When meeting the client for the first time, the nurse guides the client to tell his or her complete “story.” This
includes an explanation of what has been happening in the client’s life and what has happened that led to this encounter with the nurse. Certain types of questions are useful in getting the conversation started while others are more helpful after rapport has been developed.

The healthcare encounter begins with broad openings, such as “Tell me about yourself” or “Tell me about your family.” Broad openings are designed to give the client the freedom to tell his or her story in whatever way is most comfortable. Often, clients skip over details that are important to the nurse; therefore, it is important to ask questions that will facilitate descriptions of events over time.

Questions designed to obtain descriptions are used next. Descriptive questions include those that begin with “Who?” “What?” “Where?” and “When?” When the reason for the healthcare encounter is illness or an accident, it is important to find out how it all began. Ask what happened or when the symptoms began. Descriptive questions can help the nurse to obtain a visual picture of the circumstances of an event, such as a seizure. Ask the client to describe where and when the event took place, who was there, what was said, and to place events in time sequence. This critical information should be documented with key statements quoted directly. It is the professional nurse’s responsibility to conduct an initial assessment when a client is admitted to the health care system. Such specific information is useful for other members of the health care team and can prevent their asking the same sensitive questions over and over.

Questions that are open-ended are worded to encourage the client to give explanations or to elaborate on a topic. These questions cannot be answered with one or two words. “What happened yesterday?” is an example of an open-ended question. Whenever possible, begin the conversation with open-ended questions. Open-ended questions are also useful later in the interaction to help the client express his or her feelings. “What is it like for you taking care of a sick child for so long?” Open-ended questions are extremely valuable in developing a therapeutic relationship. They provide direction and keep the conversation focused on health care concerns while allowing clients the opportunity to express their concerns in their own words. If the student practices asking openended questions when meeting a new client, he or she will often be surprised at how quickly rapport develops.

Closed-ended questions are worded in such a way that they can be answered in one or two words. Many times the nurse needs a specific piece of information, and the closed-ended question is the most efficient way to obtain that information. For example, eventually in every admission interview the nurse asks, “Are you allergic to any medications?” Other examples of closed-ended questions include, “What is today’s date?” or “Are you in pain?” Although closed-ended questions are necessary at times, they can prevent the development of a smooth flow of conversation. It is best to avoid them at the beginning of a conversation unless a specific piece of information is needed urgently, such as “Did you take any insulin today?”

When nurses or student nurses are anxious, they are more likely to ask the client closed-ended questions one after another. This limits the flow of conversation to short answers and may lead to inferring that the client does not want to talk. If this happens, reflect on the format of your questions and switch to asking open-ended questions.

In some cases, clients have difficulty answering questions. The nurse may be interested in obtaining descriptions of the client’s pain experience and begins the assessment with an open-ended question. “Tell me about your pain” may lead to no response or a limited response, such as “I don’t know.” It is always best to obtain information in the client’s own words, but if the client is unable to explain, it may be necessary to provide some guidance. In these situations, the nurse progresses to more specific questions, such as a closed-ended question: “Does it hurt when I press here?” Another type of question that limits the client’s response is the forced-choice question. The client must choose between two alternatives. Examples include, “Is your pain sharp or dull?” “Do you feel it more here or there?” Although useful, these questions do not encourage the client to answer with a more accurate alternative. Finally, the laundry-list question provides a series of choices: “Do you feel annoyed, frustrated, or angry?” These questions are less valuable because the client must choose from the list provided rather than putting the feeling into his or her
own words. In some situations, such as clients with limited ability to speak, these questions may be effective in obtaining some response when the open-ended question leads only to silence.

After the basic facts are obtained, the nurse encourages the client to describe his or her thoughts about the information. Each client has his or her own unique way of interpreting events, and these evaluations will influence the client’s response to the events. With information about the client’s thoughts, the nurse will uncover misinterpretations and misinformation that can be addressed in health teaching at a later time. For example, Mrs. Bouchard describes extreme conflict with her adolescent daughter over breaking a curfew. The nurse asks, “What did you think when your daughter did not come home on time?” Mrs. Bouchard replies that her daughter must not care about her parents very much because if she did she would not cause them to worry. The mother’s conclusions about the meaning of her daughter’s behavior caused an emotional response of hurt and anger that was not helpful to resolving the problem. The nurse also notes that the client will need teaching about adolescence and the issues related to that stage of development.

