W chapter 2 nclex questions
A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client? Provide simple and organized information. Refer the client to a spiritual guide. Approach the client in an in-control manner. Mirror the client's feelings.
Provide simple and organized information. Rationale:The nurse should provide simple and organized information to reassure the client about the procedure and its expected outcomes. The nurse approaches the aggressive, not anxious, client in an in-control manner. The nurse refers the dying client or client with spiritual concerns to a spiritual guide. The nurse should avoid expressing anxiety or becoming anxious like the client, as it would make the client more anxious.
A client presents to the health care clinic with reports of sleeplessness and loss of appetite. The client tells the nurse that his wife is seriously ill in the hospital and he has not been able to visit her much because of transportation problems. Which open-ended question should the nurse ask the client to obtain more information about his presenting symptoms? "Do you think your wife is getting better?" "When did the sleeplessness first start?" "Are you taking any new medications?" "Have you lost any weight this week?"
"Do you think your wife is getting better?" Rationale:Open-ended questions are used to elicit information about a client's feelings or perceptions about a particular situation. In this case, the husband may be grieving over the wife's illness, the nurse needs to gather information about he feels or perceives her illness in relation to his ability to care for himself. The other questions will provide information about the client's physical symptoms.
A nurse is interviewing a client who has recently been diagnosed with terminal disease. In covering the lifestyle and health practices profile, the nurse asks the client, "Are you close to any extended family members in the area?" The client objects to the question and asks why the nurse needs to know that. Which is the best rationale for the nurse posing this question? "I'm just being friendly. We like to get to know our clients at this practice." "I just thought I might know them; I know pretty much everyone in this town." "I just wanted to see what kind of social support you might have to help care for you during your illness." "With you having a terminal illness, you will need someone to help you plan your funeral."
"I just wanted to see what kind of social support you might have to help care for you during your illness." Rationale:Ask clients to describe the composition of the family into which they were born and about past and current relationships with these family members. In this way, you can assess problems and potential support from the client's family of origin. Just being friendly and determining what acquaintances the nurse might have in common with the client are not proper rationales for asking for this personal information. Mentioning plans for the client's funeral is blunt and would likely upset the client.
A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time? "Are both of your parents still living?" "How do you feel about having to seek health care?" "What do you usually eat in a typical day?" "What diseases did you have as a child?"
"What diseases did you have as a child?" Rationale:Information covered in the personal health history section includes questions about birth, growth, development, childhood diseases, immunizations, allergies, medication use, previous health problems, hospitalizations, surgeries, pregnancies, births, previous accidents, injuries, pain experiences, and emotional or psychiatric problems. The question, "How do you feel about having to seek health care?" would be asked during the reason for seeking health care section of the interview. The question regarding the status of the client's parents would be posed in the family health history section. The question regarding what the client usually eats in a typical day would be included in the lifestyle and health practices profile section.
A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors? "Where did the numbness and tingling occur?" "What other symptoms occurred during the spell?" "How long did the spell last?" "How bad was the tingling and numbness?"
"What other symptoms occurred during the spell?" Rationale:Examples of questions related to associated factors include the following: "What other symptoms occur with it? How does it affect you? What do you think caused it to start? Do you have any other problems that seem related to it? How does it affect your life and daily activities?" The question, "How bad was the tingling and numbness?" relates to severity. The question, "How long did the spell last?" relates to duration. The question, "Where did the numbness and tingling occur?" relates to location.
A nurse is collecting data on a client's chief complaint, which is pain in the heel of his foot. The nurse asks the client, "When did this pain start?" Which component of symptom analysis does this question represent? Onset Duration Character Pattern
Onset Rationale:The onset of a symptom is when it began. The character of a symptom is a description of the quality of the symptom. Duration is how long the symptom lasts when it occurs. Pattern refers to factors that make the symptom better or worse.
A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information? Review of systems History of present illness Personal health history Chief complaint
Review of systems Rationale:The chief complaint is the abdominal pain. Any associated symptoms would be a part of the history of present illness. The information provided by the client about a past illness would be part of the personal health history. Review of systems provides specific questions about past illnesses that might still be impacting the client.
