Nokea
The client comes to the clinic and says to the nurse, 'I am coming in today to see the doctor because I started having diarrhea 2 days ago and am going six to eight times per day.' How would the nurse document this statement?
- A. Concern: Client is afraid of becoming dehydrated due to amount of diarrhea.
- B. Problem: Client is having diarrhea at least six to eight times per day.
- C. The client is having diarrhea and wants to see the physician.
- D. Chief complaint: 'Diarrhea began 2 days ago and having six to eight stools per day.'
Correct Answer: D
Rationale: The chief complaint is the current reason the client is seeking care. 'Concern' is not a relevant response and is not what the client stated. 'The client is having diarrhea and wants to see the physician' is vague and does not give enough information. 'Problem: Client is having diarrhea' is not appropriate, and not informative documentation.
You may also like to solve these questions
The nurse provides a comprehensive initial assessment on a newly admitted client. What is the benefit to establishing this database from the client?
- A. It will help determine wh
- B. It will inform the healthcare team about what medications are best for the client.
- C. It will give the healthcare team all of the information about the client.
- D. It will be a yardstick for measuring effectiveness of care.
Correct Answer: D
Rationale: Findings from this comprehensive initial assessment establish a database that gives all team members relevant client information and becomes a yardstick for measuring effectiveness of care. The physician will make the determination about what unit the client will require according to the acuity of care. The physician will determine what medications are best for the client. The information obtained will not be conclusive, and further assessment of the client's condition and information will be obtained during the hospital stay.
Which of the following should the nurse use during an admission interview?
- A. Give the client suggestions for the answers and avoid making eye contact during the interview.
- B. Allow the client ample time to answer each question and maintain eye contact.
- C. Set a time limit to answer each question and proceed to the next question if the client fails to do so.
- D. Provide the client with a self-help guide to look for answers and maintain eye contact occasionally.
Correct Answer: B
Rationale: The nurse should give the client ample time to answer each question and maintain eye contact to facilitate the interview. Giving the client suggestions for answers and avoiding eye contact during the interview might make the client uncomfortable. Giving the client a time limit to answer each question and proceeding to the next question if the client fails to do so might make the client anxious. Giving the client a self-help guide may hinder interaction between the nurse and the client.
The nurse is performing a functional assessment for a client who has had a mild stroke and will be discharged in 2 days from the hospital. What question would be important to ask when conducting this assessment?
- A. Do you have enough money to pay for the medications that you will be taking at home?'
- B. Do you have friends that will come and visit and take you out to socialize?'
- C. How will you obtain transportation to return to see the physician in 1 week?'
- D. Do you understand that your medication can cause bleeding tendencies?'
Correct Answer: C
Rationale: A functional assessment determines how well the client can manage activities of daily living (ADLs). ADLs include self-care activities, such as walking moderate distances, bathing, and toileting, and instrumental activities, such as preparing meals, obtaining transportation, and dialing the phone. This assessment component is particularly important when assessing older adults or physically challenged clients of any age. The ability to pay for medications or socialize and the side effects of the medication do not pertain to ADLs.
A client is being seen at the clinic for the first time, and the nurse asks the client about what brought them to the clinic today as well as the past medical history. What part of the interview process does this represent?
- A. Introductory phase
- B. Working phase
- C. Summary phase
- D. Closing phase
Correct Answer: B
Rationale: During the working phase, the nurse asks the client questions to gather data for the client database. The introductory phase involves the beginning introductions as well as establishing rapport. The summary or closing phase is at the end of the interview.
Questions about current and past use of prescription medications would probably be part of which of the following?
- A. The client's past health history
- B. The client's history of present illness
- C. The client's chief complaint
- D. The functional assessment
Correct Answer: A
Rationale: The client's past health history includes identifying childhood diseases and prior hospitalizations. History of present illness is gathered when the nurse asks the client to describe all present problems, including the onset, frequency, and duration of symptoms. A chief complaint is the current reason the client is seeking care. A functional assessment determines how well the client can perform activities of daily living.