What is the data the nurse collects during the interview portion of a health assessment is called?
Subjective
During an examination of a preschool child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the child’s full cooperation?
Tell the child that by using the blood pressure cuff, we can see how strong her muscles are
A woman is discussing the problems she is having with her 2-year-old son. She says, “He won’t go to sleep at night, and during the day he has several fits. I get so upset when that happens.” Which is the best response by the nurse to gain a better understanding of the problem?
“Fits? Tell me what you mean by this.”
During an assessment, the nurse uses the CAGE test. The patient answers “yes” to two of the questions. What could this be indicating?
The nurse should suspect alcohol abuse and continue with a more thorough substance-abuse assessment.
The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient?
“Do you perform testicular self-examinations?”
During an interview, the nurse would expect that most of the interview will take place at what distance?
Social distance
A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, “You don’t smoke, drink, or take drugs, do you?” This is an example of what type of question?
Using biased or leading questions
When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurse’s best response to this behavior?
Lean forward slightly and making eye contact ask “Is there anything else?”
The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom?
Chest pain
What information obtained by the nurse regarding a patient’s skin should the nurse record in the patient’s health history?
Patient denies any color change.
Your patient does not speak English well, and you need to choose an interpreter. What would be the most appropriate choice?
Trained interpreter
As the nurse enters a patient’s room, the nurse finds the patient crying. The patient states that she has just found out that the lump in her breast is cancer and says, “I’m so afraid of, um, you know.” What would be the most therapeutic response by the nurse?
“You’re afraid you might lose your breast?”
In using verbal responses to assist the patient’s narrative, some responses focus on the patient’s frame of reference and some focus on the health care provider’s perspective. Which is an example of a verbal response that focuses on the health care provider’s perspective?
Confrontation
When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed?
Functional assessment
What does the review of systems provide the nurse?
Information regarding health promotion practices
A patient who has a hearing impairment and came in because of a cold. What techniques would be most beneficial in communicating with this patient?
Determine the communication method he prefers.
A pregnant woman states, “I just know labor will be so painful that I won’t be able to stand it. I know it sounds awful, but I really dread going into labor.” The nurse responds by stating, “Oh, don’t worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain.” What type of response did the nurse use?
Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the woman’s fears.
“You mentioned having shortness of breath. Tell me more about that.” Which verbal skill is used with this statement?
Open-ended question
As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What should the nurse recommend?
MMR vaccination needs to be repeated at 4 to 6 years of age.
A patient tells the nurse that he is allergic to penicillin. What is the best response by the nurse?
“Describe what happens to you when you take penicillin.”
A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger people. What is the reason for this?
An aged person has a longer story to tell.
During an interview, a woman says, “I have decided that I can no longer allow my children to live with their father’s violence, but I just can’t seem to leave him.” Using interpretation, what would be the best response by the nurse?
“It sounds as if you might be afraid of how your husband will respond.”
The nurse asks, “I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here.” Based on this question, the nurse is at which phase of the interview process?
Opening or introduction
A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure?
Child’s reactions to previous hospitalizations
A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information?
Grav 6, Term 4, (S)Ab-2, Living 4