Test Bank NURS 2900 Interviewing and Physical Assessment Questions and Answers,100% CORRECT

Test Bank NURS 2900 Interviewing and Physical Assessment Questions and Answers 1. Which of the following should the nurse use during an admission interview? A) Give the client suggestions for the answers and avoid making eye contact during the interview. B) Allow the client ample time to answer each question and maintain eye contact. C) Set a time limit to answer each question and proceed to the next question if the client fails to do so. D) Provide the client with a self-help guide to look for answers and maintain eye contact occasionally. Ans: B Feedback: The nurse should give the client ample time to answer each question and maintain eye contact to facilitate the interview. Giving the client suggestions for answers and avoiding eye contact during the interview might make the client uncomfortable. Giving the client a time limit to answer each question and proceeding to the next question if the client fails to do so might make the client anxious. Giving the client a self-help guide may hinder interaction between the nurse and the client. 2. Which of the following is important to do at the end of an interview with the client? A) Call the client's family members to give them information. B) Call the physician to discuss findings and establish a plan of care. C) Conduct a physical examination immediately after the interview. D) Summarize the information and thank the client for cooperating. Ans: D Feedback: A nurse should end an interview with the client by summarizing what occurred and thanking the client for cooperating. The nurse should not discuss the information obtained through the interview with the client's family. It may not be necessary to call the doctor for further consultation or to conduct a physical examination immediately after the interview. 3. Which portion of the interview determines how well the client can perform activities of daily living (ADLs)? A) Cultural history B) Functional assessment C) Chief complaint D) Psychosocial history Ans: B Feedback: A functional assessment determines how well the client can perform ADLs. The psychosocial history and cultural history include the client's age, occupation, religious affiliation, cultural background, and health beliefs. The chief complaint is the current reason the client is seeking care. 4. When asking questions about the client's marital status, the nurse is gathering information about which of the following? A) Present illness B) Functional assessment C) Chief complaint D) Psychosocial history Ans: D Feedback: The psychosocial history and cultural history include the client's age, occupation, religious affiliation, cultural background, health beliefs, marital status, and home and working environments. When gathering information about the history of the present illness, the nurse asks the client to describe all present problems, including the onset, frequency, and duration of symptoms. A functional assessment determines how well the client can perform activities of daily living. The chief complaint is the current reason the client is seeking care. 5. Which assessment technique involves a systematic observation of the client? A) Auscultation B) Inspection C) Palpation D) Percussion Ans: B Feedback: Inspection is the systematic and thorough observation of the client and specific areas of the body. Auscultation involves listening with a stethoscope for normal and abnormal sounds generated by organs and structures such as the heart, lungs, and intestines. Palpation is assessing the characteristics of an organ or body part by touching and feeling it with the hands or fingertips. Percussion is tapping a portion of the body to determine whether there is tenderness or to elicit sounds that vary according to the density of underlying structures. 6. Which of the following are statements the client makes about how he or she feels? A) Objective data B) Cultural data C) Cognitive data D) Subjective data Ans: D Feedback: Subjective data are statements the client makes about what he or she feels. Objective data are facts obtained through observation, physical examination, and diagnostic testing. Cultural data include cultural background and health beliefs. 7. The nurse is completing a physical examination on a client complaining of abdominal pain. Which of the following are facts obtained during the physical examination? A) Symptoms B) Objective data C) Subjective data D) Complaints Ans: B Feedback: Objective data are facts obtained through observation, physical examination, and diagnostic testing. Feelings related to subjective data are symptoms. Subjective data are statements the client makes about what he or she feels. Complaints are reasons the client is seeking care. 8. Questions about current and past use of prescription medications would probably be part of which of the following? A) The client's past health history B) The client's history of present illness C) The client's chief complaint D) The functional assessment Ans: A Feedback: The client's past health history includes identifying childhood diseases and prior hospitalizations. History of present illness is gathered when the nurse asks the client to describe all present problems, including the onset, frequency, and duration of symptoms. A chief complaint is the current reason the client is seeking care. A functional assessment determines how well the client can perform activities of daily living. 