CH 1, 2, 3

A nurse is interviewing an adult client who had a miscarriage 3 weeks ago. The woman is crying and is having difficulty talking. The nurse moves closer and places a hand on the woman's hand. What type of communication is this?

Active listening Explanation: Active listening is the ability to focus on the client and their perspectives. It requires the nurse to constantly decode messages including thoughts, words, opinions, and emotions. For example, if a client is sad, it is appropriate for a nurse to place a hand over the client's and to show a facial expression of compassion. The purpose of restatement is to have the client elaborate on what was originally stated by the client. Reflection uses summarizing by the nurse to find the true meaning of a client's words. Encouraging elaboration encourages the client to explain or go into more detail in the client's responses.

What can the nurse assess using percussion?

Borders of the heart Explanation: Percussion allows the examiner to assess such normal anatomic details as the borders of the heart. Options B, C, and D are incorrect because they cannot be assessed by percussion.

The nurse is focusing an interview on a client's respiratory status. Which question should the nurse ask first to begin this interview?

Describe how you breathe for me? Explanation: During an interview, questions should proceed from general to specific. The question that is the most general is "describe your breathing." This provides the client with an opportunity to discuss the current breathing pattern with the nurse. The other questions are specific and will elicit a yes-no response.

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?

Empathy Explanation: Empathy is an intuitive awareness of what the client is going through; it helps the nurse to be effective in providing for the client's needs while remaining compassionately detached. Inspection and palpation are skills that help the nurse in collecting objective data of the client's physical characteristics. Sympathy is a feeling that would make the nurse as emotionally distraught as the client; this hampers the ability of the nurse to provide client care.

Equipment used in conducting a physical examination includes a gauze pad. What is this used for?

Examining the tongue Explanation: Gauze pads are used during tongue examination. An applicator or tongue blade might be used to help invert the eyelid.

When assessing pulses, the nurse would use which part of the hand for palpation?

Finger pads Explanation: The finger pads are used for fine discrimination such as pulses, texture and size. The ulnar or palmar surface is used for vibrations, thrills and fremitus. The dorsal surface is used for temperature.

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Heart murmur Explanation: The bell of the stethoscope is used to listen for low pitched sounds such as abnormal heart sounds or bruits. The diaphragm is used to listen for high pitched sounds such as normal heart, lung, & bowel sounds.

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?

Light palpation Explanation: The nurse should use the light palpation technique to check the pulse of the client. Moderate and bimanual palpations are used to note the size, consistency, and mobility of the structures that are palpated. Deep palpation enables the nurse to feel very deep organs or structures that are covered by thick muscles.

You should use the bell of the stethoscope when auscultating what type of sounds? Low-frequency sounds Abnormal sounds Sounds that are partially audible without a stethoscope High-frequency sounds

Low-frequency sounds Explanation The bell is used with light skin contact to hear low-frequency sounds.

A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure?

Measure the client's vital signs, height, and weight. Explanation: It is important to begin the assessment with less intrusive procedures such as vital signs and height and weight. These nonthreatening/nonintrusive procedures allow the client to feel more comfortable with the nurse and ease anxiety. Once a trusting relationship is established, the nurse can proceed in a systematic approach to ensure that all body systems are fully examined. Auscultation of all body systems is not an acceptable approach to a comprehensive assessment. The initial assessment data can be collected while the client is still dressed.

During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment? Auscultation Percussion Inspection Palpation

Palpation

What would be the expected tone elicited by percussion of a normal lung? Resonance Dullness Tympany Hyper-resonance

Resonance Explanation Resonance is noted with a normal lung. Hyper-resonance is noted in a lung with emphysema. Tympany is heard over air. Dullness is noted over solid tissue. Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields. Hyper-resonance is a very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema. Tympany is a very loud, high-pitched, drum-like sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thud-like sound that is percussed over solid tissue such as the liver.

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a client. The nurse should be aware of what risk when using this assessment technique?

Risk for injury Explanation: With deep palpation, you might say, "I'm going to touch you and push down more deeply than before. Let me know if you feel pain or want me to stop." As palpation proceeds, continue conversation, asking the client about pain, presenting symptoms, or contributing factors while observing for nonverbal signs of tenderness or discomfort.

When inspecting structures such as the jugular venous pulse, what would be the best lighting to use?

