Health Assessment Ch 2 Subjective data: Interview/health history

What data is collected as part of interviewing the client to obtain a nursing health history

Subjective data

Subjective data includes

Symptoms/feeling/perception/desire/preference/ideas/

beliefs/ values

Subjective data is

Personal information obtained in interview confirmed by the client, that may give clues about problems or risks.

Why is interviewing important in obtaining a valid nursing health history?

It builds trust with the client and allows the nurse to gather physiologic, psychological, sociocultural, and spiritual information.

What is the sensible thing for the nurse to do before meeting the client this is part of the introductory phase

the nurse should review the health record (pre-intro phase).

The nurse meets the client, what should they do before the interview starts during the intro phase

The nurse, explains the purpose of the interview

During the intro phase, what may help the client speak openly about personal health concerns if they are concerned about privacy

The nurse should assure the client that all shared info will remain confidential under HIPAA

Example of good rapport btwn Nurse and student

"The nurse develops trust and rapport by maintaining eye contact, using a warm tone of voice, smiling appropriately, and actively listening to the client’s concerns."

During the working phase biographical data is collected what aspect is collected that helps ID the clients coverage and ensures that the healthcare services provided can be billed correctly

Health insurance

Which of the 3 phase is described below:

the nurse collects biographical data and asks about the client’s current health concern or reason for seeking care, as well as past medical and family history. A review of body systems is conducted to identify current health problems, and information about lifestyle, health practices, and developmental level is gathered. Throughout the interview, the nurse listens carefully, observes, and uses critical thinking to interpret and validate the client’s information. The nurse and client then collaborate to identify health problems and set goals for care.

The working phase

How might this summary/closing phase be described.

The nurse finishes asking questions and immediately leaves the room without summarizing the client’s concerns or checking if they have any questions, leaving the client confused and anxious about what will happen next.

Abrupt ending, bad summary phase

Which of the 3 phase is described below:

Ends the interview smoothly rather than abruptly. The nurse summarizes the information obtained, validates the client’s problems and goals, and discusses possible plans to address any issues. The nurse also invites the client to ask questions or share any additional concerns, for example, by asking, “Is there anything else you would like to mention?”

The summary and closing phase

What form of communication is summarized below

An important part of nursing interactions, whereby the nurse demonstrates professionalism through appearance, such as wearing a clean uniform and ID badge. A warm and professional demeanor, along with neutral and friendly facial expressions, helps the client feel comfortable.

Non verbal communication

Using silence and active listening is a form of non verbal communication, what is likely to happen during this

Both client and nurse reflect on the conversation

This is an example of what sort of non verbal communication
A nurse who sits at eye level with the client and nods while listening makes the client feel heard, whereas a nurse who crosses their arms and avoids eye contact may make the client feel unwelcome.

Open posture

Btwn Verbal and Non verbal communication, what guides the nurses interview

Verbal communication

What sort of questions encourage the client to share more detailed information, such as “How are you feeling?” or “Tell me more about your pain,”

Open-ended questions,

What sort of questions, help clarify specifics and keep the interview on track such as “When did the pain start?” or “Did you take your medication?”

Closed ended questions

What is this an example of:
During verbal communication, another way to ask questions is to provide the client with a list of words to choose from in describing symptoms, conditions, or feelings, it helps you to obtain specific answers and reduces the likelihood of the client perceiving or providing an expected answer.

Using Laundry list

Example of Laundry list may phrases

“Is the pain severe, dull, sharp, mild, cutting, or piercing?” “Does the pain occur once every year, day, month, or hour?”

The client states “I’ve been feeling tired” so the nurse responds, “So you’ve noticed low energy most days?”. What example of non verbal communication is this and what is the goal.

Rephrasing , this helps clarify information and gives client a chance to reflect, this also helps confirm understanding.

Nurses rely on accurate and objective data to assess the client’s health, identify problems, and plan appropriate care. Leading or biased questions can result in false or incomplete information, which may lead to misdiagnosis, ineffective interventions, or unsafe care, Accurate client responses ensure that each step of the nursing process—assessment, diagnosis, planning, implementation, and evaluation—is based on the client’s true needs.

