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The LPN observes the RN performing an assessment of the abdomen. The RN is lightly touching the client's abdomen and feeling it with the hands and fingertips. What assessment techniques is the LPN aware that the RN is using?
- A. Inspection
- B. Palpation
- C. Percussion
- D. Auscultation
Correct Answer: B
Rationale: Palpation is assessing the characteristics of an organ or body part by touching and feeling it with the hands or fingertips. Inspection is the systematic and thorough observation of the client and specific areas of the body. Percussion is a tapping of a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures. Auscultation means listening with a stethoscope for normal and abnormal sounds.
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The nurse is ending an interview with a client who has been admitted to the hospital for pneumonia. What statement made by the nurse would be an effective way to end the interview?
- A. I appreciate your cooperation and understand that your symptoms have been getting worse for 2 days.'
- B. I will refer any questions you have to the physician.'
- C. How long do you think you will be in the hospital for pneumonia?'
- D. Let me show you where your call bell, television controls, and bathroom are.'
Correct Answer: A
Rationale: An effective way of ending the interview is to summarize what occurred and thank the client for cooperating. Referring questions to the physician without attempting to answer any is not an effective means of communication and does not end the summary phase adequately, and the client has not been thanked for cooperating. A question is not a summarization. The orientation of the client's room is not related to the interview.
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.
The nurse is having difficulty with the working phase of the interview process with a client who is not maintaining eye contact or responding openly to questions that are being asked. What question can the nurse ask that could require more discussion?
- A. Are you married?'
- B. Can you tell me more about what brought you to the hospital?'
- C. How many children do you have?'
- D. Do you work outside of the home?'
Correct Answer: B
Rationale: Questions are best phrased as open-ended questions that require discussion. 'Can you tell me more about what brought you to the hospital?' requires more than just a yes or no answer. The other answers are closed-ended questions and only require a yes or no response.
The nurse has closed the interview with a client and observes that the client appears to have something else to say. What statement made by the nurse can provide an opportunity for the client to express concerns and ask questions?
- A. Use your call bell if you need anything.'
- B. I don't know what else I could tell you, this about covers all of it.'
- C. Well that is all I have for you. Let me know if you need anything.'
- D. Do you have any questions or concerns that we have not discussed?'
Correct Answer: D
Rationale: Asking if the client needs more information provides an opportunity for the client to express concerns and ask questions. Instructions about the call bell do not allow the client to ask questions. 'I don't know what else I could tell you' inhibits the client from asking the nurse anything further as well as 'Well that is all I have for you.'
Which of the following are statements clients make about how they feel?
- A. Objective data
- B. Cultural data
- C. Cognitive data
- D. Subjective data
Correct Answer: D
Rationale: Subjective data include statements clients make about what they feel. Objective data are facts obtained through observation, physical examination, and diagnostic testing. Cultural data include cultural background and health beliefs.