A nurse is conducting a review of systems with a client and is asking about his ears. The nurse asks, "Do you have any problems with your ears or your hearing?" The client stares blankly at the nurse a moment and then says, "I'm sorry—could you repeat that?" The nurse repeats the question, to which the client replies, "No." The nurse then asks, "Do you ever experience any trouble hearing or any ringing, buzzing, or earaches?" The client responds, "No." What should the nurse record under "Ears" in the review of systems section of the client's health history? "No problems." "Client denies any problems but had trouble hearing me when I asked him a question." Nothing—it should be left blank "Denies any trouble hearing or any ringing, buzzing, or earaches."
"Denies any trouble hearing or any ringing, buzzing, or earaches." Rationale:During the review of body systems, document the client's descriptions of her health status for each body system and note the client's denial of signs, symptoms, diseases, or problems that the nurse asks about but are not experienced by the client. If the lone entry "no problems" is entered on the health history form, other health care professionals reviewing the history cannot ascertain what specific questions had been asked, if any. Care must be taken in this section to include only the client's subjective information and not the examiner's observations. Thus, the nurse should not include the observation about the client having trouble hearing the nurse, especially because the client may have simply misunderstood the question when the nurse posed it the first time.
A nurse is interviewing a man complaining of a pain in his shoulder. The nurse asks him where exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen similar cases in other clients and recognizes that is likely from prolonged work at a computer, particularly using a mouse. Which of the following is the most effective use of inferring that the nurse might implement in this situation? "Do you perform any sustained or continually repetitive motions with that arm?" "You work at a computer a lot, don't you?" "When did the pain start?" "I recommend that you change your posture while working at the computer."
"Do you perform any sustained or continually repetitive motions with that arm? Rationale:Inferring information from what the client tells you and what you observe in the client's behavior may elicit more data or verify existing data. Be careful not to lead the client to answers that are not true. The question, "Do you perform any sustained or continually repetitive motions with that arm?" is open enough to not lead the client to an expected answer but narrow enough for the nurse to help elicit more information from the client about probable causes of his pain. Recommending that the client change his posture while working at the computer is premature, as the nurse has not confirmed that the computer work is the culprit. Likewise, "You work at a computer a lot, don't you?" is a leading question, as it encourages the client to answer in the affirmative. The question, "When did the pain start?" is a close-ended question; it will elicit more information from the client but is not an example of inferring.
Which interview question by the nurse demonstrates a biased or prejudiced attitude? "Who do you consider part of your family?" "You're not homosexual, are you?" "What do you do when you feel angry?" "Are you able to understand the instructions?"
"You're not homosexual, are you?" Rationale:The way a question is phrased may actually lead a client to think that it should be answered in a certain way. Asking a client if they are homosexual and adding "are you" may lead the client to think that the nurse does not accept homosexuality. The other questions allow the client to provide information in a non-threatening manner.
A nurse collects data about a client's family health history. Which family member's health problems should the nurse include when documenting this information in the database? As many maternal and paternal relatives as the client can recall Illnesses that resulted in death or disablement Only the members with health problems that relate to the client's gender Disease processes that are known to have a genetic link
As many maternal and paternal relatives as the client can recall Rationale:Both maternal and paternal relatives are included in the family health history. Problems can arise in families that are not genetically based but are manifest by virtue of exposure to lifestyle practices. Parents, grandparents, aunts, uncles, and children are all included in this history. If the relative is deceased, the cause and age of the relative is recorded.
