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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.
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The RN is precepting an LPN who is new to the medical unit. The RN begins to assess a newly admitted client to the unit and is demonstrating an assessment technique that is used that assesses each body system separately. What type of assessment method is the RN using?
- A. Systems method
- B. Head-to-toe method
- C. Inspection
- D. Focused assessment
Correct Answer: A
Rationale: The systems method approaches the examination by assessing each body system separately. The head-to-toe method of assessment begins at the top of the body and progresses downward. Sometimes, healthcare providers use parts of both methods. Inspection is the systematic and thorough observation of the client and specific areas of the body. A focused assessment concentrates on the area of the body that is the chief complaint.
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.
The nurse is performing a functional assessment for a client who has had a mild stroke and will be discharged in 2 days from the hospital. What question would be important to ask when conducting this assessment?
- A. Do you have enough money to pay for the medications that you will be taking at home?'
- B. Do you have friends that will come and visit and take you out to socialize?'
- C. How will you obtain transportation to return to see the physician in 1 week?'
- D. Do you understand that your medication can cause bleeding tendencies?'
Correct Answer: C
Rationale: A functional assessment determines how well the client can manage activities of daily living (ADLs). ADLs include self-care activities, such as walking moderate distances, bathing, and toileting, and instrumental activities, such as preparing meals, obtaining transportation, and dialing the phone. This assessment component is particularly important when assessing older adults or physically challenged clients of any age. The ability to pay for medications or socialize and the side effects of the medication do not pertain to ADLs.
The client arrives at the clinic reports 'coughing, a sore throat, and running a fever for 2 days.' What are these feelings of discomfort called?
- A. Signs
- B. Objective data
- C. Symptoms
- D. Clinical signs
Correct Answer: C
Rationale: When clients report nausea, pain, fear, bloating, or other feelings of discomfort, they are providing subjective data. These feelings of discomfort are classed as symptoms. Signs are objective data that are abnormal, and objective data is what the nurses obtain through observation, physical examination, and diagnostic testing. Clinical signs are the same as signs.
A client is being seen at the clinic for the first time, and the nurse asks the client about what brought them to the clinic today as well as the past medical history. What part of the interview process does this represent?
- A. Introductory phase
- B. Working phase
- C. Summary phase
- D. Closing phase
Correct Answer: B
Rationale: During the working phase, the nurse asks the client questions to gather data for the client database. The introductory phase involves the beginning introductions as well as establishing rapport. The summary or closing phase is at the end of the interview.