CH 6, 8, 9

In preparing a care plan for a client receiving opioid analgesics, the nurse selects which of the following as an applicable nursing diagnosis associated with side effects of opioid use?

Constipation Explanation: The most common side effects associated with opioid use are sedation, nausea, and constipation. Respiratory depression is also a commonly feared side effect of opioid use.

When observing a client diagnosed with mania, the nurse observes his mood to be elated. Another term for this type of mood includes which of the following?

Euphoric Explanation: Terms used to describe mood include euthymic (normal), euphoric (elated), labile (changeable), and dysphoric (depressed, disquieted, restless).

A nurse assesses a cognitively impaired adult client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain?

Faces Pain Scale Explanation: The nurse should use the Faces Pain Scale (FPS) to rate the pain felt by the client. The FPS shows different facial expressions; the client is asked to choose the face that best describes the intensity or level of pain being experienced. This tool is best suited for cognitively impaired adults. A Verbal Descriptor Scale (VDS) ranges pain on a scale between mild, moderate, and severe. The Numeric Rating Scale (NRS) rates pain on a scale from 0 to 10: 0 reflects no pain and 10 reflects pain at its worst. It has been shown to be best for older adults with no cognitive impairment. The Visual Analog Scale (VAS) rates pain on a 10-cm continuum numbered from 0 to 10: 0 reflects no pain and 10 reflects pain at its worst. These scales would require verbal communication between the client and the nurse.

The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what?

Patient advocate Explanation: The nurse may assess the change in the client and will be the advocate and detective, determining when the change occurred and what was new in the treatment.

The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first?

Retake the blood pressure Explanation: When encountering an abnormal value, obtain the vital sign(s) again to assess accuracy. It would be inappropriate to notify the physician immediately, give PRN blood pressure medications, or document the findings before rechecking the reading.

The nurse suspects that a client is experiencing alcohol abuse. When completing the CAGE questionnaire, the nurse can confirm the client is having guilty feelings when she makes which statement?

"My family doesn't deserve my bad behavior." Explanation: The nurse can confirm that the client is experiencing Guilty feelings when hearing the client say her "family doesn't deserve" her bad behavior. This statement indicates the client is experiencing guilt over her alcohol use. The statement "In the past I've considered drinking a little less" confirms that the client feels the need to Cut down on her alcohol use. The statement "My husband should stop nagging me about my drinking" confirms that the client has felt Annoyed by criticism of her alcohol use. The statement "I was worried about myself when I needed a glass of wine at 9 o'clock in the morning" confirms the client has had an Eye-opener about her alcohol abuse.

A client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments?

"Nurses focus on the diagnosis of actual human responses to disease or life events." Explanation: The medical focus is on diagnoses and treatment of the disease. Nurses focus on diagnoses and treatment of the actual or potential human responses to disease or life events. The assessments are not the same and are not used to validate collected information.

Recently, lung cancer has metastasized to the bones of a 68-year-old client, precipitating a sudden increase in his pain. The client's wife and daughter are concerned about the consequent increase in the amount of hydromorphone the client requires, citing the risk of addiction. How can the nurse best respond to the family's concern?

"There's a very minimal risk of addiction, and controlling his pain is our first concern." Explanation: Concerns about addiction are normally unfounded. Nonetheless, it is inaccurate to characterize the possibility of addiction as a myth, on one hand, or a very real risk, on the other. Tolerance would not necessitate discontinuation.

As part of the mental status examination, a nurse assesses the cognitive abilities of a client. Which question should the nurse ask to assess the judgment ability in the client?

"What do you do if you have pain?" Explanation: To assess judgment ability in a client, the nurse should ask the client what he or she does when in pain. Asking about the first job and the last hospitalization helps in assessing remote memory. Asking the client about the difference between an apple and an orange elicits abstract reasoning

Which question asked by the nurse assesses judgment of the client?

"What will you do if you feel the need to use cocaine again?" Explanation: Questions such as "What will you do if you feel the need to use cocaine again?" assess the individual's judgment and ability to solve problems. An aspect of orientation is assessed by asking the individual where they are. Asking what the individual had for breakfast assesses short-term memory, whereas asking about relationships with siblings assesses long-term memory.

To calculate the ideal body weight for a woman, the nurse allows

100 pounds for 5 feet of height. Explanation: To calculate the ideal body weight of a woman, the nurse allows 100 pounds for 5 feet of height and adds 5 pounds for each additional inch over 5 feet. The nurse allows 106 pounds for 5 feet of height in calculating the ideal body weight for a man. The nurse adds 6 pounds for each additional inch over 5 feet in calculating the ideal body weight for a man. Eighty pounds for 5 feet of height is too little.