A nurse is gathering biographic data from a new client who is visiting the office for the first time. Which of the following pieces of data would likely be included in the biographic section of the client's health history? Select all that apply. Mother: Sugar L. Thompson, died 7/14/2006 from heart attack Head and neck: sore throat and enlarged lymph nodes Caucasian Occupation: Brick mason 1212 South Maple St., Sylvan, VA 23236 Lamar P. Thompson
Caucasian Occupation: Brick mason 1212 South Maple St., Sylvan, VA 23236 Lamar P. Thompson Rationale:Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client's birth date, Social Security Number, medical record number, or similar identifying data may be included in the biographic data section. The client's culture, ethnicity, and subculture may begin to be determined by collecting data about date and place of birth; nationality or ethnicity; marital status; religious or spiritual practices; and primary and secondary languages spoken, written, and read. Gathering information about the client's educational level, occupation, and working status at this point in the health history assists the examiner to tailor questions to the client's level of understanding. The information regarding the client's mother, including the date and cause of death, would appear in the family health history section. The information on the head and neck would appear in the review of systems section.
A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format of representing a deceased female relative? Circle with a cross Square with a cross Simple square Simple circle
Circle with a cross Rationale:The standard format of representing a deceased female relative in a genogram is using a circle with a cross. A simple circle indicates a living female relative. A simple square indicates a living male relative. A square with a cross indicates a deceased male relative.
A nurse receives a report on a client admitted for the onset of lung cancer and reviews the data collected during the initial comprehensive assessment. Which information does the nurse recognize as requiring further data collection to validate? Client denies any feelings of anxiety or distress over the diagnosis. Client reports a productive cough of rust-colored sputum. Client reports pain at 7/10 that occurs with deep breathing. Client reports a 30-year history of cigarette smoking.
Client denies any feelings of anxiety or distress over the diagnosis. Rationale:Some data gathered during assessment require validation. For example, subjective data may appear to conflict with objective data. A nurse would expect a client newly diagnosed with cancer to express feelings of denial or anger, so the nurse will seek to gather more information about this client's emotions regarding the diagnosis. Pain and rust-colored sputum are expected findings with lung cancer, and a history of cigarette smoking is a risk factor for lung cancer. These findings likely do not require validation.
A nurse is collecting subjective data from a client as part of the assessment process. Which behavior is most appropriate for the nurse to display in this situation? Remaining standing during the interview Reading questions from the history form Maintaining eye contact with the client at all times Explaining the reason for taking down notes
Explaining the reason for taking down notes Rationale:The nurse should explain the reason for taking notes during the interview and ensure that it will remain confidential; this will help the client to provide all the required information during the interview. Some clients may be very uncomfortable with too much eye contact, while others may believe that the nurse is hiding something from them if eye contact is avoided. Therefore, the nurse should maintain only a moderate amount of eye contact and not maintain eye contact with the client at all times. The nurse should not remain standing while taking down notes, as it could indicate being in a hurry to complete the interview; it could also indicate that the nurse is expressing superiority over the client. The nurse should not read questions from the history form, as this deflects attention from the client and results in an impersonal interview process.
A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information? Lifestyle and health practices profile Family health history History of present health concern Personal health history
Lifestyle and health practices profile Rationale:By assessing the client with regard to nutritional habits, use of substances, education, and work and stress levels, the nurse expects to obtain a lifestyle and health practices profile. To determine the history of present health concerns, the nurse should ask questions relating to the onset, duration, and treatments, if any have been conducted on the client, for the present health concern. The questions related to personal health history assist the nurse in identifying risk factors that stem from previous health problems. Family health history helps the nurse to identify potential risk factors for the client.
Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data? Maintain a professional distance during assessment. Avoid any eye contact with the client. Speak to the client using local slang. Ask one of the client's children to interpret.
Maintain a professional distance during assessment. Rationale: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.
During a health history interview, a nurse asks a client about childhood illnesses, past surgeries, and allergies. The nurse knows that this information will be charted in what section of the initial comprehensive assessment database? Review of systems Personal health history Family health history Biographic
Personal health history Rationale:Information about a client's birth, childhood illnesses, immunization status, adult illnesses, surgeries, accidents, prolonged pain or pain patterns, and allergies are part of the personal health history. Biographic data include name, address, phone number, gender, date of birth, place of birth, race, educational level, occupation, and support systems. Family health history includes age of parents (living or deceased), parent illnesses, grandparent illnesses, and children illness or handicaps. Review of systems includes asking the client specific questions to draw out current health problems or problems from the past that may still be affecting the client's health.
