Interviewing Skills
A nurse who receives a patient in the operative suite prior to the actual surgery is in charge of the patient’s care. Which of the following is NOT a task related to the nurse’s intraoperative care?
A. Go over the surgical procedure with the patient before he or she is anesthetized.
B. Go over the surgical procedure with the patient before he or she is anesthetized.
C. Provide emotional support to the patient and his family.
D. Monitor the patient’s physical status.
A. Go over the surgical procedure with the patient before he or she is anesthetized.
The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data?
A. Turn the flashlight on directly in front of the eye and watch for a response.
B. Check pupil size, and then ask the client to alternate looking at the flashlight and the examiners finger.
C. Instruct the client to look straight ahead, and then shine the flashlight from the temporal area to the eye.
D. Ask the client to follow the flashlight through the six cardinal positions of gaze
Correct Answer: D
Rationale:The nurse asks the client to follow the flashlight through the six cardinal positions of gaze to assess for eye movement related to cranial nerves III, IV, and VI. Options 1 and 3 relate to pupillary response to light. Also, shining the light directly into the client's eye without asking the client to focus on a distant object is not an appropriate technique. Option 4 assesses accommodation of the eye.
The nurse teaches a client who is diagnosed with HIV that the condition is transmitted through
A. the infection passed from a mother to her baby
B. tears
C. human bites
D. insect bites
A. the infection passed from a mother to her baby
A client with a history of asthma comes to the emergency department complaining of itchy skin and shortness of breath after starting a new antibiotic. What is the first action the nurse would take?
A. Place the client on 100% oxygen and prepare for intubation.
B. Assess for anaphylaxis and prepare for emergency treatment.
C.Teach the client about the relationship between asthma and allergies.
D. Obtain an arterial blood gas and immunoglobulin E (IgE) blood level.
Correct Answers: B
Rationale: Hypersensitivity or allergy is excessive inflammation occurring in response to the presence of an antigen to which the person usually has been previously exposed. If a client is experiencing an allergic or hypersensitivity response, the nurse's initial action is to assess for anaphylaxis. Promptly notifying the health care provider and preparing emergency equipment, including medication such as epinephrine and possible corticosteroids, is essential in preventing progression of anaphylaxis. Laboratory work is not a priority in this situation. The nurse would expect the IgE level to be elevated; the client may be hypoxic. The nurse would give the client supplemental oxygen; however, 100% is not given unless prescribed, and based on the information in the question, intubation is not the first thing the nurse would prepare this client for. Teaching the client is important; however, this is not the right time. When the client is stabilized, the nurse needs to teach or reinforce that allergies, including some medications, are common triggers for asthma attacks and that people with asthma are predisposed to more allergies than people without asthma.
The nurse is assessing a client who presents with right upper quadrant pain, which of the following organs would the nurse palpate for based on the client's complaint. When assessing a client with a complaint of right upper quadrant pain liver during an assessment, the nurse would palpate which abdominal quadrant?
A.Gallbladder
B.Liver
C.Pancreas
D.Apex of the stomach
Correct Answer: B
Rationale: The liver is located in the right upper quadrant of the abdomen; therefore, since the assessment requests palpation the gallbladder, pancreas, and apex of the stomach are easily palpated due to their position behind the liver or other organs.
A client with pneumonia is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history?
A. Focus only on the physical assessment.
B. Obtain all history information from the family members.
C. Plan short sessions with the client to obtain data.
D. Use the primary healthcare provider's medical history.
Correct Answer: C
Rationale:The best source of information is the client. Option 1 is incorrect; the physical examination is not part of the health history. Option 2 is incorrect because it refers to all information. Option 4 is incorrect because the primary health care provider's medical history provides data that are different from the nurse's assessment. All efforts need to be made to obtain as much information as possible from the client, using short sessions and closed-ended questions.
The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation?
A. An involuntary rhythmic, rapid twitching of the eyeballs.
B. A dorsiflexion of the ankle and great toe with fanning of the other toes.
C. A significant sway when the client stands erect with feet together, arms at the side and the eyes closed.
D. A lack of sense of position when the client is unable to return extended fingers to a point of reference.
Correct Answer: C
Rationale:In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the ankle and great toe with fanning of the other toes; if this occurs in anyone older than 2 years, it indicates the presence of central nervous system disease.
A client with uterine cancer asks the nurse, "Which is the most common type of cancer in women?" The nurse replies that it is breast cancer. Which type of cancer causes the most deaths in women?
A. Breast cancer
B. Lung cancer
C. Brain cancer
D. Colon and rectal cancer
B. Lung cancer.
Lung cancer is the most deadly type of cancer in both women and men. Breast cancer ranks second in women followed by colon and rectal cancer, pancreatic cancer, ovarian cancer, uterine cancer, lymphoma, leukemia, liver cancer, brain cancer, stomach cancer, and multiple myeloma.