9. The nurse identifies jaundice in an assigned client. Which assessment technique is the nurse using? A) Inspection B) Palpation C) Auscultation D) Percussion Ans: A Feedback: Inspection is the systematic and thorough observation of the client and specific areas of the body. Palpation is assessing the characteristics of an organ or body part by touching and feeling it with the hands or fingertips. Auscultation involves listening with a stethoscope for normal and abnormal sounds generated by organs and structures such as the heart, lungs, and intestines. Percussion is tapping a portion of the body to determine whether there is tenderness or to elicit sounds that vary according to the density of underlying structures. 10. The nurse is preparing to interview a client. Which of the following is a variable involved in determining the length of the interview? A) Financial status B) Mental state C) Social status D) Relationships Ans: B Feedback: The length of the interview depends on variables such as the severity of the client's condition, level of discomfort, ability to cooperate, age, and mental state. Financial status, social status, and relationships are not variables involved in determining the length of the interview. 11. The nurse is admitting a client to the medical unit with a diagnosis of chronic obstructive pulmonary disease (COPD). When should the nurse perform the assessment of the client? A) When the client is admitted to the healthcare system B) Prior to the client receiving the first dose of medication C) After the physician has made their first visit to examine the client D) Within 24 hours of the initial admission interview Ans: A Feedback: The nurse first assesses the client when he or she is admitted to the healthcare system. The other answers will delay the assessment and can delay appropriate care and treatment. 12. The nurse provides a comprehensive initial assessment on a newly admitted client. What is the benefit to establishing this database from the client? A) It will help determine what unit the patient needs to be admitted to. B) It will inform the healthcare team about what medications are best for the client. C) It will give the healthcare team all of the information about the client. D) It will be a yardstick for measuring effectiveness of care. Ans: D Feedback: Findings from this comprehensive initial assessment establish a database that gives all team members relevant client information and become a yardstick for measuring effectiveness of care. The physician will make the determination about what unit the patient will require according to the acuity of care. The physician will determine what medications are best for the client. The information obtained will not be conclusive, and further assessment of the client's condition and information will be obtained during the hospital stay. 13. The client is being interviewed by the nurse and is asked what symptoms they have had to bring them to the clinic. Which of the following data collected is considered subjective? A) Blood pressure of 110/60 mm Hg B) Client states, “My chest feels tight.” C) Bowel sounds present in 4 quadrants D) Client's skin is warm and dry. Ans: B Feedback: Subjective data are statements the client makes about what he or she feels. The other data are objective because they are facts that are obtained through observation. 14. The client arrives at the clinic and informs the nurse that he is “coughing, having a sore throat, and have been running a fever for 2 days.” What are these feelings of discomfort called? A) Signs B) Objective data C) Symptoms D) Clinical signs Ans: C Feedback: When the client tells the nurse about nausea, pain, fear, bloating, or other feelings of discomfort, he or she is providing subjective data. These feelings of discomfort are classed as symptoms. Signs are objective data that is abnormal, and objective data is what the nurses obtain through observation, physical examination, and diagnostic testing. Clinical signs are the same as signs. 15. The nurse is caring for a patient who has been admitted to the hospital with abdominal pain and is suspected to have appendicitis. What data obtained is considered objective data? A) Bowel sounds hypoactive in the right lower quadrant B) Complaints of pain when right lower quadrant palpated C) Client states that the pain began 3 hours ago. D) Client states they are nauseated. Ans: A Feedback: Objective data are facts obtained through observation, physical examination, and diagnostic testing. When the nurse assesses blood pressure or heart rate or examines results from urinalysis, he or she obtains objective data. The other answers are examples of subjective data. 16. The nurse is assessing a patient and determines that the vital signs are not within normal range for the patient. With the results of the objective data being abnormal, what does the nurse document these findings as? A) Symptoms B) Subjective data C) Physical assessment D) Signs Ans: D Feedback: When objective data are abnormal, they are called signs. Symptoms refer to feelings of discomfort felt by the client. Subjective data is what the client states to the nurse. Physical assessment is a general term used regarding the assessment of the patient. 