A nurse is interviewing a client who seems anxious. Which nonverbal communication by the nurse helps to facilitate a relaxed environment for the client during the interview process? Wearing casual, neat, and comfortable clothes Ensuring that there are no periods of silence Sitting back with crossed arms during the interview Portraying a neutral and friendly expression
Portraying a neutral and friendly expression Rationale:The nurse should portray a neutral and friendly expression throughout the assessment and appear to be understanding and concerned. This will help the client to open up and provide necessary information regarding his or her health status. The client expects to see a health professional; the nurse should wear a laboratory coat with nametag and credentials clearly visible. The nurse should allow periods of silence during the interview to allow the client to reflect and organize thoughts; this facilitates more accurate reporting. The nurse should not sit back with crossed arms during the interview, as this may cause the client to think that the nurse is not interested in the client's health condition.
When gathering information about medication use, a nurse should ask a client about which types of drugs? Prescription and OTC medications Vitamins and herbal supplements Prescription medications only Over the counter (OTC) medications
Prescription and OTC medications Rationale:It is important to ask a client about prescription, OTC, vitamin & herbal supplements, as well as information about substance use/abuse. Many OTC and herbal supplements can interfere with the action of prescription drugs or cause untoward side effects.
What is the best action by a nurse when a client has difficulty describing the chief complaint? Ignore the complaint & return to it at a later time in the interview Provide the client with a laundry list of words to choose from Restate the question using simple terms Wait in silence until the client can find the correct words
Provide the client with a laundry list of words to choose from Rationale:A laundry list of descriptive terms can assist the client to describe symptoms, conditions, or feelings. The laundry list will assist the nurse to obtain specific answers & reduce the likelihood of the client perceiving or providing an expected answer. Restating the question would be useful if the client does not understand the questions being asked. Silence will not assist the client in describing symptoms but may make the situation even more uncomfortable. Ignoring the problem send the client a message that his concerns are not important to the nurse.
A client is admitted to the health care facility with new onset of abdominal pain. The client becomes angry with the nurse when questions about personal information are asked. How should the nurse proceed with the interview? Remind the client that this information must be obtained to provide proper care Encourage the client to use a more appropriate method to cope with feelings Touch the client lightly on the shoulder to dissipate the anger Remain in control and allow the client to vent feelings
Remain in control and allow the client to vent feelings Rationale:An angry client should be approached in a calm, reassuring, in control manner by the nurse. Allow the client to ventilate their feelings may help to diffuse the anger. Telling the client that this information is necessary does not convey an understanding of feelings by the nurse. Touching or arguing with the client may escalate their anger. Encouraging the client to use other methods of coping may help when dealing with a seductive client.
A nurse is interviewing a 16-year-old girl regarding her health history. When inquiring about her chief complaint, the girl lowers her voice and says, "I've been with a guy recently, and I'm worried that I might have caught something from him." The nurse responds by saying, "So, you're concerned that you may have a sexually transmitted infection?" Which verbal communication technique is the nurse using here? Open-ended question Laundry list Well-placed phrase Rephrasing
Rephrasing Rationale:Rephrasing information the client has provided is an effective way to communicate during the interview. This technique helps to clarify information the client has stated; it also enables the nurse and the client to reflect on what was said. Open-ended questions are used to elicit the client's feelings and perceptions, and typically begin with the words "how" or "what." The laundry list approach involves providing the client with a choice of words describing symptoms, conditions, or feelings, which reduces the likelihood of the client's perceiving or providing an expected answer. The nurse can encourage client verbalization by using well-placed phrases such as "uh-huh," "yes," or "I agree."
In interviewing a client about substance use, a nurse asks her whether she takes any herbal supplements. Which of the following is the best rationale for asking this question? Taking herbal supplements is an indicator that the client is concerned with maintaining her health. Some herbal supplements may interact with prescribed medications. Abuse of herbal supplements can result in cardiac dysfunction. Taking herbal supplements may be the client's mechanism for coping with stress.
