Nokea
The nurse is having difficulty with the working phase of the interview process with a client who is not maintaining eye contact or responding openly to questions that are being asked. What question can the nurse ask that could require more discussion?
- A. Are you married?'
- B. Can you tell me more about what brought you to the hospital?'
- C. How many children do you have?'
- D. Do you work outside of the home?'
Correct Answer: B
Rationale: Questions are best phrased as open-ended questions that require discussion. 'Can you tell me more about what brought you to the hospital?' requires more than just a yes or no answer. The other answers are closed-ended questions and only require a yes or no response.
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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.
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.
Questions about current and past use of prescription medications would probably be part of which of the following?
- A. The client's past health history
- B. The client's history of present illness
- C. The client's chief complaint
- D. The functional assessment
Correct Answer: A
Rationale: The client's past health history includes identifying childhood diseases and prior hospitalizations. History of present illness is gathered when the nurse asks the client to describe all present problems, including the onset, frequency, and duration of symptoms. A chief complaint is the current reason the client is seeking care. A functional assessment determines how well the client can perform activities of daily living.
The nurse is caring for a client who has been admitted to the hospital with abdominal pain and is suspected to have appendicitis. What data obtained is considered objective data?
- A. Bowel sounds hypoactive in the right lower quadrant
- B. Complaints of pain when right lower quadrant palpated
- C. Client states that the pain began 3 hours ago
- D. Client states feeling nauseated.
Correct Answer: A
Rationale: Objective data are facts obtained through observation, physical examination, and diagnostic testing. When assessing blood pressure or heart rate, or examining results from urinalysis, the nurse is obtaining objective data. The other answers are examples of subjective data.
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.