Nokea
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.'
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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.
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.
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 an older adult client who has recently been admitted and is performing a physical assessment. What test can the nurse perform to obtain a baseline cognitive function?
- A. Mini-Cog
- B. Neurovascular assessment
- C. Cardiovascular assessment
- D. Pupillary response
Correct Answer: A
Rationale: When performing a physical assessment for an older client, ascertain a baseline cognitive function level at onset of interview. The Mini-Cog is a quick and simple four-question method. Neurovascular and cardiovascular assessment and pupillary response are not specific assessment techniques to assess cognitive function.
The nurse identifies jaundice in an assigned client. Which assessment technique is the nurse using?
- A. Inspection
- B. Palpation
- C. Auscultation
- D. Percussion
Correct Answer: A
Rationale: Inspection is the systematic and thorough observation of the client and specific areas of the body. Palpation is assessing the characteristics of an organ or body part by touching and feeling it with the hands or fingertips. Auscultation involves listening with a stethoscope for normal and abnormal sounds generated by organs and structures such as the heart, lungs, and intestines. 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.