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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.
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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 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 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.
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.
The LPN is transferring a medical client to the intensive care unit and is met by the RN. The RN is listening with the stethoscope to determine how much fluid the client may have in the lungs. What type of assessment technique is the RN performing?
- A. Inspection
- B. Palpation
- C. Percussion
- D. Auscultation
Correct Answer: D
Rationale: Auscultation means listening with a stethoscope for normal and abnormal sounds generated by organs and structures such as the heart, lungs, intestines, and major arteries. Inspection is the visual observation of the client and specific structures. Palpation is the touching of the patient with the fingertips or hands. Percussion is tapping a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures.