Prior to taking the health history, the nurse should first do which of the following?
Offer the client a beverage of choice
Establish that insurance coverage exists
Establish a rapport with the patient
Ask the patient to disrobe and put on a gown
The Correct Answer is C
Choice A reason: Offering a beverage is a hospitable gesture but not the first step in taking a health history. The priority is to establish communication and trust.
Choice B reason: Confirming insurance coverage is important but not the initial step in the health history process. The focus should first be on the patient's immediate needs and concerns.
Choice C reason: Establishing a rapport with the patient is the first and most crucial step in taking a health history. It involves creating a comfortable and trusting environment for the patient to share personal health information.
Choice D reason: Asking the patient to disrobe and put on a gown may be necessary for a physical examination but is not the first step in taking a health history. The nurse should first establish a rapport with the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This response demonstrates empathy and active listening. It acknowledges the client's feelings without judgment and opens the door for further discussion about their concerns. It is a therapeutic communication technique that helps build rapport and trust between the nurse and the client. When a client feels understood, it can reduce their anxiety and promote a sense of safety, which may improve their ability to sleep and concentrate.
Choice B reason: While it is important for clients to communicate with their healthcare providers, this response might make the client feel dismissed or that their immediate concerns are not being addressed by the nurse. It could be perceived as deflecting the responsibility to someone else, rather than the nurse providing support at that moment.
Choice C reason: Asking the client to self-reflect on the reasons for their anxiety could be helpful, but it might also be overwhelming for them if they are already in a heightened state of anxiety. This question should be asked with caution and at an appropriate time when the client is more likely to engage in productive self-reflection.
Choice D reason: This statement minimizes the client's experience by suggesting that their problem is common and insignificant. It fails to acknowledge the severity of the client's distress and does not offer any comfort or assistance. It is not a therapeutic response because it does not validate the client's feelings or encourage further communication.
Correct Answer is D
Explanation
Choice A reason: The severity of the condition may not always correlate with the level of pain experienced by the client. Pain is a subjective experience, and two individuals with the same condition may report different levels of pain.
Choice B reason: Vital signs can be indicators of pain but are not always reliable. For example, some clients may exhibit increased heart rate or blood pressure when in pain, while others may not show significant changes in vital signs despite severe pain.
Choice C reason: Nonverbal behavior can be an indicator of pain, especially in clients who are unable to communicate verbally. However, it is still considered less reliable than self-report because it is subject to interpretation by the observer.
Choice D reason: Self-report of pain is considered the most reliable indicator of a patient's pain experience. It is a direct expression of the client's experience and should be the primary source of assessment whenever possible.
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