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75 mm Hg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?

120/55 mm Hg Explanation: A drop in both the systolic and diastolic readings of 20 mm Hg or more from the sitting position to the standing position indicates orthostatic hypotension. A drop of less than 20 mm Hg from the sitting position is considered normal. An elevation is not called hypotension but hypertension.

A client was administered PO pain medications at 1530. By what time should the nurse re-assess and document the effects of the pain medication?

1630. Explanation: The JCAHO has set a standard that states that nurses must assess and reassess pain regularly. Most hospitals have a standard timeframe for reassessment, such as 1 hour for oral medication and 30 minutes for pain medication given intravenously. They base these timeframes on the time it takes a pain medication to provide a noticeable decrease in pain intensity.

Which Glasgow Coma Score indicates the client is in a deep coma?

3 Explanation: A Glasgow Coma Scale score indicates the client is in a deep coma. All other scores indicate some impairment with a score of 15 being no impairment.

A nurse has assessed the blood pressure of a recently admitted client and obtained a reading of 128/78 mm Hg. What is this client's pulse pressure?

50 mm Hg Explanation: The pulse pressure is the difference between the SBP and the DBP and reflects the stroke volume. Normal pulse pressure is approximately 40 mm Hg. The mean arterial pressure is calculated by adding one third of the SBP and two thirds of the DBP. A mean pressure of 60 mm Hg is needed to perfuse the vital organs.

A client is reporting pain and rates it as 7 on a scale of 1 to 10. When the nurse asks him to describe the pain, he states, "It feels like a knife is stabbing or cutting me." The nurse knows that this type of pain is conducted by which fibers?

A-delta fibers Explanation: A-delta fibers are myelinated and conduct impulses rapidly, resulting in pain being described as sharp or stabbing. C fibers are unmyelinated and cause pain that is achy and ongoing. There are no known AC or P fibers related to pain.

A client presents to the health care clinic with reports of a 2-day history of sore throat, ear pressure, fever, and stiff neck. The client states she has taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data?

Acute pain related to sore throat Explanation: The client describes pain of 2 days' duration, which is within the definition for acute pain. The client did not describe or display any major defining characteristics of anxiety such as restlessness, concern about lifestyle changes, or sleep disturbances. The stiff neck was not confirmed by objective data collected by the nurse. No evidence exists for the client to have risk for deficient fluid volume.

During a lecture on pain management, the nursing instructor informs the group of nursing students that the primary treatment measure for pain is which of the following?

Analgesics Explanation: Analgesics are most often the primary treatment measure for pain, although a growing trend involves the integration of complementary, nonpharmacologic measures with conventional medicine.

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Ashen gray Explanation: The skin of a dark-skinned client with cyanosis would be ashen gray. The skin tone would appear yellowish in a light-skinned client if the client had jaundice. A beige-pink skin tone would be a normal finding for the light-skinned client. A reddish skin tone could be related to fever, sunburn, or infection.

A nurse is assessing a client's nutrition. Which of the following would best assist in assessing a client's dietary habits? (Select all that apply.)

Assess for the presence of any chronic illnesses that affect intake or absorption of nutrients Obtain a 24-hour dietary recall of all foods and fluids consumed Explanation: The nurse can best assess dietary habits by asking the client about an average daily intake of food and fluids, where and when food is consumed, and whether there are any conditions or diseases that may affect intake or absorption of nutrients. One meal will not provide the best assessment of overall dietary habits. Height and weight measurements may not accurately reflect dietary intake.

A 72-year-old man comes to the clinic with his daughter for a follow-up visit after a recent hospitalization. He had been admitted to the local hospital for speech problems and weakness in his right arm and leg. On admission his MRI showed a small stroke. The client was in rehabilitation for 1 month following his initial presentation. He is now walking with a walker and has good use of his arm. His daughter complains, however, that everyone is still having trouble communicating with him. The nurse asks the client how he thinks he is doing. Although it is hard to make out his words, the nurse believes the client's answer is "well . . . fine . . . doing . . . okay." His prior medical history involved high blood pressure and coronary artery disease. He is a widower and retired handyman. He has three children who are healthy. He denies tobacco, alcohol, or drug use. He has no other current symptoms. On examination he is in no acute distress but does seem embarrassed when it takes him so long to answer. Blood pressure is 150/90; other vital signs are normal. Other than his weak right arm and leg, physical examination findings are unremarkable. What disorder of speech does he have?

