Nokea
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.
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The nurse is completing a physical examination on a client who reports abdominal pain. Which are facts the nurse will obtain during the physical examination?
- A. Symptoms
- B. Objective data
- C. Subjective data
- D. Complaints
Correct Answer: B
Rationale: Objective data are facts obtained through observation, physical examination, and diagnostic testing. Feelings related to subjective data are symptoms. Subjective data are statements clients make about what they feel. Complaints are reasons the client is seeking care.
Which of the following should the nurse use during an admission interview?
- A. Give the client suggestions for the answers and avoid making eye contact during the interview.
- B. Allow the client ample time to answer each question and maintain eye contact.
- C. Set a time limit to answer each question and proceed to the next question if the client fails to do so.
- D. Provide the client with a self-help guide to look for answers and maintain eye contact occasionally.
Correct Answer: B
Rationale: The nurse should give the client ample time to answer each question and maintain eye contact to facilitate the interview. Giving the client suggestions for answers and avoiding eye contact during the interview might make the client uncomfortable. Giving the client a time limit to answer each question and proceeding to the next question if the client fails to do so might make the client anxious. Giving the client a self-help guide may hinder interaction between the nurse and the client.
The nurse is interviewing a client who is being placed on medication for the treatment of depression. What question would be essential for the nurse to ask the client to avoid complications related to drug therapy?
- A. Are you presently taking an herbal preparation for the treatment of depression?'
- B. Do you have enough money or insurance coverage to pay for this medication?'
- C. How many times have you been treated for depression?'
- D. Will you be seeing a counselor or therapist?'
Correct Answer: A
Rationale: During client interviews, nurses identify any current and past use of prescription and nonprescription drugs or herbal products. They ask about clients' use of alcohol and tobacco because these drugs can create or contribute to other health problems. If clients are using herbal preparations for the treatment of depression, this can cause complications with the medication that the physician is prescribing. The other questions do not relate to the past or present prescription and nonprescription drug use.
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.
Which of the following is important to do at the end of an interview with the client?
- A. Call the client's family members to give them information.
- B. Call the physician to discuss findings and establish a plan of care.
- C. Conduct a physical examination immediately after the interview.
- D. Summarize the information and thank the client for cooperating.
Correct Answer: D
Rationale: A nurse should end an interview with the client by summarizing what occurred and thanking the client for cooperating. The nurse should not discuss the information obtained through the interview with the client's family. It may not be necessary to call the doctor for further consultation or to conduct a physical examination immediately after the interview.