Tangential lighting Explanation: Tangential lighting is optimal for inspecting structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart. It casts light across body surfaces that throws contours, elevations, and depressions, whether moving or stationary, into sharper relief.

Which statements made by the nurse demonstrate utilization of effective therapeutic communication techniques during an assessment interview? Select all that apply. You Selected: "Walking will be easier once you have the surgery to correct your torn ligament." "I had an ulcer once, so I know how you feel." Correct response: "Please describe exactly how your knee feels when you walk up the stairs." "Now let me summarize what you've told me about what seems to trigger your headaches." "Having such limited use of your right arm seems to make you angry.

Techniques such as guided questioning, empathic response, and summarization are all effective communication techniques that support the client and the interview therapeutically. Telling the client the nurse "knows how they feel" or providing premature reassurance should be avoided since such statements fail to validate the client's feelings while providing false reassurance.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax. Explanation: The nurse uses the technique of percussion to produce sounds over various parts of the body. The nurse detects resonance over the lungs by percussing the thorax. Inspection involves smelling for odors and conscious observation of the client's physical characteristics and behaviors, such as noting symmetry of the thorax. The nurse uses palpation to detect crepitus over the thorax by the use of touch. Auscultation is used by the nurse to assess lung sounds, such as rustling.

While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose?

To clarify Explanation: Another way to clarify is to ask, "What happens when you get low blood sugar?" Such questions prompt clients to identify other symptoms or give more information so that you can better understand the situation.

It is recommended that a left-handed examiner adopt a right-sided position.

True

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's

bone Explanation: Flatness is a sound heard over very dense tissue like bone.

The nurse is conducting a physical examination of a client who is in a lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular

c, d, e, b, a Explanation: When conducting a head-to-toe assessment for a client in the lying position, the nurse should begin with the structures closest to the head and progress downward. The nurse will assess the breasts, the chest and thorax, the cardiovascular system, the groin, hips, and knees, and then the shins and ankles.

Light palpation is most appropriate to assess the

inflamed areas of skin Explanation: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin (e.g., over an intravenous site).

An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?

last surgery date validated by adult daughter not unable to recall exact date of last surgery Explanation: The client's memory was cloudy but the adult daughter was able to provide the exact date based upon a life event that can be validated. This interaction does not indicate that the adult daughter is controlling the interview. The client was unable to recall the exact date of the surgery but with the daughter's help, the date was provided. The exact information about the surgical date and the person who provided the information should be documented. The client may have been confused, but that is not what needs to be documented.

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion Explanation: Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures.

The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview?

"Have you ever had a problem with mental or emotional illness?" not "When was the last time you talked with a psychiatrist?" Explanation: The nurse should begin by asking a non-threatening, open-ended question such as "Have you ever had a problem with mental or emotional illness?" Even though the nurse has information about this topic in the documentation, asking the question opens a dialogue with the client in which the client can share as feels comfortable. The question may elicit important information about the client's prior experiences seeking care for mental illness, for example. Asking specifically about medication for depression assumes the client has a history of depression. Asking about talking with a psychiatrist or counseling may cause the client to become defensive.

Which statement made by the nurse demonstrates an understanding of the termination phase of the interviewing process?

"Let me stress the importance of being medication adherent." Explanation: The termination phase of the interview contains a summary of important points such as the need to be medication adherent. Setting expectations is addressed in the introduction phase while expanding the client's story and negotiating a plan of care are completed during the interview's working phase.

Which of the following questions is most useful in the assessment of a client's diabetes management?

"What is your routine for checking your blood sugar these days? not "You check your sugars before each meal, don't you?" Explanation "What is your routine for checking your blood sugar these days?" is an open-ended question designed to elicit as much information as possible about how the client is monitoring blood sugar. The other choices are leading questions that clearly signal a "right" answer; the client might feel reluctant to respond "incorrectly." These questions also elicit yes-no responses; closed-ended questions such as these are appropriately used to clarify or obtain more accurate information about issues disclosed in response to open-ended questions.

Which assessment finding should the nurse document as objective data?

Body functions Explanation Subjective data is what the client tells the nurse. Objective data is what the nurse assesses or observes when performing care of a client.

The nurse would use what part of the hand when assessing temperature during palpation? Finger pads Palmar surface Ulnar surface Dorsal surface

Dorsal surface Explanation: The dorsal surface is used for temperature. The finger pads are used for fine discrimination such as pulses, texture, and size. The ulnar or palmar surface is used for vibrations, thrills, and fremitus.