Broca's aphasia Explanation: In Broca's aphasia, clients articulate very slowly and with great effort. Nouns, verbs, and important adjectives are usually present, and only small grammatical words are dropped from speech. Broca's area is on the lateral portion of the frontal lobes.

The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus?

Burning, tingling Explanation: The nurse should assess for neuropathic pain associated with diabetic neuropath. Neuropathic pain: Pain that results from damage to nerves in the peripheral or central nervous system (Staats, et al., 2004). Examples of neuropathic pain include diabetic peripheral neuropathy, post herpetic neuralgia, and postmastectomy pain. You should also be alert for the common terms that clients use to report neuropathic pain, such as burning, painful tingling, pins and needles, and painful numbness.

What action is appropriate for a nurse to perform when an irregular radial pulse is palpated on a client?

Count the pulse for a full minute for an accurate rate Explanation: The appropriate nursing action is to count the pulse for a full minute to obtain an accurate heart rate. Changing the client's position may change the amplitude of the pulse but not the rate. Coughing will not give the nurse any information about the irregular rate. Without any data to support the fact that the client is unstable, there is no need to place the client on a telemetry monitor immediately.

A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?

Critical thinking Explanation: Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems. Diagnostic reasoning is important in developing diagnostic statements, not in caring for multiple clients with complex care needs. Physical assessment is important in the building the foundation of the nursing care plan. The nursing care plan directs the care that will be provided for the individual client, but does not address the needs of caring for multiple clients.

A nurse is teaching a class on hypertension in a community setting. What risk factor would the nurse be sure to address to the class?

Family history Explanation: Clients should be educated about the risks of hypertension. Risk factors include obesity, cigarette smoking, heavy alcohol consumption, prolonged stress, high cholesterol and triglyceride levels, family history, and renal disease. Weight loss, low triglyceride level, and smoking cessation are not risk factors for hypertension.

A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process?

Flight of ideas Explanation: This represents flight of ideas, because the ideas are connected in some logical way. Derailment, or loosening of associations, has more disconnection within clauses. Circumstantiality is characterized by the client speaking "around" the subject and using excessive detail, though thoughts are meaningfully connected. Incoherence lacks meaningful connection and often has odd grammar or word use.

During a mental health assessment, how can the nurse obtain subjective data? Select all that apply.(Select all that apply.)

From the client From the client's family From an overheard conversation the client has with someone else Explanation: Subjective data are what the client says directly to the nurse or is overheard telling someone else or what family and friends have said. Subjective data does not include observations of the client or the nurse's opinion about the client.

An assessment that concentrates on patterns of role performance that all humans share is called what?

Functional Explanation: A functional assessment focuses on the functional patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs.

The nurse needs to assess the visual, perceptual, and constructional ability of a client. Which of the following assessments should the nurse use?

Have the client draw the face of a clock Explanation: Having the client draw the face of a clock is one way to assess visual, perceptual, and constructional ability. The SLUMS exam tests cognitive function. Giving directions to the client to perform a series of tasks, such as picking up and manipulating a pencil, is an assessment of concentration. Asking the client today's date is an assessment of orientation.

A nurse is assessing the effect of a client's chronic back pain on his affective dimension. Which question should the nurse ask for this assessment?

How does the pain influence your overall mood? Explanation: The question regarding the influence of the pain on mood would address the client's affective dimension, which includes feelings and emotions that result from the pain. The question regarding medical conditions would help assess the client's physical dimension. The question regarding the location of the pain would address the client's sensory dimension. The question regarding the client's education would address his cognitive dimension.

The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what?

In coma Explanation: A Glasgow Coma Score of 3 indicates a deep coma. A score of 7 indicates the client is in a coma. Higher scores indicate minimal or no impairment 3 and lower deep coma 7 and lower in coma 8-14 some impairment 15 no impairment

The client states her husband died a few months ago and she has not been the same since. Which nursing diagnosis is most appropriate?

Ineffective coping Explanation: Ineffective coping would be most appropriate. Anticipatory grieving occurs prior to change. There is no evidence of fear or mental status change. Expects death of love one

A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what?

Isolated systolic hypertension Explanation: The elderly are prone to isolated systolic hypertension (systolic greater than 140 but diastolic under 90) due to arteriosclerosis that makes blood vessels stiff and less compliant. Orthostatic hypotension is a blood pressure that drops when a client changes positions. Stage 1 hypertension is a blood pressure reading of 140 to 159/90 to 99 mm Hg. Hypertension is not normal for any client.