17.A client is arriving at the clinic for the first time. The nurse provides an introduction and establishes an initial rapport with the client. What phase of the interview process is this? A) Introductory phase B) Working phase C) Summary phase D) Closing phase Ans: A Feedback: The introductory phase establishes initial rapport with the client and family members and informs the client about the nurse's need to ask questions and gather information. When making introductions, the nurse should address the client by his or her surname. The working phase is the second part of the process, and the summary and closing phase is the last. 18.The nurse is conducting an interview with a client at the hospital. The client has a roommate in the room. Where would the optimal place for this interview to take place? A) In the waiting area B) In the client's room C) In a private treatment room D) At the nurse's station Ans: C Feedback: A private setting for the interview is essential to eliminate interruptions and maintain the client's confidentiality. The nurse should explain that information obtained during the interview helps with planning care. He or she should tell the client that all information is kept confidential, although all members of the healthcare team share the data. The other responses are not private, and information may be overheard. 19.A client is being seen at the clinic for the first time, and the nurse asks the client about what brought them to the clinic today as well as the past medical history. What part of the interview process does this represent? A) Introductory phase B) Working phase C) Summary phase D) Closing phase Ans: B Feedback: During the working phase, the nurse asks the client questions to gather data for the client database. The introductory phase involves the beginning introductions as well as establishing rapport. The summary or closing phase is at the end of the interview. 20.A client will be admitted to the hospital to have a surgical procedure in the morning. The nurse is aware that the client is hearing impaired and is planning the care as well as how to communicate with the client. What solution for communication could the nurse use? A) Use a whiteboard or paper and pencil so that the client will clearly understand what is being asked. B) See if the client can lip-read so communication will be clear. C) Tell the client he must bring an interpreter with him to the hospital to stay. D) Speak in a loud voice so that the client may hear some of what is said. Ans: A Feedback: Using the whiteboard or paper and pencil will allow a clear communication between the nurse and the client without room for misinterpretation of questions. Lipreading is not always convenient if the client or nurse is facing away from one another and can be misinterpreted. The client is under no obligation to have an interpreter with them at all times. Speaking loudly can be a HIPAA violation and is not an effective means of communication. 21. The nurse is having difficulty with the working phase of the interview process with a client who is not maintaining eye contact or responding openly to questions that are being asked. What question can the nurse ask that could require more discussion? A) “Are you married?” B) “Can you tell me more about what brought you to the hospital?” C) “How many children do you have?” D) “Do you work outside of the home?” Ans: B Feedback: Questions are best phrased as open-ended questions that require discussion. “Can you tell me more about what brought you to the hospital?” requires more than just a yes or no answer. The other answers are closed-ended questions and only require a yes or no response. 22. The nurse has received a client in the emergency department that is very short of breath. The nurse only wants to ask closed questions to decrease the workload on the client. What would be an example of a question for the nurse to ask? A) “Can you tell me about the precipitating factors that lead you to come to the hospital?” B) “What did you do when the shortness of breath began?” C) “Do you use oxygen at home?” D) “Can you give me a history of previous medical problems?” Ans: C Feedback: “Do you use oxygen at home?” is a closed-ended question that only requires a yes or no answer. The other questions require more than a yes or no response. 23. The client comes to the clinic and says to the nurse, “I am coming in today to see the doctor because I started having diarrhea 2 days ago and am going six to eight times per day.” How would the nurse document this statement? A) Concern: Client is afraid he is going to be dehydrated from the amount of diarrhea he is having. B) Problem: Client is having diarrhea at least six to eight times per day. C) The client is having diarrhea and wants to see the physician. D) Chief complaint: “Diarrhea began 2 days ago and having six to eight stools per day.” Ans: D Feedback: The chief complaint is the current reason the client is seeking care. “Concern” is not a relevant response and is not what the client stated. “The client is having diarrhea and wants to see the physician” is vague and does not give enough information. “Problem: Client is having diarrhea” is not appropriate, not informative documentation. 