ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 4 Questions
Question 1 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.
Question 2 of 5
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?
Correct Answer: A
Rationale: 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. A question is not a summarization. The orientation of the client's room is not related to the interview.
Question 3 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 4 of 5
The nurse is completing a physical examination on a client who reports abdominal pain. Which are facts the nurse will obtain during the physical examination?
Correct Answer: B
Rationale: Objective data are facts obtained through observation, physical examination, and diagnostic testing. Feelings related to subjective data are symptoms. Subjective data are statements clients make about what they feel. Complaints are reasons the client is seeking care.
Question 5 of 5
The nurse is caring for a client who has been admitted to the hospital with abdominal pain and is suspected to have appendicitis. What data obtained is considered objective data?
Correct Answer: A
Rationale: Objective data are facts obtained through observation, physical examination, and diagnostic testing. When assessing blood pressure or heart rate, or examining results from urinalysis, the nurse is obtaining objective data. The other answers are examples of subjective data.