Interview and Health History practice flashcards

Flashcards covering the phases of client interviews, communication techniques, health history components, and specialized assessment tools based on Thompson's Essential Health Assessment.

According to the transcript, what categories of information constitute subjective data?

Subjective data consist of sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information.

What are the three phases of the patient interview?

The three phases are Introductory, Working, and Summary and closing.

What activities should a nurse perform during the Introductory Phase of an interview?

The nurse should introduce themselves, explain their role and purpose, discuss the types of questions to be asked, assure confidentiality, mention note-taking, estimate the time frame, and ensure client comfort and privacy.

What is the primary focus of the Working Phase of the interview?

The Working Phase is the longest phase where the nurse collects data using open and closed-ended questions, establishes rapport, stays alert to nonverbal cues, and hears the patient's story.

What occurs during the Summary and closing phase of the interview?

The nurse clarifies and summarizes the patient’s self-report, restates the findings, and confirms the goals.

What percentage of communication is estimated to be nonverbal versus verbal?

Communication is said to be $10\%$ to $20\%$ verbal and $80\%$ to $90\%$ nonverbal.

What does the mnemonic 'Be CLEAR' stand for in Holistic Communication?

Center yourself, Listen wholeheartedly, Empathize, Attention (be fully present), and Respect.

What are common verbal communication barriers to avoid during a patient interview?

Biased or leading questions, medical jargon or clichés, assuming, asking too many questions or 'Why,' reading the questions, false reassurance, giving opinions, and patronizing language (Elderspeak).

How should a nurse interact with an angry client?

Approach in a calm, in-control manner, allow venting, avoid arguments or touching, facilitate personal space, and never let the client position themselves between the nurse and the door.

What is the 'HITS' screening tool used for, and what score is considered positive?

It assesses intimate partner violence (Hurt, Insult, Threaten, Scream); a score greater than $10$ is considered positive.

What does the CAGE questionnaire screen for, and what score is clinically significant?

It screens for alcohol and drug use (Cut down, Annoyed, Guilty, Eye opener); a score of $2$ or greater is clinically significant.

What is the difference between a primary and secondary source of data?

A primary source is the patient; secondary sources include family members, significant others, or medical records.

What does the BATHE assessment screen for, and what are its five questions?

It screens for anxiety, depression, and situational stress. The questions are: Background ('What is going on?'), Affect ('How do you feel?'), Trouble ('What troubles you most?'), Handle ('What helps you handle it?'), and Empathy.

What is a Genogram?

A pictorial diagram of the family medical history, typically documenting $3$ or more generations.

What are the components of the FICA Model for Spiritual Assessment Tool?

Faith and beliefs, Importance of faith and beliefs, Communities, and Addresses issues in health care.

What are the functional assessment categories for Activities of Daily Living (ADL)?

Bathing, dressing, eating, walking, meal preparation, and driving.

What is the purpose of the Mini-Mental State Examination (MMSE), and what score indicates impairment?

It is a cognitive assessment testing orientation, registration, attention/calculation, recall, and language. A score of $23$ or lower indicates cognitive impairment.

What is the 'SENC SAFETY ALERT' regarding patients with suicidal thoughts?

Never leave a patient alone if you suspect they are having suicidal thoughts.

What are 'pertinent positives' and 'pertinent negatives' in a Review of Systems?

Pertinent positives are reported symptoms (e.g., itchy eyes), while pertinent negatives are symptoms the patient denies (e.g., denies HA or sinus pressure).

Define the three types of health histories: Comprehensive, Focused, and Follow-up.

Comprehensive reviews all body systems; Focused targets an acute problem or symptom; Follow-up concentrates on new data since the last history.