24. The nurse at the clinic asks the client about what brought him in to see the physician today. What is the purpose of asking the client about his primary health concern? A) To discover what the client perceives as the health problem that needs treatment B) To triage the patient and determine if he really need to see the physician today C) To determine if the insurance company will pay for the visit D) To see if a prescription can be called in without having to see the physician Ans: A Feedback: The purpose of asking the client about his or her primary health concern is to discover what the client perceives as the health problem that needs treatment. Recording information in the client's own words is best. The nurse cannot determine if the client should see the physician today and if the client should not be denied treatment based on the insurance companies willingness to pay. The client can opt to pay for the visit themselves. Physicians do not generally give prescriptions any longer without seeing the clients. 25. The nurse is interviewing a client whose chief complaint is abdominal pain. What information requested by the nurse is part of a focus assessment? A) “Have you had any problems with your breathing lately?” B) “How long have you had this pain, and what does the pain feel like? Can you rate the pain on a scale of 0 to 10?” C) “Do you smoke? If so, how many packs per day do you smoke?” D) “Have you had any swelling in your feet or ankles? Ans: B Feedback: Asking for more detailed information about one body system or problem is called a focus assessment because it adds depth to the original data. For example, a client may reveal that he or she has experienced abdominal pain for the past several weeks. Further questioning then addresses what causes the pain, how long it lasts, what the quality of the pain is, and what makes it better or worse. The other answers relate to questions that do not have anything to do with the patient's chief complaint. 26. The nurse is performing a functional assessment for a client who has had a mild stroke and will be discharged in 2 days from the hospital. What question would be important to ask when conducting this assessment? A) “Do you have enough money to pay for the medications that you will be taking at home?” B) “Do you have friends that will come and visit and take you out to socialize?” C) “You have an appointment to see the physician in 1 week. How will you obtain transportation to come to the office?” D) “Do you understand that your medication can cause bleeding tendencies?” Ans: C Feedback: A functional assessment determines how well the client can manage activities of daily living (ADLs). ADLs include self-care activities, such as walking moderate distances, bathing, and toileting, and instrumental activities, such as preparing meals, obtaining transportation, and dialing the phone. This assessment component is particularly important when assessing older adults or physically challenged clients of any age. The other answers do not pertain to ADLs. 27. The nurse is interviewing a client who is being placed on medication for the treatment of depression. What question would be essential for the nurse to ask the client to avoid complications related to drug therapy? A) “Are you presently taking an herbal preparation for the treatment of depression?” B) “Do you have enough money or insurance coverage to pay for this medication?” C) “How many times have you been treated for depression?” D) “Will you be seeing a counselor or therapist? Ans: A Feedback: The nurse identifies any current and past use of prescription and nonprescription drugs or herbal products. He or she asks about the client's use of alcohol and tobacco because these drugs can create or contribute to other health problems. If the client is using herbal preparations for the treatment of depression, this can cause complications with the medication that the physician is prescribing. The other questions do not relate to the past or present prescription and nonprescription drug use. 28. The nurse is ending an interview with a client who has been admitted to the hospital for pneumonia. What statement made by the nurse would be an effective way to end the interview? A) “I appreciate your cooperation and understand that your symptoms have been getting worse for 2 days.” B) “I will refer any questions you have to the physician.” C) “How long do you think you will be in the hospital for pneumonia?” D) “Let me show you where your call bell, television controls, and bathroom are.” Ans: A Feedback: An effective way of ending the interview is to summarize what occurred and thank the client for cooperating. Referring questions to the physician without attempting to answer any is not an effective means of communication and does not end the summary phase adequately, and the client has not been thanked for cooperating. Option