EXAMS 1 Flashcards
A nurse is preparing to assess a client who is new to the clinic. When beginning the
collection of the client database, which of the following actions should the nurse
prioritize?
Establishing a trusting relationship
A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview?
Working
A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental?
“You must quit smoking because it affects others, not only you.”
A nurse is interviewing a 22-year-old client of the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?
Using a moderate amount of eye contact
A nurse is providing feedback to a colleague after observing the colleague’s interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement?
“Are you allergic to any medications?”
A client has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the client’s complaint?
Provide a laundry list of descriptive words.
A nurse is eliciting a client’s health history and the client asks, “Can I take the herb ginkgo biloba with my other medications?” What action would be best if the nurse is unsure of the answer?
romise to find out the information for the client.
The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first?
The client’s sensory abilities
A nurse provides care in a rural hospital that serves a community that has few minority residents. When interviewing a client from a minority culture, the nurse has enlisted the assistance of a “culture broker.” How can this individual best facilitate the client’s care?
By interpreting the client’s language and culture
Upon entering an exam room, the client states, “Well! I was getting ready to leave. My schedule is very busy and I don’t have time to waste waiting until you have the time to see me!” Which response by the nurse would be most appropriate?
“You’re certainly justified in being upset, but I am ready to begin your exam now.”
A nurse has admitted a client to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe?
“This helps us have an appropriate focus for the physical examination.”
A clinic nurse has reviewed a new client’s available health record and will now begin taking the client’s health history. Which of the following questions should the nurse ask first when obtaining the health history?
C) “What is your major health concern at this time?”
A client has presented for care with complaints of persistent lower back pain. When using the mnemonic COLDSPA, which question should the nurse use to evaluate the “P”?
“What makes it worse?”
A medical nurse has completed the review of systems component of the client’s health history. Which assessment finding should the nurse document under the review of systems?
“Menarche at age 13”
A client has been admitted following an unexplained weight loss of 15 pounds over the past 3 months. How should the nurse best assess the subjective component of the client’s nutritional status?
Obtain a 24-hour diet recall.
A client’s elevated body mass index (BMI) has prompted the nurse to assess the client’s activity and exercise level. Which statement would indicate to the nurse that the client is getting the recommended amount of exercise?
“I go to a step class for an hour three times a week.”
During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would
be most appropriate to determine a client’s current medication regimen?
Ask the client to bring all the medications and supplements to an interview.
The nurse is preparing to assess an adult woman’s activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data?
“Could you describe how you perform self-breast exams?”
A nurse is creating a genogram of a client’s family health history. The nurse should use which of the following symbols to denote the client’s female relatives?
Circle
A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?
Explain the purpose of the interview.
During the interview, the client states, “Is today the 12th? My wife died 2 months ago today.” Which of the following responses would be most appropriate?
“How does that make you feel right now?”
The nurse is using the mnemonic “COLDSPA” to assess a client’s complaint of lower abdominal pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint?
Severity
The nurse is obtaining information about a client’s past health history. Which client statement would best reflect this component of assessment?
“I had surgery 5 years ago to repair an inguinal hernia.”
A nurse is teaching a recent nursing graduate about the significance of verbal and nonverbal communication during client care. The new graduate demonstrates an understanding of these techniques by citing what example of verbal communication?
Providing a laundry list of descriptors when needed