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■ “How have you been managing since your husband died?”
■ “What is it like having a teenager in the house?”
■ “Can you tell me more about that?”
■ “That must have been difficult.” (State this in a caring, questioning manner,
and pause for a response.)
In contrast, closed-ended (focused) questions elicit a specific response.
Examples include:
■ “What do you have for breakfast?”
■ “When did the pain start?”
■ “Are you sleeping well?”

Probing Questions
Probing questions are used with a gentle, empathetic manner. They are
necessary to clarify some issue or verify an understanding. This type of
question is particularly useful when patients use abstract or medical terms
that could have different meanings. Examples include:
■ “You mention you are nervous. What do you notice or feel when you are
nervous?”
■ “What do you experience when you have an ulcer attack?”
■ “Many people today worry about sexually transmitted diseases. Do you
worry about being at risk?” This question should be asked only when
probing is appropriate, indicated by the presence of risk factors.

Confrontational Questions
Confrontational questions should not be used frequently but may be useful
when there is a contradiction in the reports. Also, they can be appropriate to
bring behavior up for discussion. Examples include:
■ “You mentioned before that this started after your divorce 2 years ago.
Are you saying it was just a month ago? I must have misunderstood.”
■ “You sound angry about your work situation. Are you?”
■ “I think that was very hard for you. Is that why you made that choice?”

Screening Questions
Screening questions provide a large amount of information about a pattern.
They can be used on admission when a full assessment is not possible. For
example:
■ “Do you feel well rested and ready to go most mornings?” If the patient
answers yes, and no other contradictory cues are present, then this is the
desired outcome, and no further follow-up questions would be needed.

Clarifying Questions or Observations

Clarifying questions or observations are necessary to prevent mispercep-
tions when patients use vague or ambiguous terms. Otherwise, the nurse

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might put her or his own meanings and assumptions on the data. For
example:
■ If a patient responds that he or she is afraid of dying, there are at least
four common fears he or she could be experiencing, all of which require
different interventions. Clarification would be necessary, so the nurse
would ask: “You know there are a lot of fears around dying. There is pain,
who will assume responsibilities, what happens after, and what will
happen to my family. Are any of these concerns making you afraid?”
■ If a patient responds, “I don’t know if it is worth going on,” the meaning of
this statement is unclear. Avoid responding with a cheery comment, such
as: “Of course it is worth going on; you are doing so well.” This can close
communication. Rather, ask the patient why he or she feels it is not worth
going on, and look for signs of depression.
Try to avoid leading questions that reveal the answer you expect. Also be
aware of nonverbal communications. For example, nodding of the head can
signal that you understand, which can stop the reporting, or it can signal
empathy.
Remember that listening is the main feature of a nursing history. Talk only
enough to guide the patient in telling his or her health history.

The Examination
Nursing observations during the examination focus on functional health
pattern indicators. Repeating the physician’s entire physical examination
seems inefficient, unless it is being performed for learning purposes. Two
important points about indicators are:
■ Some are observed during the history, and some require separate
attention.
■ Others may be indicators of possible problems and explain why certain
patterns exist, have changed, or are emerging developmentally.
The examination phase in individual, family, and community assessment
verifies or expands the understanding gained during the history. It provides
further data, not surprises. The following are a few tips to ensure accuracy:
■ Maintain privacy, and drape the patient appropriately. This will help the
patient relax.
■ Keep a small piece of newsprint in your pocket to test vision.
■ In family assessment, examining the home may be important. Ask permis-
sion, and try to use something in previous discussion that would be a
reason: “You mentioned that you had little space to dress the baby. Could
we look at that now?”
■ Make sure to use instruments correctly that extend perceptual capabilities,
such as the stethoscope.

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Interpreting Information
Throughout the nursing history and the examination, the nurse derives
meaning from the data to identify problems and plan care. There are various
levels of meaning used in analyzing assessment data; all are important
because errors can occur at any level: simple evaluation, simple inference,
and complex inference are three levels used in analysis.

Simple Evaluation

Simple evaluation determines if a piece of information meets the criterion

for health (normal) or not (abnormal). This is done by applying norms, also
known as normative criteria. Common norms are:
■ Developmental level.
■ Culture.
■ Gender.
■ Context of the person and situation.
For example: Skin should feel warm and dry. White skin should not have a
bluish cast. An individual should brush teeth twice a day. Adults have urinary
continence; infants do not.

Simple Inference

Simple inference is a step beyond evaluation. It involves inferential reason-

ing. For example, consider the following scenario:
■ It is 7:30 a.m. The patient’s bed sheets are wrinkled, the blanket is half on
the floor, the pillowcase is coming off the pillow, and the patient turns to
one side and then the other.
From this scenario the nurse can infer that the patient is restless. Four cues
are used to make the inference:
1. Wrinkled bed sheets.
2. Blanket falling on floor.
3. Pillowcase coming off.
4. Patient turning side to side.

Complex Inference

Complex inference involves reasoning and judgment based on clustering

multiple cues and inferences. This may result in a nursing diagnosis, either
tentative or fully confirmed, or a judgment to be referred to the physician.
Consider again the scenario of the restless patient:

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■ After determining that the patient was restless, the nurse generated possi-
ble explanations, obtained further information from the patient to investi-
gate the possibilities, and then made the following judgment: The patient
has Fear (surgical prognosis).

Ending the Admission Assessment

Objectives at the end of the interview and examination are:
■ Give the patient the opportunity to add information by asking if there are
any other things he or she would like to mention.
■ Summarize the assessment.
■ Make plans for treatment of the problems identified.
Sharing diagnostic judgments and intervention plans at this time may not be
possible. If so, summarize the assessment in a supportive way, using data
the patient reported. For example:
■ “Let’s both think about what might be causing your family to react this
way, and we can talk about it this afternoon.”
■ “You’ve mentioned a number of things; I think you can work out some
solutions. Let’s talk more about them tomorrow.”
In some cases you may be able to say, “You are doing so well! Just keep up
the things we talked about, and your blood pressure should be good.”

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