NURS 202: Chapters 2 & 3

The nurse is performing a follow-up assessment and interview of a 72-year-old woman with a history of congestive heart failure. The nurse asks the client, "Have you been experiencing any activity intolerance since I last saw you?" What would be a more appropriate way for the nurse to elicit this information?

"Has this been having an effect on your ability to carry out your routines and get around your home?"- When initiating an interview, it is important to use language that is understandable and appropriate to the client. "Dyspnea," "SOB," and "activities of daily living" are potentially unclear to a client and reflect clinical language rather than clear communication.

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

"How do you manage your stress?"- To investigate the amount of stress clients perceive they are under and how they cope with it, ask questions that address what events cause stress for the client and how they usually respond. In addition, find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive.

The student nurse is caring for a patient with emphysema. What sound would the student nurse expect to hear when percussing the patient's lungs?

A hyperresonant lung sound is very loud, low in pitch, long in duration, and booming in quality. This is the sound heard from emphysematous lungs.

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

A nurse collects data about a client's family health history. Which family members' health problems should the nurse include when documenting this information in the database?

As many genetic relatives as the client can recall

The nurse is having difficulty auscultating a patient's bowel sounds during a physical examination of the abdomen. What can the nurse do to improve hearing the patient's sounds of this body area?

Auscultating bowel sounds can be difficult because of environmental noise. The nurse should reduce all environmental noise and auscultate the bowel sounds again. The steps used to assess the abdomen are inspection, auscultation, percussion, and palpation. The techniques of percussion and palpation will cause the patient to experience bowel sounds and, therefore, should be performed after bowel sounds are auscultated. Assessment of the abdomen is best performed with the patient in the lying position.

Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client did not want to wait. The nurse has heard about this client many times from colleagues and is aware that she is very talkative. Which of the following is a helpful technique to improve the quality of the interview for both provider and client?

Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed.

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing

Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle.

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

Determine if a structure is filled with air or fluid or is a solid structure

When interviewing a patient with a language barrier, it is best to use a family member to help interpret so the patient has a level of comfort with the process.

False

When interviewing, the nurse should logically move from specific to open-ended questions.

False

Learning about the effects of the illness does what for the nurse and the patient?

Gives them the opportunity to create a complete and congruent picture of the problem- Learning about the effects of the illness gives the nurse and the patient the opportunity to create a complete and congruent picture of the problem.

A nurse needs to measure the degree of flexion and extension that a student athlete has available at his knee joint 6 weeks after orthopedic surgery. Which of the following pieces of equipment would be best for the nurse to use?

Goniometer- A goniometer is a device used for measuring the degree of flexion and extension available at a joint. A reflex (percussion) hammer is used to test deep tendon reflexes, such as the patellar reflex of the knee. Skinfold calipers are used to measure skinfold thickness of subcutaneous tissue. A flexible metric measuring tape may be used for many purposes, including measuring the size of extremities.

What is the single most important method of preventing infection transmission by the nurse when coming into contact with a client?

Handwashing

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use?

Light- Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin. Moderate palpation should be used to assess the size, shape, and consistency of abdominal organs. Pressure is firm enough to depress approximately 1 to 2 cm in depth. During deep palpation, the nurse uses a pressure to palpate 2 to 4 cm in depth. Intermediate palpation is a distracter for this question.

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- 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 with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?

Snellen chart

What is used to gauge central and peripheral nervous system disorders?

Strength of a reflex

A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask the patient next. What is a useful interview technique for the student to use at this point?

Summarization- Summarization can be used at different points in the interview to structure the visit, especially at times of transition. This technique also allows the nurse to organize his or her clinical reasoning and to convey it to the patient, making the relationship more collaborative. It is also a useful technique for learners when they draw a blank on what to ask the patient next.

A nurse is preparing to assess a client's abdomen. Which client position would be best for this assessment?

Supine- The supine position, in which the patient lies down on her back, would be the best position for assessment of the abdomen. The abdomen would be inaccessible in the Sims' position, in which the client lies on her right or left side. The abdomen would be contracted, and thus not assessable, in the sitting and dorsal recumbent positions.

A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client?

The client may not want her sister to know her private information.

Which describes the nurse using the technique of palpation?

The nurse notes increased warmth surrounding an abdominal incision.

A nurse is examining a client suspected of having a fungal infection of the skin. Which piece of equipment should the nurse use to confirm the presence of fungus?