There has been a serious explosion at a local factory and many of the injured are arriving at the hospital. Which of the following patients should a nurse attend to first?
A. A 30-year-old male who is able to walk into the hospital on his own but who has numerous lacerations on the chest and face
B. A 45-year-old male who was brought in on a stretcher, who has been assessed as having respiration and circulation within normal limits and he can follow simple commands
C. A 50-year-old woman who can walk but has a broken arm and numerous lacerations
D. A 19-year-old man who has numerous lacerations all over the body and whose respiration exceeds 30 breaths per minute
D. A 19-year-old man who has numerous lacerations all over the body and whose respiration exceeds 30 breaths per minute
The official, established nonproprietary name assigned to a drug is which of the following?
SATA
A. chemical
B. generic
C. trade name
D. brand name
B. Trade
A home health nurse is visiting a client with type 1 diabetes mellitus. The client states to the nurse "I am not feeling well and had a respiratory problem for the past week, which seems to be getting worse." After interviewing the client, what would be the initial nursing action?
A. Document the assessment data.
B. Check the client's blood glucose.
C. Notify the primary health care provider (PHCP).
D. Obtain the client's sputum for culture and sensitivity.
Correct Answers: B
Rationale: Uncontrolled hyperglycemia may lead to the production of ketones, thus leading to diabetic ketoacidosis (DKA), a life-threatening condition. The most common precipitating factor for the development of DKA is infection. Assessment data need to be documented but are not a priority. The PHCP may need to be notified if the client's blood glucose is elevated and the client has other symptoms of DKA or a respiratory infection. After determining the client's blood glucose, the nurse would obtain a sputum sample if the client is expectorating yellow, green, or bloody secretions.
After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse would expect to note which finding?
A. Waves of loud gurgles auscultated in all four quadrants.
B. Low-pitched swishing auscultated in one or two quadrants.
C. Relatively high-pitched clicks or gurgles auscultated in one or two quadrants.
D. Very high pitched, loud rushes auscultated in especially in one or two quadrants.
A. Waves of loud gurgles auscultated in all four quadrants.
The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse would explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply.
A. Jaundice
B. Flu-like symptoms
C. Clay-colored stools
D. Elevated bilirubin levels
E. Dark or tea-colored urine
Correct Answers: A, C, D, E
Rationale:There are three stages associated with viral hepatitis. The first (preicteric) stage includes flu-like symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage, also known as the recovery stage, occurs when the jaundice decreases and the colors of the urine and stool return to normal.
Which is the priority assessment in the care of a client who is newly admitted to the hospital for acute arterial insufficiency of the left leg and moderate chronic arterial insufficiency of the right leg?
A. Monitor oxygen saturation with pulse oximetry.
B. Assess activity tolerance before and after exercise.
C. Observe the client's cardiac rhythm with telemetry.
D. Assess peripheral pulses with an ultrasonic Doppler device.
Correct Answers: D
Rationale: Acute arterial insufficiency is associated with interruption of arterial blood flow to an organ, tissue, or extremity. It is associated with an acutely painful pasty-colored leg. The priority is for the nurse to perform a comprehensive assessment of peripheral circulation. When pulses are difficult to palpate, the Doppler device is useful to determine the presence of blood flow to the area. The Doppler directs sound waves toward the artery being examined, which emits an audible sound. The nurse must document that the pulse was present via Doppler and not palpation. Although the remaining options may be components of the assessment, they are not the priority.
An RN is preparing to hang the first bag of total parenteral nutrition (TPN) solution. The client has a central line and this is the first bag he will receive. Which of the following is the most essential piece of equipment to obtain prior to hanging the bag?
A. Blood glucose meter.
B. Noninvasive blood pressure monitor.
C. Electronic infusion pump.
D. Urine test strips.
C. Electronic infusion pump.
Before hanging the TPN solution, the nurse obtains an electronic infusion pump. Due to the high glucose content it is necessary to ensure that the solution does not infuse too rapidly or fall behind. Because the client's blood glucose level is monitored, a glucose meter will also be necessary but is not the most essential item needed. A blood pressure monitor is unnecessary and urine test strips are rarely used because of the advent of blood glucose monitoring.
Which client is at greatest risk for committing suicide?
A. client with metastatic cancer
B. client with a newly diagnosed cardiac disorder
C. A client who just had an argument with the fiancé
D. A newly divorced client who states has custody of the children
Correct Answers: A
Rationale: The person at greatest risk for suicide is the client with terminal illness. Other high-risk groups include adolescents, drug abusers, persons who have experienced recent losses, those who have few or no social supports, and those with a history of suicide attempts and a suicide plan.