Some herbal supplements may interact with prescribed medications. Rationale:Because many people use vitamins or a variety of herbal supplements, it is important to ask which ones and how often. These supplements and prescription medications may interact (e.g., garlic decreases coagulation and interacts with warfarin [Coumadin]). There is no indication that using herbal supplements can result in cardiac dysfunction. Taking herbal supplements may be an indicator of concern for one's health and a mechanism for coping with stress, but neither of these is as good a rationale as the one regarding interactions with prescribed medications.
An elderly female client is accompanied by her daughter on a visit to the health care facility. The nurse observes that the client is doing quite well, except for the use of a hearing aid. How can the nurse best facilitate the interview process with this client? Occupy a position close to the client and speak softly Ask the client's daughter to be present during the interview Speak slowly and clearly, using straightforward language Direct the questions to the daughter to enhance communication
Speak slowly and clearly, using straightforward language Rationale:The nurse should speak slowly and clearly, using straightforward language, keeping the language as simple as possible for easy understanding. The nurse need not ask the client's daughter to be present during the interview, as the client is quite able except for the use of a hearing aid. The nurse should establish and maintain trust, privacy, and partnership with the older client for effectively collecting data and sharing concerns. The nurse should not occupy a position close to the client and speak softly, as the client has hearing loss; in such cases, the nurse should face the client at all times and speak loudly.
A client reports chest pain that occurs with exercise but subsides with rest. The nurse recognizes this as what type of data? Subjective Reflective Objective Introspective
Subjective Rationale:Subjective data includes the following: sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information collected from the client. This information can be elicited and verified only by the client. Introspection and reflection are not types of data collection but ways in which a nurse can assist a client to work towards changing behaviors. Objective data are obtained by the nurse through observation using the four physical assessment techniques.
What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking? Ask the client why he started smoking at a young age Remind the client that excessive smoking could cause cancer Keep a stern expression to communicate the severity of the issue What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking? Ask the client why he started smoking at a young age Remind the client that excessive smoking could cause cancer Keep a stern expression to communicate the severity of the issue Suggest methods and provide resources to assist with smoking cessation
Suggest methods and provide resources to assist with smoking cessation Rationale:The client will know that the nurse understands that it is hard to quit smoking if the nurse suggests methods available to help kick the smoking habit. The nurse should keep a neutral and friendly expression, and avoid any display of surprise or shock at the situation. A neutral, friendly expression will help the client to open up and explain to the nurse his efforts at breaking free from the habit. The nurse need not tell the client that excessive smoking could cause cancer, as the client will be well aware of the dangers of smoking.
A nurse has completed assessment of a client and is now validating the information gathered and reviewing goals with the client. Which phase of the interview process is this? Introductory Analysis Working Summary
Summary Rationale:During the summary and closing, the nurse summarizes information obtained during the working phase and validates problems and goals with the client. In the introductory phase, the nurse meets the client and explains the purpose of the interview, discusses what type of questions will be asked, explains reasons for taking notes, and assures the client that confidential information will remain confidential. Analysis is not a phase of the interview process. The working phase is when data collection occurs.
An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary? The client The physician The client's wife The client's medical record
The client Rationale:Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client is considered the primary source and all others (including the client's medical record) are secondary sources. In some cases, the client's immediate family or caregiver may be a more accurate source of information than the client. An example would be an older adult client's wife who has kept the client's medical records for years or the legal guardian of a mentally compromised client. In any event, validation of the information by a secondary source may be helpful.
A nurse assesses a client who reports the onset of a severe headache. During which phase of the nursing interview should the nurse ask the client about the history of the present health concern and the reasons for seeking care? Closing Introductory Summary Working
Working Rationale:During the working phase, the nurse asks the client about the history of the present health concern and the reasons for seeking care. In the introductory phase the nurse explains the purpose of the interview and assures the client that confidential information will remain confidential. During the summary phase or the closing phase, the nurse summarizes information obtained during the working phase and validates problems and goals with the client.