Select the example of good verbal communication:

During the interview, the client says, “I’ve been having headaches almost every day.” The nurse responds, “I see, tell me more about when they usually happen,” encouraging the client to share more details without influencing their answer.

Nurses rely on accurate and objective data to assess the client’s health, identify problems, and plan appropriate care. Leading or biased questions can result in false or incomplete information, which may lead to misdiagnosis, ineffective interventions, or unsafe care, Accurate client responses ensure that each step of the nursing process—assessment, diagnosis, planning, implementation, and evaluation—is based on the client’s true needs.

Select the example of bad verbal communication:

The client says, “I’ve been having headaches almost every day.” The nurse responds, “It must be because of stress, right?” This leads the client to agree even if it isn’t true, potentially giving inaccurate information.

Two situations occur during a client interview:

Situation 1: The nurse interrupts the client and says, “It’s probably just gas, right?” moving quickly to the next question. The client feels rushed and hesitant to share.

Situation 2: The nurse sits at eye level, uses simple language, and says, “Tell me more about when the pain started,” encouraging the client to provide a full description.

Which situation demonstrates more effective verbal communication, and why?

Situation 2 is more effective because the nurse listens actively, avoids leading questions, and encourages the client to share accurate and complete information, fostering trust and better assessment.

What should a nurse consider about the health status of older adult clients during an interview?

Older adults may be frail or healthy. Always assess their hearing and vision first to ensure effective communication.

Why is trust important when interviewing older adult clients?

Speak slowly, clearly, and face the client directly so they can see your lips and facial expressions., eg If an older client asks, “What did you say?” the nurse repeats the question slowly while maintaining eye contact instead of raising their voice or speaking quickly.

Why is building trust important when interviewing older adults, and how can you do it?

Helps the client feel heard and respected, making them more willing to share information. Build trust by sitting at their level, listening patiently, and acknowledging their concerns.

What general communication strategies help ensure older adults feel respected and understood?

Speak clearly, show respect, avoid rushing, and check that the client understands. These strategies improve both the interview quality and the accuracy of the information collected.

How can cultural variations affect a client’s willingness to share personal information during a nursing interview?

Some clients may be reluctant to share personal information due to cultural beliefs about privacy, modesty, or trust. Nurses need to build rapport and respect cultural boundaries to encourage communication

In what ways can language and verbal/nonverbal communication vary across cultures, and how should nurses adapt?

Language barriers, tone, gestures, eye contact, and body language can differ by culture. Nurses should use interpreters if needed, speak clearly, observe nonverbal cues, and avoid assumptions about meaning.

Why is it important to understand a client’s perception of disease or illness within their cultural context?

Clients may have different beliefs about causes, treatments, or seriousness of illness. Understanding these perceptions helps nurses provide culturally sensitive care and education.

How can a client’s cultural time orientation (past, present, future) affect nursing care and communication?

Some clients focus on past experiences, others on immediate concerns, and some on long-term outcomes. Nurses should tailor explanations, care planning, and goal-setting according to the client’s time perspective.

How can family roles in different cultures influence the nursing interview and care planning?

Family members may have a major role in decision-making, caregiving, or providing consent. Nurses should identify the family structure, involve appropriate members, and respect cultural expectations in care planning.

When working with an interpreter, what strategies can help ensure accurate communication and maintain client trust?

Consider how preparation, patience, and presence influence understanding. Speaking slowly, pausing for translation, and avoiding side conversations help. Using a trained interpreter rather than a child or unqualified person is essential to protect accuracy and confidentiality.

Why is it important to pause and allow the interpreter time to translate during a client interview? How could rushing affect the interaction?

This ensures the client fully understands and the information is accurately conveyed. Rushing may cause miscommunication, incomplete history, or client frustration, which could affect assessment and care planning.

A client is anxious and uncooperative during an interview. How can you adjust your approach to communicate effectively?

Providing simple, organized information, explaining your role, and asking concise questions can help. Positioning yourself to respect personal space, reducing external stimuli, and maintaining a neutral demeanor helps decrease anxiety. Seek support from other healthcare professionals if needed.