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

Lethargy Explanation: Opening the eyes, answering questions, and falling back asleep describes lethargy. Being completely unresponsive to all stimuli with the eyes closed describes a coma. Being awakened with vigorous or painful stimuli describes stupor. Opening the eyes to loud voices, responding slowly with confusion, and being unaware of the environment describes obtunded.

A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client?

Marfan syndrome Explanation: Marfan syndrome Arm span is greater than height and pubis to sole measurement exceeds pubis to crown measurement gigantism increased height and weight with delayed sexual development anorexia nervosa Extreme weight loss Cushing syndrome Central body weight gain with excessive cervical obesity (Buffalos hump), also referred to as endogenous obesity

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?

Neuropathic Explanation: Neuropathic pain can occur from central nervous system brain injury caused by a stroke. Nociceptive pain is caused by tissue damage. Somatic pain is another term used for nociceptive pain. Idiopathic pain does not have an identified cause. deep somatic pain originates from structures such as joints, bones, tendons, and muscles. ----Pain nociception has various locations. Visceral pain originates from abdominal organs; clients often describe this pain as crampy or gnawing. Somatic pain originates from the skin, muscles, bones, and joints; clients usually describe somatic pain as sharp (D'Arcy, 2014). Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. It is often burning or sharp, such as with a partial-thickness burn. Referred pain originates from a specific site, but the person experiencing it feels the pain at another site along the innervating spinal nerve. An example is a cardiac pain that a person experiences as indigestion, neck pain, or arm pain. Phantom pain is pain in an extremity or body part that is no longer there

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test.

Orientation, memory, and cognitive function. Explanation: Cognitive abilities include orientation, concentration, recent and remote memory, abstract reasoning, judgment, visual perception, and constructional ability.

A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition?

Orthostatic hypotension NOT Ambulatory bradycardia Explanation: Orthostatic hypotension (postural hypotension) is a low blood pressure associated with weakness or fainting when one rises to an erect position (from supine to sitting, supine to standing, or sitting to standing). It is the result of peripheral vasodilation without a compensatory rise in cardiac output

Why is it important for a nurse to gather information about a client's past experiences with pain?

Provides insight into positive or negative expectations for relief Explanation: Past experiences with pain may shed light on the previous history of the client in addition to possible positive or negative expectations of pain therapies. Identifying factors that increase or decrease pain, assessing how much it impacts the client's lifestyle, and understanding the course of the pain are questions that assist the nurse to elicit important information about the pain itself

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure. Explanation: A thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure.

The client comes to the emergency department reporting indigestion and left arm pain. The physician orders an EKG along with drawing of cardiac enzymes. When the results are back, the client is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?

Referred pain Explanation: Referred pain originates from a specific site, but the person feels the pain at another site along the innervated spinal nerve. An example is cardiac pain that the person experiences as arm pain and indigestion. Visceral pain originates from abdominal organs. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Somatic pain originates from skin, muscles, bones, and joints.

You are educating your client on taking blood pressure at home. What would be important to include in your client education?

Routine recalibration of the device Explanation: Follow the guidelines listed, and advise your clients about how to choose the best cuff for home use. Urge them to have their home devices recalibrated routinely.

A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what type of pain?

Somatic Explanation: Pain nociception has various locations. Visceral pain originates from abdominal organs; clients often describe this pain as crampy or gnawing. Somatic pain originates from skin, muscles, bones, and joints; clients usually describe somatic pain as sharp (D'Arcy, 2014). Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. It is often burning or sharp, such as with a partial-thickness burn. Referred pain originates from a specific site, but the person experiencing it feels the pain at another site along the innervating spinal nerve.

A client recovering from abdominal surgery is complaining of pain. The nurse realizes that the client is most likely experiencing which type of pain?

Somatic Explanation: Somatic pain is a type of nociceptive pain. Somatic pain is caused by tissue damage, which would occur after abdominal surgery. Psychogenic pain relates to factors that influence the client's report of pain such as anxiety and depression. Idiopathic pain does not have an identified cause. Neuropathic pain results from direct injury to the peripheral or central nervous system. -Neuropathic pain is described as burning, painful numbness, or tingling..

When a nurse asks a client "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing?

Suicide risk Explanation: Suicide risk is assessed by asking, "Do you have any thoughts of wanting to harm or kill yourself?" This question does not assess attempts at suicide, means of suicide, or plans of suicide.

In light of the low incidence of suicide, nurses are encouraged to perform what type of screening?

