Download Test Bank NURS 2900 Interviewing and Physical Assessment Question and Answers,100% CORRECT and more Exams Nursing in PDF only on Docsity! Page 1 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 Page 2 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. Page 5 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. Page 6 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 Page 7 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 Page 10 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 Page 11 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 Page 12 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 Page 15 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 Page 16 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 Page 17 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 Page 20 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 Page 21 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. Page 22 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