When discussing sensitive issues such as dying, spirituality, or sexuality, what should a nurse consider about their own self-awareness, and why?

The nurse should reflect on their own thoughts and feelings about these topics to avoid bias or discomfort influencing the interview. Self-awareness helps the nurse remain nonjudgmental and support the client in sharing openly.

A nurse who feels uneasy discussing sexuality may -

refer the client to a counselor rather than avoid the topic altogether.

How should nurses approach asking clients about sensitive topics during a health interview?

Use simple, nonjudgmental questions and allow time for the client to express feelings. If the nurse is uncomfortable, appropriate referrals should be made to ensure the client’s needs are addressed.

Why is completing a thorough health history important in the nursing process?

It helps identify relevant nursing problems, focuses the physical exam, and guides care planning. Explaining the purpose of the questions encourages client cooperation and accurate reporting.

What key components are included in a complete health history?

Biographical data

Reason for seeking health care/present health concern

Past health history (personal)

Family health history

Review of systems for current problems

Lifestyle, health practices, and developmental level

What aspect of health history Identifies the client and guides communication.

Biographical data

If the nurse asks pt their Marital status, religious/spiritual practices, occupation-education lvl, and working status, significant others of support persons, this falls under what aspect of health history

Biographical data

What aspect of health history focuses assessment on current issues.

Reason for seeking health care/present health concern

The nurse asks the client about their major health problems or concerns at this time, the client describes the issue in their own words rather than simply reciting a medical diagnosis. The nurse encourages the client to explain the health problem in detail, including a thorough symptom analysis to understand the nature, severity, and impact of the concern…this is an example of what aspect of health history

Reason for seeking health care/present health concern

What is aspect of health history reveals previous conditions that may affect current health.

Past health history (personal)

What aspect of health history identifies genetic or hereditary risks

Family health history

What aspect of health history detects signs or symptoms across body systems

Review of systems for current problems

What aspect of health history assesses behaviors and factors that impact health and care planning

Lifestyle, health practices, and developmental level

This mnemonic method was developed as a more comprehensive analysis of any symptom to promote a greater degree of accuracy in clinical judgment, it is designed to help the nurse explore symptoms, signs, or health concerns.

COLDSPA

When assessing a client’s symptom using COLDSPA, which component asks the client to describe what the symptom feels like, focusing on the quality or description of the symptom? (e.g., sharp, dull, burning, or throbbing)

Character

When using COLDSPA, which component asks the client to identify where the symptom is located and whether it spreads to other areas?

Location

When using COLDSPA, which component asks the client to describe when the symptom began, focusing on the timing or start of the symptom

Onset

When using COLDSPA, which component asks the client how long the symptom lasts, whether it recurs, and if it is constant or intermittent?

Duration

In COLDSPA, which component asks about the intensity of the symptom, how much it bothers the client, or uses a 0–10 scale?

Severity

Which COLDSPA component explores what makes the symptom better or worse, including triggers and relieving factors?

Pattern

In COLDSPA, which component identifies other symptoms that occur with the main complaint or any related factors?

Associated Factors

When collecting a client’s personal health history, which part focuses on illnesses experienced during early years that may affect current health?

Childhood illnesses

When collecting a client’s personal health history, which items help identify illnesses or conditions that may have long-term effects on their health?

Chronic illnesses; Illnesses or allergies

Which parts of a personal health history provide information about treatments, medications, or medical interventions the client has received in the past or currently?

Medications (recent past or current) Hospitalization, surgery, accidents, injuries

What aspect of health history, involves addressing each body system to gather information about current and past health problems. This process collects only subjective information, including the client’s descriptions of their health status or any denial of signs, symptoms, diseases, or problems. Nurses should use lay terminology that the client can understand. The review typically covers all major body systems

Review of systems (ROS)

The nurse gathers information about their typical day and environment, nutrition and weight management, activity level and exercise, and sleep and rest patterns. Substance use—including medications, tobacco, alcohol, and other substances—is reviewed, along with self-concept and self-care responsibilities. The nurse also explores coping strategies, stress management, social activities, relationships, values, beliefs, education, and work…What sort of health history information is the nurse gathering

Lifestyle and health practices.