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The nurse is interviewing a client whose chief complaint is abdominal pain. What information requested by the nurse is part of a focused assessment?
- A. Have you had any problems with your breathing lately?'
- B. How long have you had this pain, and what does the pain feel like?'
- C. Do you smoke? If so, how many packs per day do you smoke?'
- D. Have you had any swelling in your feet or ankles?'
Correct Answer: B
Rationale: Asking for more detailed information about one body system or problem is called a focused assessment because it adds depth to the original data. For example, a client may reveal having experienced abdominal pain for the past several weeks. Further questioning then addresses what causes the pain, how long it lasts, what the quality of the pain is, and what makes it better or worse. The questions related to breathing, smoking, and swelling in the feet or ankles do not have anything to do with the client's chief complaint.
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Which portion of the interview determines how well the client can perform activities of daily living (ADLs)?
- A. Cultural history
- B. Functional assessment
- C. Chief complaint
- D. Psychosocial history
Correct Answer: B
Rationale: A functional assessment determines how well the client can perform ADLs. The psychosocial history and cultural history include the client's age, occupation, religious affiliation, cultural background, and health beliefs. The chief complaint is the current reason 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.
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.
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.
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.