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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.
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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.
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 ending an interview with a client who has been admitted to the hospital for pneumonia. What statement made by the nurse would be an effective way to end the interview?
- A. I appreciate your cooperation and understand that your symptoms have been getting worse for 2 days.'
- B. I will refer any questions you have to the physician.'
- C. How long do you think you will be in the hospital for pneumonia?'
- D. Let me show you where your call bell, television controls, and bathroom are.'
Correct Answer: A
Rationale: An effective way of ending the interview is to summarize what occurred and thank the client for cooperating. Referring questions to the physician without attempting to answer any is not an effective means of communication and does not end the summary phase adequately, and the client has not been thanked for cooperating. A question is not a summarization. The orientation of the client's room is not related to the interview.
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.
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.