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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.
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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.
What type of assessment is the nurse performing when beginning the assessment at the head and progressing down to the lower extremities?
- A. Focused assessment
- B. Head-to-toe assessment
- C. Total body assessment
- D. Systems method
Correct Answer: B
Rationale: A head-to-toe assessment begins at the top of the body and progresses downward. A focused assessment focuses on a part of the body that is the primary site of problem such as a respiratory assessment for a cough. The total body assessment has no direction for an assessment and can be done in any order. A systems method approaches the examination by assessing each body system separately.
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 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.
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.