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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.
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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.
A client is arriving at the clinic for the first time. The nurse provides an introduction and establishes an initial rapport with the client. What phase of the interview process is this?
- A. Introductory phase
- B. Working phase
- C. Summary phase
- D. Closing phase
Correct Answer: A
Rationale: The introductory phase establishes initial rapport with the client and family members and informs the client about the nurse's need to ask questions and gather information. When making introductions, the nurse should address the client by surname. The working phase is the second part of the process, and the summary and closing phase is the last.
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.
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.
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.