Targeted Explanation: Currently, given the low incidence of suicide, nurses are urged to intensify targeted rather than general screening.

The nurse assesses a client using the Glasgow Coma Scale. Which of the following indicators will be used to determine the score?

The Glasgow Coma Scale rates responses to eye opening, verbal, and motor responses.

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen. Explanation: Auscultation is used by the nurse to assess bowel sounds, such as gurgling throughout the abdomen. Inspection involves conscious observation of the client's physical characteristics and behaviors and smelling for odors, such as foul smelling urine. The nurse uses palpation to detect nodules in the breast by the use of touch. The nurse uses the technique of percussion to produce sounds over various parts of the body, such as dullness over the liver.

A client comes to the cardiovascular intensive care unit (CVICU) directly after a three-vessel coronary artery bypass graft (CABG). The client's orders state "maintain systolic blood pressure greater than 90 but less than 120." How does this order affect the monitoring of the client's blood pressure?

The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits Explanation: Vital signs reflect health status, cardiopulmonary function, and overall body function. They are called vital signs because of their importance as indicators of physiological state and response to physical, environmental, and psychological stressors. Changes in vital signs often indicate changes in health. Assessment of vital signs helps nurses to establish a baseline, monitor a client's condition, evaluate responses to treatment, identify problems, and monitor risks for alterations in health. It would not be appropriate to monitor this client's BP every hour or every 4 hours or to delegate the taking of this client's BP to a client care assistant.

The CAGE assessment is used by the nurse to determine if further assessment is needed. The nurse may assess that it is highly likely the client has a problem and would seek additional assessments if the client

answered "yes" to three of the four CAGE questions. Explanation: The CAGE assessment is a quick questionnaire used to determine if an alcohol assessment is needed. If two or more of these questions is answered yes, then further assessment is advised

When the nurse asks the client to say "No ifs, ands, or buts," the client tries but is unable to repeat the phrase with fluency. The nurse understands that this may indicate a form of

aphasia

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

confabulation Explanation: Confabulation is the fabrication of facts or events in response to questions in order to fill in the gaps from impaired memory. Derailment is tangential speech with shifting topics that are loosely connected or unrelated. Perseveration is persistent repetition of words or ideas. Flight of ideas is an almost continuous flow of accelerated speech with abrupt changes from one topic to the next.

A client known to a health clinic arrives wearing soiled clothing with matted hair and streaks of dirt on the face and hands. What should this client's appearance suggest to the nurse?

depression Explanation: Grooming and personal hygiene may deteriorate in depression. Mania is characterized by elation and euphoria. There is no particular change in appearance with mania. The client with Parkinson's disease will demonstrate a flat affect. There is no particular change in appearance in Parkinson's disease. Excessive fastidiousness may be seen in obsessive-compulsive disorder.

A female client is assessed to have a score of 6 points on the AUDIT. This would alert the nurse that this client

has a hazardous alcohol consumption. Explanation: The AUDIT questionnaire may be used to assess alcohol-related disorders by asking the client questions and then calculating a score. Since the effects of alcohol vary with average body weight and differences in metabolism, establishing the cut-off point for all women at a score of 7 will increase sensitivity for these population groups.

Which of the following is a normal temperature in centigrade for a healthy adult?

oral: 36.8°C Explanation: Normal values for temperature fall within a range. Normal values for an oral temperature are around 36.8°C, a rectal temperature around 37.1°C, an axillary temperature around 36.0°C, and a tympanic temperature around 37.0°C.

The nurse is having difficulty auscultating Korotkoff sounds. The nurse should (Select all that apply.)

reposition the stethoscope consider shock be certain there is full skin contact with the bell

When the client begins to cry, the nurse recognizes the need to focus the assessment on the client's emotional health. What factor will have the greatest effect on the nurse's ability to gather information concerning why the client is crying?

the rapport that exists between the nurse and the client Explanation: The amount of success that nurse has in discovering the reason behind the client's crying is heavily dependent upon the relationship (rapport) that exists between the nurse and the client. It is this mutual respect and trust that allows the nurse to enter into conversations that would otherwise be off limits. The remaining options have the potential to affect the conversation, but the conversation will not likely occur without the presence of an effective nurse-client relationship.

The nurse is assessing an elderly postsurgical client in the home. To begin the physical examination, the nurse should first assess the client's

vital signs. Explanation: It is a good idea to begin the "hands-on" physical examination by taking vital signs. This is a common, noninvasive physical assessment procedure that most clients are accustomed to.