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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.
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The nurse identifies jaundice in an assigned client. Which assessment technique is the nurse using?
- A. Inspection
- B. Palpation
- C. Auscultation
- D. Percussion
Correct Answer: A
Rationale: Inspection is the systematic and thorough observation of the client and specific areas of the body. Palpation is assessing the characteristics of an organ or body part by touching and feeling it with the hands or fingertips. Auscultation involves listening with a stethoscope for normal and abnormal sounds generated by organs and structures such as the heart, lungs, and intestines. 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 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.
The nurse is conducting an interview with a client at the hospital. The client has a roommate in the room. Where would the optimal place for this interview take place?
- A. In the waiting area
- B. In the client's room
- C. In a private treatment room
- D. At the nurse's station
Correct Answer: C
Rationale: A private setting for the interview is essential to eliminate interruptions and maintain the client's confidentiality. The nurse should explain that information obtained during the interview helps with planning care and is kept confidential, although all members of the healthcare team share the data. The other settings are not private, and information may be overheard.
What type of assessment is the nurse performing when beginning the assessment at the head and progressing down to the lower extremities?
- A. Focused assessment
- B. Head-to-toe assessment
- C. Total body assessment
- D. Systems method
Correct Answer: B
Rationale: A head-to-toe assessment begins at the top of the body and progresses downward. A focused assessment focuses on a part of the body that is the primary site of problem such as a respiratory assessment for a cough. The total body assessment has no direction for an assessment and can be done in any order. A systems method approaches the examination by assessing each body system separately.
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.