Wood's light

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

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

The nurse is planning to interview a client who is being treated for depression. When the nurse enters the examination room, the client is sitting on the table with shoulders slumped. The nurse should plan to approach this client by:

expressing interest in a neutral manner

During a client interview, the nurse asks questions about the client's past health history. The primary purpose of asking about past health problems is to

identify risk factors to the client and his or her significant others- The past health history focuses on questions related to the client's personal history, from the earliest beginnings to the present. These questions elicit data related to the client's strengths and weaknesses in his or her health history. The information gained from these questions assists the nurse in identifying risk factors that stem from previous health problems. Risk factors may be to the client or significant others.

A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? Select all that apply.

• Gown • Gloves • Face shield

Which of the following techniques are used in a physical assessment? Select all that apply.

• Inspection • Auscultation * Percussion • Palpation

What should the nurse do before conducting a physical examination of a patient?

• Obtain and check needed equipment. • Ensure a quiet environment. • Wash hands. • Identify ways to ensure patient privacy.

The nurse is focusing an interview on a patient's respiratory status. Which question would be the best to begin this interview?

"Describe your breathing."- During an interview, questions should proceed from general to specific. The question that is the most general is "describe your breathing." This provides the patient 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 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?"- 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.

"How many steps can you climb before you get short of breath?" is an example of what kind of question?

A question that elicits a graded response- The nurse should ask questions that require a graded response rather than a single answer.

"How many steps can you climb before you get short of breath?" is an example of what kind of question?

A question that elicits a graded response- The nurse should ask questions that require a graded response rather than a single answer. "How many steps can you climb before you get short of breath?" is better than "Do you get short of breath climbing stairs?" This question is neither qualitative nor imprecise.

A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?

Adequate lighting- Adequate lighting is most important for the physical examination of the client with scabies. Sunlight (when available) would be preferable; however, even a portable lamp or a good overhead light is sufficient for illuminating the skin and for viewing shadows and contours. A warm and comfortable room, a quiet area free of disturbance, and a firm examination bed or table are subsequent preparations to the physical setting for the examination.

After the physical examination of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes, non-intact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform?

Application of an antiseptic handrub- The nurse could apply an antiseptic handrub if the hands do not appear to be soiled. If during the examination the nurse's hands are soiled due to contact with any body fluids or excretion, mucous membranes, non-intact skin, or wound dressings, the nurse would be required to hand wash with nonantimicrobial soap and water, or antiseptic soap.

The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action?

Ask permission to talk to the client in front of visitors.

Universal precautions are primarily designed to protect the health care worker from what?

Blood-borne pathogens- Universal precautions are a set of guidelines designed to prevent transmission of HIV, hepatitis B virus, and other blood-borne pathogens when providing first aid or health care.

A nurse is preparing to evaluate an elderly client's risk for developing pressure sores after a 2-week stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose?

Braden scale- The Braden scale for predicting pressure sore risk would be the appropriate tool for evaluating a client's risk for developing pressure sores.

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- 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 is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface

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?

Explaining the reason for taking down notes- 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.

During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit

Hyper-resonance is a sound heard when percussing over the lungs of a client with emphysema.

You should use the bell of the stethoscope when auscultating what type of sounds?

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

During the physical examination of your patient you auscultate the sound of the patient's breathing. What area of the patient are you assessing?

Lungs

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

Maintain a professional distance during assessment- When assessing a non-native 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 because, 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 significant others 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 recognizes that it is best to begin the objective data collection with which procedure?

Measure the client's vital signs, height, and weight- It is important to begin the assessment with less intrusive procedures such as vital signs and height & 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.

When using an interpreter to facilitate an interview, where should the interpreter be positioned?

Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client- A priority is for the examiner is to have a good view of the client and to avoid having to look back and forth between client and interpreter. The nurse should remember to use short simple phrases while speaking directly to the client and ask the client to repeat back what he or she understands.

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope

A client admitted to the health care facility for new onset of abdominal pain expresses to nurse that they were treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

Past health history

A client admitted to the health care facility for new onset of abdominal pain expresses to nurse that they were treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

Past health history- 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 illnesses in the past are part of the past health history. Review of systems provides specific questions about past illnesses that might still be impacting the client.

What occurs during the termination phase of an interview?

Planning for follow-up care- The main activity that takes place during the termination phase is planning for follow-up and closing the interview.

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?

