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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.
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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.
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.
The nurse is caring for a client who has been admitted to the hospital with abdominal pain and is suspected to have appendicitis. What data obtained is considered objective data?
- A. Bowel sounds hypoactive in the right lower quadrant
- B. Complaints of pain when right lower quadrant palpated
- C. Client states that the pain began 3 hours ago
- D. Client states feeling nauseated.
Correct Answer: A
Rationale: Objective data are facts obtained through observation, physical examination, and diagnostic testing. When assessing blood pressure or heart rate, or examining results from urinalysis, the nurse is obtaining objective data. The other answers are examples of subjective data.
The client is being interviewed by the nurse and is asked what symptoms they have had to bring them to the clinic. Which of the following data collected is considered subjective?
- A. Blood pressure of 110/60 mm Hg
- B. Client states, 'My chest feels tight.'
- C. Bowel sounds present in 4 quadrants
- D. Client's skin is warm and dry.
Correct Answer: B
Rationale: Subjective data are statements clients make about what they feel. The other data are objective because they are facts that are obtained through observation.
The nurse is preparing to interview a client. Which of the following is a variable involved in determining the length of the interview?
- A. Financial status
- B. Mental state
- C. Social status
- D. Relationships
Correct Answer: B
Rationale: The length of the interview depends on variables such as the severity of the client's condition, level of discomfort, ability to cooperate, age, and mental state. Financial status, social status, and relationships are not variables involved in determining the length of the interview.