseases for which the client may be at risk

To provide counseling and health teaching in high-risk areas

To identify genetic family trends for which the client is at risk

To elicit negative family history

To help the client feel at ease and not worry about being sick

To help identify those diseases for which the client may be at risk

To provide counseling and health teaching in high-risk areas

To identify genetic family trends for which the client is at risk

The nurse asks the client about the health of close family members (i.e., parents, grandparents, siblings) to help identify those diseases for which the client may be at risk and to provide counseling and health teaching. Information concerning client and family history may be elicited to identify genetic family trends. The primary reasons are not to identify a negative family history or help the client feel at ease and not worry about being sick.

Which observation would cause the nurse to suspect an abusive situation? Select all that apply.

A child is persistent in trying to please a parent.

A caregiver of a cognitively intact older adult dominates the interview

A preschooler rubs her perineum and complains of it hurting.

The explanation of an injury seems appropriate.

A parent allows the adolescent to speak privately with the nurse.

A child is persistent in trying to please a parent.

A caregiver of a cognitively intact older adult dominates the interview.

A preschooler rubs her perineum and complains of it hurting.

Observations suggestive of possible abuse include a caregiver of a cognitively intact older adult dominating the interview, a child being persistent in trying to please a parent, and a preschooler rubbing her perineum and complaining of it hurting. Observations not suggestive of abuse include a parent allowing an adolescent to speak privately with the nurse and an explanation that is appropriate for an injury.

A pregnant woman comes to the physician's office for her first prenatal visit. The nurse knows the importance of performing a comprehensive health history in this case and understands the following must be included (check all that apply):

information about current pregnancy

food preferences

previous pregnancies

obstetrical and gynecological history

family history

information about current pregnancy

previous pregnancies

obstetrical and gynecological history

family history

When the nurse is assessing the value-belief health patterns of a client with a poor prognosis for a diagnosis of pancreatic cancer, which question would be most appropriate to ask

"Where do you find your strength and hope?"

"How have your regular routines changed?"

"How well do you think you can manage your care?"

"Do you feel rested after a night of sleep?'

"Where do you find your strength and hope?"

Asking the client where the client finds strength and hope describes patterns of values, beliefs (including spiritual), and goals that guide choices and decisions. This would be important to identify for this client because the client is facing end-of-life issues. Asking the client how regular routines have changed fits within the activity-exercise health pattern. Asking the client how well the client thinks can manage care fits within the self-perception-self-concept health pattern. Asking if the client feels rested after a night of sleep fits within the sleep-rest health pattern.

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

value-belief

self-perception

role-relationship

coping-stress-tolerance

value-belief

The value-belief health pattern describes patterns of values, beliefs or goals that guide choices or decisions. The self-perception-self-concept pattern describes body image, feeling state, self-esteem, personal identity, and social identity. The role-relationship pattern describes patterns of role interactions and relationships including family functioning and problems, and work and neighborhood environment. The coping-stress-tolerance pattern describes general coping pattern and its effectiveness in terms of stress tolerance.

When beginning the collection of the client data base, which of the following would be most important for the nurse to do?

Establish a trusting relationship

Determine the client's strengths

Identify health problems

Make inferences

Establish a trusting relationship

It is essential for the nurse to develop trust and rapport with the client to elicit accurate and meaningful information. This trust is the focus of the interview and must be developed in the initial phase of the interview. Determining the client's strengths, identifying health problems, and making inferences occur during the working phase of the interview.

The nurse suspects that a female client has an alcohol use disorder. When completing the AUDIT-C screening tool, which response requires further follow-up by the nurse?

"I have one drink a night, about two to four nights a month."

"Sometimes at parties I will have about five or six drinks."

"I'll rarely have six or more drinks on any one occasion; I do so about once a month."

"On the weekends I will go out and have about six to seven drinks with friends."

"On the weekends I will go out and have about six to seven drinks with friends."

The female client who states that she has six or more drinks on a weekly basis or greater has an AUDIT-C score of greater than 3, which requires further follow-up by the nurse. Having a drink a night for two to four nights a month, having five to six drinks on any one occasion, and having six or more drinks only once a month all respectively indicate an AUDIT-C score of less than 3, which does not require additional follow-up by the nurse.

During the working phase of an interview the nurse encourages the client to continue and expand on the health issues. What technique is the nurse using?

empathy

empowering

summarizing

active listening

active listening

Active listening is the process of paying close attention to what the client is communicating, being aware of the client's emotional state, and using verbal and nonverbal skills to encourage the speaker to continue and expand. Empathy is the ability to perceive, reason, and communicate understanding of another person's feelings without criticism. Empowerment instills confidence in the client. Summarizing provides an overview of the client's story.

A client with a foot wound returns to the outpatient wound clinic for a weekly appointment and treatment. Which type of assessment should the nurse complete with this client?