A nurse is preparing to perform a genital examination of a female client. Which of the following positions should the nurse place the client in? Lithotomy Supine Prone Standing

Lithotomy Explanation: The lithotomy position is used to examine the female genitalia, reproductive tracts, and the rectum. It involves the client lying on her back with the hips at the edge of the examination table and the feet supported by stirrups. In the supine position, the client lies down with the legs together on the examination table. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. In the standing position, the client stands still in a normal, comfortable, resting posture. This position allows the examiner to assess posture, balance, and gait. This position is also used for examining the male genitalia. In the prone position, the client lies down on the abdomen with the head to the side. The prone position is used primarily to assess the hip joint.

During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?

Palpation Explanation: Palpation is the use of tactile pressure from the fingers to assess contours and sizes of organs. Inspection is close observation of the details of a client's appearance, behavior, and movement. Percussion is the use of a finger of one hand to strike a finger of another hand for the purpose of eliciting a tone or sound wave. Auscultation is the use of a stethoscope to heart sounds within the body organs.

During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved?

Working Explanation: During the working phase, the nurse collects data by asking specific questions. Two types of questions are closed-ended and open-ended. Each type has a purpose; the nurse chooses which type will help solicit the appropriate information. The pre-interaction phase is prior to meeting with the client. The nurse review the client's medical records to collect important data. The beginning phase is the phase when introductions are exchanged and the purpose of the interaction is explained to the client. The closing phase is a time for summarizing information shared with the client and assessing any learning deficits.

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information?

past medical history Explanation: An adult medical illness is documented as part of the past medical history. Health patterns identify the client's personal/social history and daily living routines that may influence health and illness. The review of systems focuses on the presence or absence of common symptoms related to each major body system. Health maintenance is a part of the past medical history and identifies actions taken to improve or maintain health.

A client presents to the ED with pain in the upper right quadrant that worsens after eating. The client describes the pain as sharp, stabbing, and at times very intense. This is a description of which type of pain?

Acute Explanation: Acute pain results from tissue damage, whether through injury or surgery. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Phantom pain is pain in an extremity or body part that is no longer there. Cutaneous pain and phantom pain are not described as above. Chronic pain, also known as persistent pain, is a description of a pain that is present for more than six months, and can be described in many different terms, not just as above.

Nurses weave the individualization of the client interview through all aspects of the encounter. The nurse should avoid assuming that clients follow cultural beliefs. In place of making this assumption, what should a nurse do?

Assess the degree to which the client perceives the cultural beliefs Explanation: The nurse should avoid assuming clients follow cultural beliefs and assess the degree to which each individual perceives those beliefs. Knowing the mores of the culture and the nurse's own cultural beliefs are important, but do not answer the question at hand. The nurse would have difficulty assessing how acculturated the client is within the client's cultural beliefs.

Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data?

Maintain a professional distance during assessment. Explanation: When assessing a nonnative client, the nurse should maintain a professional distance during assessment; the size of personal space affects one's comfortable interpersonal distance. The nurse should not speak to the client using local slang; if the client finds it difficult to learn the proper language, slang would be much more difficult to understand. The nurse need not avoid any eye contact with the client, but should maintain eye contact with the client as required, without giving the client reason to think that the nurse is being rude. Asking one of the client's children to interpret during the interview may actually impair the assessment process. In addition, health care institutions often have specific policies regarding interpreters that you must be aware of prior to using an interpreter.

A nurse in the community is completing manual blood pressure assessments at a recreation center. Which action should the nurse take to ensure the assessment is accurate?

Turn down the volume if the television or radio is on. Explanation: When completing a manual blood pressure assessment, it is important to ensure that external noise does prevent the nurse's ability to hear the systolic and diastolic blood pressure sounds. Turning the television volume down assists the nurse in obtaining a more accurate measurement of the blood pressure. Turning down the lights in the room could prevent the nurse from being able to read the blood pressure accurately. The client may sit or lie down; having the client lie down is not necessary for an accurate reading. Asking the client to take deep breaths would promote relaxation; however, it would not improve the accuracy of the assessment.

During a health history a client recalls the date when being first diagnosed with hypertension. Which term should the nurse use to categorize the quality of the client's data?

reliable not questionable Explanation: The client's memory is intact and would be considered reliable. The terms puzzling, concerning, and questionable would not apply because the client was able to provide an exact date.