ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 4 : Interviewing and Physical Assessment Questions
Question 1 of 5
The nurse has received a client in the emergency department who 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?
Correct Answer: C
Rationale: 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 and are considered open-ended questions.
Question 2 of 5
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?
Correct Answer: D
Rationale: 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, and not informative documentation.
Question 3 of 5
The nurse at the clinic asks the client about what brought them in to see the health care provider today. What is the purpose of asking the client about their primary health concern?
Correct Answer: A
Rationale: The purpose of asking the client about their 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 health care provider today and whether the client should be denied treatment based on the insurance company's willingness to pay. The client can opt to pay for the visit out of pocket. Health care providers do not generally give prescriptions any longer without seeing the clients.
Question 4 of 5
The nurse is interviewing a client whose chief complaint is abdominal pain. What information requested by the nurse is part of a focused assessment?
Correct Answer: B
Rationale: Asking for more detailed information about one body system or problem is called a focused assessment because it adds depth to the original data. For example, a client may reveal having 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 questions related to breathing, smoking, and swelling in the feet or ankles do not have anything to do with the client's chief complaint.
Question 5 of 5
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?
Correct Answer: C
Rationale: 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 ability to pay for medications or socialize and the side effects of the medication do not pertain to ADLs.