Nokea
The nurse is admitting a client to the medical unit with a diagnosis of chronic obstructive pulmonary disease (COPD). When should the nurse perform the assessment of the client?
- A. When the client is admitted to the healthcare system
- B. Prior to the client receiving the first dose of medication
- C. After the physician has made their first visit to examine the client
- D. Within 24 hours of the initial admission interview
Correct Answer: A
Rationale: The nurse performs assessment when the client is first admitted to the healthcare system. Waiting until the client has received medication, seen a physician, and within 24-hours of initial interview will delay the assessment and can delay appropriate care and treatment.
You may also like to solve these questions
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 is assessing a client and determines that the vital signs are not within normal range for the client. With the results of the objective data being abnormal, what does the nurse document these findings as?
- A. Symptoms
- B. Subjective data
- C. Physical assessment
- D. Signs
Correct Answer: D
Rationale: When objective data are abnormal, they are called signs. Symptoms refer to feelings of discomfort felt by the client. Subjective data is what the client states to the nurse. Physical assessment is a general term used regarding the assessment of the client.
The client comes to the clinic and says to the nurse, 'I am coming in today to see the doctor because I started having diarrhea 2 days ago and am going six to eight times per day.' How would the nurse document this statement?
- A. Concern: Client is afraid of becoming dehydrated due to amount of diarrhea.
- B. Problem: Client is having diarrhea at least six to eight times per day.
- C. The client is having diarrhea and wants to see the physician.
- D. Chief complaint: 'Diarrhea began 2 days ago and having six to eight stools per day.'
Correct Answer: D
Rationale: The chief complaint is the current reason the client is seeking care. 'Concern' is not a relevant response and is not what the client stated. 'The client is having diarrhea and wants to see the physician' is vague and does not give enough information. 'Problem: Client is having diarrhea' is not appropriate, and not informative documentation.
When asking questions about the client's marital status, the nurse is gathering information about which of the following?
- A. Present illness
- B. Functional assessment
- C. Chief complaint
- D. Psychosocial history
Correct Answer: D
Rationale: The psychosocial history and cultural history include the client's age, occupation, religious affiliation, cultural background, health beliefs, marital status, and home and working environments. When gathering information about the history of the present illness, the nurse asks the client to describe all present problems, including the onset, frequency, and duration of symptoms. A functional assessment determines how well the client can perform activities of daily living. The chief complaint is the current reason the client is seeking care.
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.