UNIT TWO — NURSING DATA COLLECTION, DOCUMENTATION & ANALYSIS

Question 1

a purposeful, time-limited verbal interaction between the nurse and the patient or his/her significant other.

Answer 1

Nursing Interview

Question 2

done to collective subjective data about the patient

Answer 2

Nursing Interview

Question 3

Factors Influencing the Interview

Answer 3

approach, environment, confidentiality, note-taking, time length duration, biases and preconception

Question 4

gather all appropriate information before approaching the patient

Answer 4

Approach

Question 5

begin by introducing your name & title.

Answer 5

Approach

Question 6

INITIALLY, call the patient by his/her formal name & ask
how the patient prefers to be addressed.

Answer 6

Approach

Question 7

has a direct influence on the amount & quality of information gathered.

Answer 7

environment

Question 8

ideal setting for interview: private room, less distractions/interruptions, & increase comfort level for the patient

Answer 8

environment

Question 9

essential in developing trust.

Answer 9

confidentiality

Question 10

verbal assurance of confidentiality often eases the patient’s concerns.

Answer 10

confidentiality

Question 11

reasons for sharing confidential information:

Answer 11

✓ patient poses danger to self or others.
✓ Institutional policy (inform the patient prior when the info should be shared).

Question 12

advisable but may cause patient discomfort.

Answer 12

Note-Taking

Question 13

explain the necessity of jotting down
pertinent information

Answer 13

Note-Taking

Question 14

show to patient the form you will be using.

Answer 14

Note-Taking

Question 15

pay attention to patient & defer recording if
patient discusses sensitive issues.

Answer 15

Note-Taking

Question 16

pay attention to patient & defer recording if
patient discusses sensitive issues.

Answer 16

Note-Taking

Question 17

jot down phrases, words, & dates that can
be used.

Answer 17

Note-Taking

Question 18

interview times should be least disruptive to patient’s daily routine, & try to accommodate patient’s request.

Answer 18

Time, Length, Duration

Question 19

be sensitive to personal as well as patient contexts in order to treat all patients fairly & respectfully.

Answer 19

Biases & Preconceptions

Question 20

avoid faulty assumptions by continually validating information & personal impressions (use effective interview techniques).

Answer 20

Biases & Preconceptions

Question 21

stages of the interview process.

Answer 21

introductory stage, working stage, termination stage

Question 22

factors affecting communication

Answer 22

active listening, nonverbal cues, distance/proxemics, personal space

Question 23

primary goal: to decode patient messages in order to understand the situation or problem as the other person sees it.

Answer 23

Active Listening

Question 24

always pay particular attention &
formulate an appropriate response.

Answer 24

Active Listening

Question 25

communicating a message without words

Answer 25

Nonverbal Cues

Question 26

may include: body position, nervous repetitive movements of the hands or legs, rapid blinking, lack of eye contact, yawning, fidgeting, excessive smiling or frowning, repetitive clearing of the throat, etc.

Answer 26

Nonverbal Cues

Question 27

nthe amount of space a person considers appropriate for interaction is a significant factor in the interview process and is determined in part by cultural influences

Answer 27

Distance/Proxemics (proximity

Question 28

intimate zone

Answer 28

<18 inches fr. the patient

Question 29

personal distance

Answer 29

18 inches to 4 feet

Question 30

social distance

Answer 30

4 to 12 feet

Question 31

public distance

Answer 31

>12 feet

Question 32

the space over which the person claims ownership (e.g. patient’s hospital room & bathroom).

Answer 32

personal space

Question 33

patient may be protective over this space & consider unauthorized use of it as an invasion of privacy.

Answer 33

personal space

Question 34

non-therapeutic interview techniques

Answer 34

requesting an explanation, probing, offering false reassurance, giving approval or disapproval, advising, using problematic questioning techniques

Question 35

encourages patient to provide general rather than more focused communication.

Answer 35

Using Open-Ended Questions

Question 36

restrict or regulate patient response to a “yes”, a “no” or a response less than 3 words.

Answer 36

Using Close-Ended Questions

Question 37

used to focus the interview, pinpoint specific areas of concern, & elicit valuable information quickly & efficiently

Answer 37

Using Close-Ended Questions

Question 38

can disrupt communication if frequently used.

