When conducting a client health history, how should the nurse respond when the client hesitates to discuss sensitive topics?
Use therapeutic silence and allow the client time to gather their thoughts.
Provide a quick summary to move to the next question.
Skip the questions entirely to prevent awkwardness.
Press the client to provide answers immediately.
The Correct Answer is A
Choice A reason: Therapeutic silence is a powerful communication tool that conveys acceptance and patience. It provides the client with the necessary psychological space to process complex emotions or memories related to sensitive health information. This approach fosters a trusting nurse-client relationship, which often leads to more accurate and complete data.
Choice B reason: Moving quickly to the next question or providing a summary can be perceived by the client as dismissive or insensitive. This prevents the nurse from obtaining critical subjective data that may be vital for the care plan. Rushing the interview process often shuts down further communication on sensitive topics.
Choice C reason: Skipping essential health history questions to avoid awkwardness is a failure in the assessment phase. Sensitive topics, such as sexual health or substance use, are often critical to the diagnosis and treatment. The nurse must find a professional way to address these areas rather than ignoring them.
Choice D reason: Pressing a client for immediate answers is non-therapeutic and can be perceived as aggressive or judgmental. This approach increases the client's anxiety and defensiveness, making them less likely to share honest information. Effective data collection relies on the client feeling safe and respected throughout the interview.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Elevated bilirubin levels result in jaundice, which manifests as a yellowish discoloration of the skin, mucous membranes, and sclera. This is a common finding in hepatic, biliary, or hemolytic disorders. It is distinct from pallor, which is the loss of normal skin tones and a transition to a pale or ashen appearance.
Choice B reason: Inflammation typically presents with rubor (redness) due to localized vasodilation and increased blood flow to the affected area. It is also usually accompanied by heat, swelling, and pain. Pale skin around the nail beds and lips is the physiological opposite of the hyperemic response seen in acute inflammatory processes.
Choice C reason: Pallor in the nail beds and lips (perioral and ungual regions) often indicates a reduction in circulating oxyhemoglobin or decreased peripheral blood flow. This is a clinical hallmark of anemia, where hemoglobin levels are insufficient, or various circulatory issues such as peripheral vascular disease or hypovolemic shock, where blood is shunted away from the periphery.
Choice D reason: Inadequate oxygenation, specifically a lack of oxygen in the blood (hypoxemia), typically manifests as cyanosis, which is a bluish discoloration of the skin and mucous membranes. While pallor can precede cyanosis in some cases of respiratory distress, the specific finding of a pale or white appearance is more strongly associated with blood volume or hemoglobin deficits.
Correct Answer is A
Explanation
Choice A reason: This structured approach follows the standard medical model for a comprehensive history, beginning with the Chief Complaint and History of Present Illness. Prioritizing the current condition and surgical history provides the most relevant data for immediate perioperative safety while ensuring that psychosocial factors are eventually addressed.
Choice B reason: While medications and allergies are high-priority items, focusing exclusively on them is insufficient for a comprehensive pre-operative assessment. Neglecting the patient's prior surgical experiences or chronic conditions could lead to missed complications, such as a history of malignant hyperthermia or undiagnosed respiratory or cardiovascular issues that affect anesthesia.
Choice C reason: Family history and lifestyle habits are important components of a health history, but they are generally lower in priority than the patient's current illness and past medical/surgical history when preparing for an imminent procedure. The assessment should be focused on identifying immediate risks to the patient's surgical outcome.
Choice D reason: The nursing process usually begins with gathering subjective data through the interview before proceeding to the objective physical examination. Subjective symptoms often guide the nurse on which objective assessments require more focus. Reversing this order may lead to an incomplete understanding of the patient's physiological and psychological state.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.