Nokea
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.
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The client comes to the clinic and says to the nurse, 'I am coming in today to see the doctor because I started having diarrhea 2 days ago and am going six to eight times per day.' How would the nurse document this statement?
- A. Concern: Client is afraid of becoming dehydrated due to amount of diarrhea.
- B. Problem: Client is having diarrhea at least six to eight times per day.
- C. The client is having diarrhea and wants to see the physician.
- D. Chief complaint: 'Diarrhea began 2 days ago and having six to eight stools per day.'
Correct Answer: D
Rationale: The chief complaint is the current reason the client is seeking care. 'Concern' is not a relevant response and is not what the client stated. 'The client is having diarrhea and wants to see the physician' is vague and does not give enough information. 'Problem: Client is having diarrhea' is not appropriate, and not informative documentation.
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.
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 nurse is admitting a client to the medical unit with a diagnosis of chronic obstructive pulmonary disease (COPD). When should the nurse perform the assessment of the client?
- A. When the client is admitted to the healthcare system
- B. Prior to the client receiving the first dose of medication
- C. After the physician has made their first visit to examine the client
- D. Within 24 hours of the initial admission interview
Correct Answer: A
Rationale: The nurse performs assessment when the client is first admitted to the healthcare system. Waiting until the client has received medication, seen a physician, and within 24-hours of initial interview will delay the assessment and can delay appropriate care and treatment.
The nurse has closed the interview with a client and observes that the client appears to have something else to say. What statement made by the nurse can provide an opportunity for the client to express concerns and ask questions?
- A. Use your call bell if you need anything.'
- B. I don't know what else I could tell you, this about covers all of it.'
- C. Well that is all I have for you. Let me know if you need anything.'
- D. Do you have any questions or concerns that we have not discussed?'
Correct Answer: D
Rationale: Asking if the client needs more information provides an opportunity for the client to express concerns and ask questions. Instructions about the call bell do not allow the client to ask questions. 'I don't know what else I could tell you' inhibits the client from asking the nurse anything further as well as 'Well that is all I have for you.'