Portraying a neutral and friendly expression

When gathering information about medication use, a nurse should ask a client about which types of drugs?

Prescription and OTC medications- 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?

Provide the client with a laundry list of words to choose from- 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

During an interview with an adult client for the first time, the nurse can clarify the client's statements by:

Rephrasing the client's statements- Rephrasing information the client has provided is an effective way to communicate during the interview. This technique helps you to clarify information the client has stated; it also enables you and the client to reflect on what was said.

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens?

Respiratory hygiene/cough etiquette is another area that the CDC is addressing. Patients and other people with symptoms of a respiratory infection are asked to cover their mouths and noses with a tissue when coughing or sneezing.

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- 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.

How would the nursing instructor explain the goal of guided questioning to his or her students?

The main goal of guided questioning is to facilitate the patient's fullest communication. The early generation of a plan is not a paramount goal and it is incorrect to suggest particular answers to the patient.

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the patient's breath.- Inspection involves conscious observation of the patient's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a fruity odor to the patient's breath. The nurse uses the technique of palpation to note increased warmth surrounding an incision. Auscultation is used by the nurse to assess the lub-dub sounds of the heart. The nurse detects tympanic sounds of the bowel by percussing the abdomen.

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?

The nurse makes sure to disinfect the stethoscope between clients to avoid the spread of pathogens. Disinfecting the stethoscope after touching the client does not answer the question being asked. Placing the stethoscope directly on the client's skin does not answer the question being asked. Nothing noted in the question would require the nurse to wear a personal protection gown.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.- 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 patient'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.

The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?

The nurse should ask clients to repeat questions or statements if the nurse is unable to understand what the client said. The nurse can also paraphrase client responses to verify understanding. (less)

Which is an example of percussion? Select all that apply.

The nurse uses the technique of percussion to produce sounds over various parts of the body, such as resonance over the thorax, dullness over the liver, and tympany throughout the abdomen. Auscultation is used by the nurse to assess lung sounds, such as rustling, and gurgling bowel sounds

A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case?

The ulnar—or palmar—surface is the part of the hand used to palpate vibrations. The fingertips are not used to palpate. The dorsal surface is sensitive to temperature and the fingerpads are used to detect fine discriminations, such as pulses, texture, size, consistency, shape, and crepitus.

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

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

During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?

Working- During the working phase, the nurse collects data by asking specific questions. Two types of questions are closed-ended and open-ended questions. Each type has a purpose; the nurse chooses which type will help solicit the appropriate information. Pre-interaction, beginning, and closing are all phases in the interview process. The pre-interaction phase is prior to meeting the client, when the nurse collects data from the medical record. The information gathered from the medical record is used to conduct the client interview. The beginning phase is when introductions are exchanged, privacy is ensured, and actions are made by the nurse to relax the client. The closing phase is when a review of the interview is conducting, summarizing areas of concerns or importance, allowing the client to ask any closing questions.

The nurse is beginning a health history interview with an adult client who expresses anger at the nurse. The best approach for dealing with an angry client is for the nurse to:

allow the client to ventilate his or her feelings- When interacting with an angry client approach this client in a calm, reassuring, in-control manner. Allow him to ventilate feelings.

The nurse is interviewing a client in the clinic for the first time. When the client tells the nurse that he smokes "about two packs of cigarettes a day," the nurse should

encourage the client to quit smoking- If you are interviewing a client who smokes, avoid lecturing condescendingly about the dangers of smoking. Also, avoid telling the client that he or she is foolish and avoid projecting an attitude of disgust. This will only harm the nurse-client relationship and will do nothing to improve the client's health. The client is, no doubt, already aware of the dangers of smoking. Forcing guilt on him is unhelpful. Accept the client, be understanding of the habit, and work together to improve the client's health. This does not mean you should not encourage the client to quit; it means that how you approach the situation makes a difference. Let the client know you understand that it is hard to quit smoking, support efforts to quit, and offer suggestions on the latest methods available to help kick the smoking habit.

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have

knowledge of his or her own thoughts and feelings about these issues.

The nurse is planning to interview a client who has demonstrated manipulative behaviors during past clinic visits. During the interview process, the nurse should plan to

provide structure and set limits with the client

During an interview with an adult client, the nurse can keep the interview from going off course by

using closed-ended questions- Use closed-ended questions to obtain facts and to focus on specific information. Closed-ended questions are useful in keeping the interview on course.