A nurse is assessing a day-old infant for jaundice. Which of the following is the best method for this?
A. applying pressure over a bony area such as the forehead and evaluating the skin color after this pressure is removed
B. assessing the color of the infant’s hands and feet
C. assessing the infant’s tongue
D. assessing the infant’s arms and legs
A. applying pressure over a bony area such as the forehead and evaluating the skin color after this pressure is removed
You are instructing the mother of a child with atopic dermatitis (eczema). The physician has prescribed a topical corticosteroid. You instruct the mother on how to apply the cream and this includes:
A. Avoid cleansing the area before application of the cream.
B. Apply a thin layer of cream and rub it in thoroughly.
C. Apply the cream over the entire body.
D. Apply a thick layer of cream to affected areas only.
B. Apply a thin layer of cream and rub it in thoroughly.
A topical corticosteroid should be applied sparingly and rubbed into the area thoroughly. The affected area should be cleansed gently before application. Never apply a topical corticosteroid over extensive areas due to systemic absorption may occur.
The nurse is reviewing laboratory test results for the client with liver cancer and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels?
A. Evaluating for asterixis
B. Inspecting for petechiae
C. Palpating for peripheral edema
D. Evaluating for decreased level of consciousness
Correct Answers: C
Rationale: Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. The remaining options are incorrect and are not associated with a low albumin level.
The unit in which you work has a team nursing delivery system. This delivery system is characterized by all of the following EXCEPT:
check all answers that apply
A. Each team is led by a nurse team leader.
B. One primary nurse is responsible for managing and coordinating the client’s care.
C. The registered nurse assumes total responsibility for planning and delivering care to a client.
D. The team leader determines the work assignment.
B and C
In team nursing, the team is led by a team leader who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client’s plan of care. The team leader determines the work assignment. When one primary nurse is responsible for managing and coordinating the client’s care, this is relationship-based practice (primary nursing). In client-focused care the registered nurse assumes total responsibility for planning and delivering care to a client.
When would the nurse determine that it will be safe to remove the restraints from a client who demonstrated violent behavior?
A. Administered medication has taken effect.
B. The client verbalizes the reasons for the violent behavior.
C. The client apologizes and tells the nurse that it will never happen again.
D. No aggressive behavior has been observed for 1 hour after the release of two of the extremity restraints.
Correct Answers: D
Rationale: The best indicator that the behavior is controlled is the fact that the client exhibits no signs of aggression after partial release of restraints. The remaining options do not ensure that the client has controlled the behavior
The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply.
A. Set the room temperature at a comfortable level.
B. Remove distracting objects from the interviewing area.
C. Place a chair for the client across from the nurse's desk.
D. Ensure comfortable seating at eye level for the client and nurse.
E. Provide seating for the so that the faces a strong light.
F. Ensure that the distance between the client and the nurse is at least 7 feet.
A, B, and D
A client is at risk for vasovagal attacks that cause bradydysrhythmias. The nurse would tell the client to avoid which actions to prevent this occurrence? Select all that apply.
A. Applying pressure on the eyes
B. Raising the arms above the head
C. Taking stool softeners on a daily basis
D. Bearing down during a bowel movementE. Simulating a gag reflex when brushing the teeth
Correct Answers: A,B,D,E
Rationale:Vasovagal attacks or syncope occurs when the client faints because the body overreacts to certain triggers. The vasovagal syncope trigger causes the heart rate and blood pressure to drop suddenly. That leads to reduced blood flow to the brain, causing the client to briefly lose consciousness. The client at risk would be taught to avoid actions that stimulate the vagus nerve. Actions to avoid include raising the arms above the head, applying pressure over the carotid artery, applying pressure over the eyes, stimulating a gag reflex when brushing the teeth or putting objects into the mouth, and bearing down or straining during a bowel movement. Taking stool softeners is an important measure to prevent the bearing down and straining during a bowel movement.
The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary healthcare provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube?
A.Checking for normal serum electrolyte levels
B.Checking for normal pH of the gastric aspirate
C.Checking for proper nasogastric tube placement
D.Checking for the presence of bowel sounds in all 4 quadrants
Correct Answers: D
Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place but would not assist in determining the readiness for removing the nasogastric tube.
Rehabilitation after illness is which of the following levels of healthcare?
check all answers that apply
A. primary
B. secondary
C. tertiary
D. all three
C. tertiary
Tertiary care includes rehabilitation after illness to return the patient to a level of maximum functioning. It involves assessing the patient’s strengths and weaknesses, assisting the patient to increase strengths and cope with limitations, assisting with rehabilitation measures, and encouraging self-care