Nokea
The LPN is transferring a medical client to the intensive care unit and is met by the RN. The RN is listening with the stethoscope to determine how much fluid the client may have in the lungs. What type of assessment technique is the RN performing?
- A. Inspection
- B. Palpation
- C. Percussion
- D. Auscultation
Correct Answer: D
Rationale: Auscultation means listening with a stethoscope for normal and abnormal sounds generated by organs and structures such as the heart, lungs, intestines, and major arteries. Inspection is the visual observation of the client and specific structures. Palpation is the touching of the patient with the fingertips or hands. Percussion is tapping a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures.
You may also like to solve these questions
A client is arriving at the clinic for the first time. The nurse provides an introduction and establishes an initial rapport with the client. What phase of the interview process is this?
- A. Introductory phase
- B. Working phase
- C. Summary phase
- D. Closing phase
Correct Answer: A
Rationale: The introductory phase establishes initial rapport with the client and family members and informs the client about the nurse's need to ask questions and gather information. When making introductions, the nurse should address the client by surname. The working phase is the second part of the process, and the summary and closing phase is the last.
The nurse at the clinic asks the client about what brought them in to see the health care provider today. What is the purpose of asking the client about their primary health concern?
- A. To discover what the client perceives as the health problem that needs treatment
- B. To determine if the client really needs to see the health care provider today
- C. To determine if the insurance company will pay for the visit
- D. To see if a prescription can be called in without having to see the health care provider
Correct Answer: A
Rationale: The purpose of asking the client about their primary health concern is to discover what the client perceives as the health problem that needs treatment. Recording information in the client's own words is best. The nurse cannot determine if the client should see the health care provider today and whether the client should be denied treatment based on the insurance company's willingness to pay. The client can opt to pay for the visit out of pocket. Health care providers do not generally give prescriptions any longer without seeing the clients.
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.
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 RN is precepting an LPN who is new to the medical unit. The RN begins to assess a newly admitted client to the unit and is demonstrating an assessment technique that is used that assesses each body system separately. What type of assessment method is the RN using?
- A. Systems method
- B. Head-to-toe method
- C. Inspection
- D. Focused assessment
Correct Answer: A
Rationale: The systems method approaches the examination by assessing each body system separately. The head-to-toe method of assessment begins at the top of the body and progresses downward. Sometimes, healthcare providers use parts of both methods. Inspection is the systematic and thorough observation of the client and specific areas of the body. A focused assessment concentrates on the area of the body that is the chief complaint.