Nokea
The client is being interviewed by the nurse and is asked what symptoms they have had to bring them to the clinic. Which of the following data collected is considered subjective?
- A. Blood pressure of 110/60 mm Hg
- B. Client states, 'My chest feels tight.'
- C. Bowel sounds present in 4 quadrants
- D. Client's skin is warm and dry.
Correct Answer: B
Rationale: Subjective data are statements clients make about what they feel. The other data are objective because they are facts that are obtained through observation.
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The nurse is caring for a client who has been admitted to the hospital with abdominal pain and is suspected to have appendicitis. What data obtained is considered objective data?
- A. Bowel sounds hypoactive in the right lower quadrant
- B. Complaints of pain when right lower quadrant palpated
- C. Client states that the pain began 3 hours ago
- D. Client states feeling nauseated.
Correct Answer: A
Rationale: Objective data are facts obtained through observation, physical examination, and diagnostic testing. When assessing blood pressure or heart rate, or examining results from urinalysis, the nurse is obtaining objective data. The other answers are examples of subjective data.
Which assessment technique involves a systematic observation of the client?
- A. Auscultation
- B. Inspection
- C. Palpation
- D. Percussion
Correct Answer: B
Rationale: Inspection is the systematic and thorough observation of the client and specific areas of the body. Auscultation involves listening with a stethoscope for normal and abnormal sounds generated by organs and structures such as the heart, lungs, and intestines. Palpation is assessing the characteristics of an organ or body part by touching and feeling it with the hands or fingertips. Percussion is tapping a portion of the body to determine whether there is tenderness or to elicit sounds that vary according to the density of underlying structures.
The nurse is conducting an interview with a client at the hospital. The client has a roommate in the room. Where would the optimal place for this interview take place?
- A. In the waiting area
- B. In the client's room
- C. In a private treatment room
- D. At the nurse's station
Correct Answer: C
Rationale: A private setting for the interview is essential to eliminate interruptions and maintain the client's confidentiality. The nurse should explain that information obtained during the interview helps with planning care and is kept confidential, although all members of the healthcare team share the data. The other settings are not private, and information may be overheard.
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.
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.