C is not a summarization nor has the client been thanked. Option D relates to the orientation of the client's room. 29. The nurse has closed the interview with the client and observes that the client appears to have something else to say. What statement made by the nurse can provide an opportunity for the client to express concerns and ask questions? A) “Use your call bell if you need anything.” B) “I don't know what else I could tell you, this about covers all of it.” C) “Well that is all I have for you. Let me know if you need anything.” D) “Do you have any questions or concerns that we have not discussed?” Ans: D Feedback: Asking the client if he or she needs more information provides an opportunity for the client to express concerns and ask questions. Option A does not allow the client to ask questions and is not specific for questions or concerns. “I don't know what else I could tell you” inhibits the client from asking the nurse anything further as well as “Well that is all I have for you.” 30. The RN is precepting an LPN who is new to the medical unit. The RN begins to assess a newly admitted client to the unit and is demonstrating an assessment technique that is used that assesses each body system separately. What type of assessment method is the RN using? A) Systems method B) Head-to-toe method C) Inspection D) Focused assessment Ans: A Feedback: The systems method approaches the examination by assessing each body system separately. The head-to-toe method of assessment begins at the top of the body and progresses downward. Sometimes, healthcare providers use parts of both methods. Inspection is the systematic and thorough observation of the client and specific areas of the body. A focused assessment concentrates on the area of the body that is the chief complaint. 31. What type of assessment is the nurse performing when beginning the assessment at the head and progressing down to the lower extremities? A) Focused assessment B) Head-to-toe assessment C) Total body assessment D) Systems method Ans: B Feedback: A head-to-toe assessment begins at the top of the body and progresses downward. A focused assessment focuses on a part of the body that is the primary site of problem such as a respiratory assessment for a cough. The total body assessment has no direction for an assessment and can be done in any order. A systems method approaches the examination by assessing each body system separately. 32.A client comes to the clinic for someone to “check a mole” that is changing color and getting larger. The nurse asks the client to remove the shirt so that the mole may be observed. What part of the assessment is this considered? A) Inspection B) Palpation C) Percussion D) Auscultation Ans: A Feedback: Inspection is the systematic and thorough observation of the client and specific areas of the body. Palpation is assessing the characteristics of an organ or body part by touching and feeling it with the hands or fingertips. Percussion is tapping a portion of the body to determine if there is any tenderness or to elicit sounds that vary according to the density of underlying structures. Auscultation means listening with a stethoscope for normal and abnormal sounds. 33. The LPN observes the RN performing an assessment of the abdomen. The RN is lightly touching the patient's abdomen and feeling it with the hands and fingertips. What assessment techniques is the LPN aware that the RN is using? A) Inspection B) Palpation C) Percussion D) Auscultation Ans: B Feedback: Palpation is assessing the characteristics of an organ or body part by touching and feeling it with the hands or fingertips. Inspection is the systematic and thorough observation of the client and specific areas of the body. Percussion is a tapping of a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures. Auscultation means listening with a stethoscope for normal and abnormal sounds. 34. The LPN is transferring a medical client to the intensive care unit and is met by the RN. The RN is listening with the stethoscope to determine how much fluid the client may have in the lungs. What type of assessment technique is the RN performing? A) Inspection B) Palpation C) Percussion D) Auscultation Ans: D Feedback: Auscultation means listening with a stethoscope for normal and abnormal sounds generated by organs and structures such as the heart, lungs, intestines, and major arteries. Inspection is the visual observation of the client and specific structures. Palpation is the touching of the patient with the fingertips or hands. Percussion is tapping a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures. 35. The nurse is caring for an older adult client who has recently been admitted and is performing a physical assessment. What test can the nurse perform to obtain a baseline cognitive function? A) Mini-Cog B) Neurovascular assessment C) Cardiovascular assessment D) Pupillary response Ans: A Feedback: When performing a physical assessment for an older client, ascertain a baseline cognitive function level at onset of interview. The Mini-Cog is a quick and simple four-question method. The other answers are not specific assessment techniques in order to assess cognitive function.