Answer 38

Using Close-Ended Questions

Question 39

encourages patient to continue talking.

Answer 39

Facilitating

Question 40

coupled with nonverbal cues - eye contact, nodding & leaning slightly forward,

Answer 40

Facilitating

Question 41

helps structure & pace the interview, convey respect & acceptance, and prompt additional patient data

Answer 41

Using Silence

Question 42

on the part of the patient, may convey anxiety, confusion or embarrassment.

Answer 42

Using Silence

Question 43

the nurse verbalizes perceptions about the patient’s behavior, then shares them with the patient.

Answer 43

Making Observations

Question 44

involves repeating or rephrasing the main idea expressed by the patient & lets the patient know that you are paying attention.

Answer 44

Restating

Question 45

the nurse directs the patient’s own questions, feelings & ideas back to the patient & provides opportunity for the patient to reconsider &/or expand on what was said.

Answer 45

Reflecting

Question 46

used by the nurse to make clear something the patient says or to pinpoint something in the message when the patient’s words & nonverbal cues do not agree

Answer 46

Clarifying

Question 47

enables the nurse to link events that perhaps the patient was not able to piece together.

Answer 47

Interpreting

Question 48

involves asking the patient to place a symptom, a problem, or an event in its proper sequence.

Answer 48

Sequencing

Question 49

facilitating the conversation such that occurrence of symptoms/events are pieced together chronologically by patient

Answer 49

Sequencing

Question 50

helps the patient to deal more effectively with unfamiliar situations by placing the symptoms or problems in the context of something else that is familiar

Answer 50

Encouraging Comparisons

Question 51

especially useful at the end of the health assessment interview.

Answer 51

summarizing

Question 52

also provides a means of smoothly transitioning to a new topic or section of the health assessment

Answer 52

Summarizing

Question 53

allows the nurse to concentrate on or “track” a specific point the patient has made.

Answer 53

focusing

Question 54

useful to patients w/ heightened anxiety & altered concentration, or jumping from topic to topic.

Answer 54

focusing

Question 55

enables the nurse to develop, in more detail, a specific area of content or patient concern.

Answer 55

Exploring

Question 56

helps the nurse identify patterns or themes in symptom presentation or in the way patients handle problems or health concerns.

Answer 56

Exploring

Question 57

typically used with psychiatric or confused patients, or to patients who exaggerate or make grandiose statements.

Answer 57

Presenting Reality

Question 58

done in a non argumentative way, encourages patient to rethink a statement and perhaps modify it.

Answer 58

Presenting Reality

Question 59

a verbal response that the nurse makes to some perceived discrepancy or incongruency in the patient’s thoughts, feelings, or behaviors

Question 60

can be used to focus the patient’s attention on some aspect of behavior that, if changed, could lead to more effective functioning.

Answer 60

Confronting

Question 61

done in a caring, empathetic manner, rather than a critical or accusatory one.

Answer 61

Confronting

Question 62

providing the patient with needed information, such as explaining the nature and/or the reasons for any necessary tests or procedures

Answer 62

Informing

Question 63

allows the nurse to help patients become aware of possible choices & then evaluate those choices correctly.

Answer 63

Informing

Question 64

the nurse & patient work together, rather than the nurse taking control of the interaction.

Answer 64

collaborating

Question 65

conveys the message that the patient has important knowledge and information to share & encourages active involvement of patient in their own health care, in setting goals, in gathering information, & in problem solving.

Answer 65

collaborating

Question 66

setting specific limits on inappropriate patient behavior; such situations may include: a. sexually aggressive pt. b. hostile pt. c. talkative pt.

Answer 66

Limit Setting

Question 67

provide guidance by calmly, clearly, and respectfully telling the patient what behavior is expected.

Answer 67

Limit Setting

Question 68

imit only the behavior that is problematic or detrimental to the purpose of the interview and avoid making a “big issue” of whatever it is that the patient is doing.

Answer 68

Limit Setting

Question 69

do not argue or use empty threats or promises, but do offer the patient alternatives.

Answer 69

Limit Setting

Question 70

allows the nurse to offer appropriate reassurance that the patient’s response may be quite common for the situation and helps decrease patient’s anxiety and fear of being misunderstood.

Answer 70

Normalizing