When the client’s thoughts are clarified, it is helpful to encourage recognition of the feelings associated with the situation. Recognizing feelings and expressing them appropriately will bring a feeling of relief and will allow the client to better understand what he or she is experiencing. Feelings can be frightening, and many people are accustomed to ignoring or denying their feelings. The nurse’s goal is to give the client permission to share feelings rather than to place demands on him or her when he or she may not be ready to express emotions. One of the most common emotions observed in clinical settings is sadness and grief.

If a client appears sad or ready to cry, the nurse can comment in a supportive tone of voice: “You look very sad right now.” This sharing of the nurse’s observations serves to bring the emotion to the client’s attention. The supportive message suggests to the client that the nurse is willing to share the painful feelings. This often results in the client becoming tearful. It is important that the nurse stay with the client until the crying has ended without trying to prevent expression of the feelings. Being present for someone who is crying can be uncomfortable. The nurse may have the urge to tell the client to stop crying or to give false reassurances such as, “Everything will work out for the best.” This has the effect of closing off the expression of emotions. The message is, “I do not wish to be burdened with your painful feelings.” Be aware of your nonverbal behavior. If you hand the client a tissue you may communicate that it is time to stop crying and dry your tears. A hug or even a touch on the client’s hand can interrupt the expression of emotion. Wait until clients finish expressing sadness to console them.

In every new situation, clients will experience some degree of anxiety.² The tension that results from anxiety will be expressed in behavior such as restlessness or talkativeness. Helping the client to recognize and understand their anxiety will be comforting in itself. Comments such as, “I notice that you are restless” or “Many people are a bit nervous when they come to the hospital,” may help clients pinpoint their own anxiety. If the client believes that being anxious is a sign of weakness, he or she will tend to deny it when asked. When the nurse conveys that it is acceptable to be anxious, a direct question will often be helpful. Asking “Are you feeling nervous right now?” may then be answered with a “Yes!” This admission of anxiety makes it possible to offer help with relaxation strategies.

Helping the client to express other basic emotions, such as sadness or anger, requires observation on the part of the nurse. The nurse observes for evidence of emotional responses in the client. Clients can be feeling a strong emotion but can be unaware of that emotion at a conscious level. If the nurse confronts the client when he or she is unaware of the feeling, the client may simply deny it. This is frustrating for the nurse, and it is not helpful for the client. For example, the nurse observed that Mrs. Bouchard seemed angry. Her facial muscles were tense and her fists were clenched during the description of her daughter’s behavior. The nurse asked, “What are you feeling right now?” Mrs. Bouchard answered, “I don’t know. I thought we would always be so close, like good friends.” When asked about what she was feeling directly, she was unable to put it into words. She told the nurse her thoughts rather than her feelings. To help Mrs. Bouchard express her feelings, the nurse commented about her nonverbal behavior. “I notice that you are clenching your fists when you speak about your daughter. Could it be that you are angry?”

Emotional expression is part of communication, and sharing feelings is a very important supportive function of the nurse. Students sometimes worry that they “caused” the feeling. A comment such as, “I made my client cry!” expresses this concern. When clients are sad about the losses they experience, tears may be unexpressed until a supportive person is available to share them. A student who makes him- or herself available may have the privilege of sharing in this powerful human experience.

Asking why may seem to be a simple way to gain an understanding of a client’s problems, but “why?” is actually very difficult to answer truthfully. Questions that begin with why are confrontational and often put the client on the defensive. With a why question, you are asking the client to do something that is at the least uncomfortable and may even be impossible, which is to explain or defend his or her actions or beliefs. Such a question can interfere with the development of a therapeutic relationship and is never considered therapeutic.

Ask only one question at a time. Although this seems obvious, nurses and nursing students often ask two or more questions without pausing for an answer. Under these conditions, the client may react with anxiety and be less likely to respond at all. At best, he or she can only answer one question at a time. In the following example, the client will be more likely to avoid answering a question about emotions and answer the second, less threatening question instead.