Nokea
The nurse provides a comprehensive initial assessment on a newly admitted client. What is the benefit to establishing this database from the client?
- A. It will help determine wh
- B. It will inform the healthcare team about what medications are best for the client.
- C. It will give the healthcare team all of the information about the client.
- D. It will be a yardstick for measuring effectiveness of care.
Correct Answer: D
Rationale: Findings from this comprehensive initial assessment establish a database that gives all team members relevant client information and becomes a yardstick for measuring effectiveness of care. The physician will make the determination about what unit the client will require according to the acuity of care. The physician will determine what medications are best for the client. The information obtained will not be conclusive, and further assessment of the client's condition and information will be obtained during the hospital stay.
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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 is important to do at the end of an interview with the client?
- A. Call the client's family members to give them information.
- B. Call the physician to discuss findings and establish a plan of care.
- C. Conduct a physical examination immediately after the interview.
- D. Summarize the information and thank the client for cooperating.
Correct Answer: D
Rationale: A nurse should end an interview with the client by summarizing what occurred and thanking the client for cooperating. The nurse should not discuss the information obtained through the interview with the client's family. It may not be necessary to call the doctor for further consultation or to conduct a physical examination immediately after the interview.
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.
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.
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.