Focused

Follow-up

Comprehensive

Problem-oriented

Follow-up

A follow-up history is a form of a focused assessment. The client is returning to have a problem evaluated after treatment. Data is gathered to evaluate if the treatment plan was successful. A focused or problem-oriented assessment focuses on the client's current problem. The client's symptoms, age, and this history will determine the extent of the physical examination to perform. A comprehensive assessment is completed when admitting a client to a facility.

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?

risk factors

health maintenance

screening test completion

compliance with treatment

health maintenance

One area within health maintenance is completion of vaccinations. If the client cannot recall when the last immunizations were received, this would impact health maintenance. Risk factors focus on tobacco use, environment, safety, and substance use. Screening tests are a subcategory within health maintenance. It is possible that the client is unaware of which vaccinations should be obtained. If this is the case, the client should not be labeled as not being compliant with treatment.

During which of the following phases of the interview process will the nurse assure the client that all personal data the client discusses with the nurse will be kept confidential?

preintroductory

introductory

working

summary and closing

introductory

The introductory phase includes the nurse's introduction to the client, explaining to the client about the type of questions that will be asked, and assuring the client of confidentiality in all areas that are discussed during the interview. The preintroductory phase occurs before the nurse meets the client. During the working phase the nurse obtains biographical data, reasons for seeking care, history of the present concern, past medical history, family history, and review of body systems (ROS). During the summary and closing phase, the nurse summarizes information obtained during the working phase and validates problems and goals with the client.

A middle-aged client has an appointment for a routine physical. Which type of assessment is the most appropriate for the nurse to complete?

focused

follow-up

emergency

comprehensive

comprehensive

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 focused assessment gathers information about the current health problem. A follow-up assessment evaluates a specific problem after treatment. An emergency assessment focuses on data to quickly resolve the immediate health problem.

When considering the attributes of a symptom and the OLD CART mnemonic, which questions will the nurse ask a client who is reporting pain in the left knee? Select all that apply.

"Is there a particular action that causes the knee pain?"

"Can you point to where you feel the greatest amount of knee pain?"

"What do you think is causing your knee pain?"

"Do you feel the pain in places other than just your left knee?"

"What do you do to make the knee pain less severe?"

"Is there a particular action that causes the knee pain?"

"Can you point to where you feel the greatest amount of knee pain?"

"Do you feel the pain in places other than just your left knee?"

"What do you do to make the knee pain less severe?"

Onset, Location, Associated manifestations, and Relieving factors

When interviewing a client who does not speak English, the nurse enlists the assistance of a "culture broker," based on the understanding of what as this person's primary function?

to interpret the language and culture

to evaluate the client's health practices

to teach the client about health care

to make the client feel comfortable and safe

to interpret the language and culture

If misunderstanding or difficulty in communicating is evident, the nurse will seek help from an expert who is thoroughly familiar not only with the client's language, culture, and related health care practices but also with the health care setting and system of the dominant culture, often called a culture broker. The role of a culture broker is not to evaluate the client's health practices, teach the client about health care, or make the client feel comfortable and safe.

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

"Do you feel stress at work?"

"How often do you feel stressed?"

"Is stress a problem in your life?"

"How do you manage your stress?"

"How do you manage your stress?"

To investigate the amount of stress clients perceive they are under and how they cope with it, ask questions that address what events cause stress for the client and how they usually respond. In addition, find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive.

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.

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

Laugh a lot, which puts the client at ease

Do not look the client in the eye

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

The nurse is interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of guided questioning?

Use directed questioning: start with the general and proceed to the specific in a manner that does not make the client give a yes/no answer.

Reassure the client that the urinary symptoms are most often treated successfully.

Offer the client multiple choices to clarify the character of the urinary symptoms that she is experiencing.

Ask the client to tell you exactly what she means when she states that she has a urinary tract infection.

Reassure the client that the urinary symptoms are most often treated successfully.

Reassurance is not part of clarifying the client's story; it is part of establishing rapport and empathizing with the client.

Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the client's quality of life. When assessing ADLs, the nurse asks if the client can grasp small objects and open jars. This is an example of assessing the client's:

self-perception

mobility

home maintenance

values and beliefs

mobility

This is an example of assessing the client's mobility. Self-perception is how the client views himself or herself. Home maintenance includes such things as housekeeping chores, cooking, shopping, and driving. Values and beliefs guide a person's choices or decisions.

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

Gives them the basis to establish a trusting relationship

Gives them each a better understanding of the other

Gives them the ability to communicate better

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

When recording the client's reason for seeking care (chief concerns) during the health history, it is recommended that the interviewer:

Quote the client's words

Summarize the client's words

Paraphrase the client's words

Describe the client's concerns and health goals

Quote the client's words

When recording the client's reason for seeking care (chief concern), it is preferable to quote the client's exact words whenever possible.

The nurse completes an initial health history on a client. The nurse recognizes which of the following as being subjective data? Select all that apply.

client verification of allergies to penicillin

observations by nurse or family members

personal health history

client report of headache

client's flat affect

client verification of allergies to penicillin

personal health history

client report of headache

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?

"How bad was the tingling and numbness?"

"How long did the spell last?"

"Where did the numbness and tingling occur?"

"What other symptoms occurred during the spell?"

"What other symptoms occurred during the spell?"

Examples of questions related to associated factors include the following: "What other symptoms occur with it? How does it affect you? What do you think caused it to start? Do you have any other problems that seem related to it? How does it affect your life and daily activities?" The question, "How bad was the tingling and numbness?" relates to severity. The question, "How long did the spell last?" relates to duration. The question, "Where did the numbness and tingling occur?" relates to location.

The nurse is conducting an initial health history with a client. The nurse asks about the client's history of neurological, respiratory, cardiovascular, and musculoskeletal problems. Which part of the subjective health assessment is the nurse performing?

health and lifestyle practices

biological information

review of the systems

family history

review of the systems

In asking about the client's history of neurological, respiratory, cardiovascular, and musculoskeletal problems, the nurse is conducting a review of the systems. Health and lifestyle practices focuses on lifestyle practices that place the client at risk for certain diseases. Biological information includes name, religion, and occupation. Family history provides information about diseases that may be genetic and predispose the client.

The nurse is teaching the client how to self-administer insulin. Which functional health pattern does this nursing intervention address?

Health perception-health management

Role-relationship

Coping/stress tolerance

Cognition-perception

Health perception-health management

Teaching a client to self-administer insulin would be a nursing intervention addressing the health perception-health management pattern. The health perception-health management pattern assessing the client's ability perceptions of their health and practices they perform to maintain and promote their health. The Role-Relationship pattern assesses the client's ability to fulfill personal roles and the relationships they have with family and others. The coping-stress tolerance pattern includes the client's general coping pattern and their effectiveness in handling stress. Sensory perceptions and though patterns are included in the cognition-perception functional health pattern.

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?

"Do you have adequate health insurance coverage?"

"Are you generally fairly healthy?"

"What is your major health concern at this time?"

"Did you bring all your medications with you?

"What is your major health concern at this time?"

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 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?

health patterns

chief complaint

review of systems

history of present illness

chief complaint

The chief complaint is the reason for the person seeking care. Health patterns focuses on the client's social history. The review of systems is where the presence or absence of common symptoms related to each major body system are reviewed and documented. The history of present illness describes how each symptom developed. It includes the client's thoughts and feelings about the illness, relevant parts of the review of systems, and medications, allergies, and lifestyle habits that impact the present illness.

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?

"What medication do you take for your depression?"

"When was the last time you talked with a psychiatrist?"

"Have you considered counseling for your mental problems?

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

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

The nurse should begin by asking a non-threatening, open-ended question such as "Have you ever had a problem with mental or emotional illness?" Even though the nurse has information about this topic in the documentation, asking the question opens a dialogue with the client in which the client can share as feels comfortable. The question may elicit important information about the client's prior experiences seeking care for mental illness, for example. Asking specifically about medication for depression assumes the client has a history of depression. Asking about talking with a psychiatrist or counseling may cause the client to become defensive.

The nurse has been assigned to a group of clients on a medical surgical unit. What is the best action of the nurse prior to receiving a report on these clients?

Conduct a brief review of the client's charts.

Perform a quick assessment on all the clients.

Provide a brief introduction to the clients.

Validate problems and goals with the clients.

Conduct a brief review of the client's charts.

During the pre-introductory phase of the interview, the nurse should review the client's chart. Information from the chart may assist the nurse with conducting the interview. Physical assessment is conducted during the working phase of the interview. The introduction is done during the introductory phase of the interview. Validating problems and goals is performed during the summary and closing phase of the interview.

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

yes-or-no questions to determine

relevant areas of the physical examination

specific questions to secure a description of every symptom

pertinent positive and negative questions to determine relevant details

open-ended questions to allow full freedom of response

open-ended questions to allow full freedom of response

Open-ended questions such as "How can I help you?" should be asked by the nurse first to allow full freedom of response. Specific questions are then used to get the features of every symptom. Yes-or-no questions, also referred to as pertinent positives and negatives, are used to retrieve information from the review of systems assessment.

A nurse receives a new order for intravenous fluids (IVF) for a client. The nurse reviews the client's health history prior to administration. For which of the following findings should the nurse clarify this order?

The client has allergies to shellfish and iodine.

There is a family history of cardiac disease.

The client's last admission was eight (8) months ago.

The client has a long history of congestive heart failure and fluid overload.

The client has a long history of congestive heart failure and fluid overload.

A client receiving continuous intravenous fluids is at risk for fluid overload. A client with a history of congestive heart failure is at high risk for fluid overload. The nurse should clarify this order. The other options—having allergies to shellfish and iodine, family history of cardiac disease, and client's last admission date—do not affect the nurse's decision as to whether or not to administer the IVF.