Nokea
The nurse has received a client in the emergency department who is very short of breath. The nurse only wants to ask closed questions to decrease the workload on the client. What would be an example of a question for the nurse to ask?
- A. Can you tell me about the precipitating factors that lead you to come to the hospital?'
- B. What did you do when the shortness of breath began?'
- C. Do you use oxygen at home?'
- D. Can you give me a history of previous medical problems?'
Correct Answer: C
Rationale: Do you use oxygen at home?' is a closed-ended question that only requires a yes or no answer. The other questions require more than a yes or no response and are considered open-ended questions.
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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 preparing to interview a client. Which of the following is a variable involved in determining the length of the interview?
- A. Financial status
- B. Mental state
- C. Social status
- D. Relationships
Correct Answer: B
Rationale: The length of the interview depends on variables such as the severity of the client's condition, level of discomfort, ability to cooperate, age, and mental state. Financial status, social status, and relationships are not variables involved in determining the length of the interview.
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.
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.'
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.