Tywin has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview?
A. “What brought you to the clinic today?”
B. “Would you describe your overall health as good?”
C. “Do you understand what is happening?”
D. “Is there anything else you would like to tell me?”
Correct Answer: D. “Is there anything else you would like to tell me?”
By asking the client if there is anything else, the nurse allows the client to end the interview by discussing feelings and concerns. The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions.
Option A: Asking about what brought the client to the clinic is an ambiguous question to which the client may answer “my car” or any similarly disingenuous reply. The health history is typically done on admission to the hospital, but a health history may be taken whenever additional subjective information from the patient may be helpful to inform care (Wilson & Giddens, 2013).
Option B: Asking if the client describes his overall health as good is a leading question that puts words in his mouth. Objective data is information that the health care professional gathers during a physical examination and consists of information that can be seen, felt, smelled, or heard by the health care professional. Taken together, the data collected provides a health history that gives the health care professional an opportunity to assess health promotion practices and offer patient education (Stephen et al., 2012).
Option C: Asking if the client understands what is happening is a yes-or-no question that can elicit little information. Data gathered may be subjective or objective in nature. Subjective data is information reported by the patient and may include signs and symptoms described by the patient but not noticeable to others. Subjective data also includes demographic information, patient and family information about past and current medical conditions, and patient information about surgical procedures and social history.