The nurse is caring for a client who is of a different culture than that of the nurse. When the nurse begins the physical assessment, the client seems apprehensive. What action should the nurse take?

Explain the parts of the assessment and ask permission to move forward

Return at a later time to complete the physical assessment and interview

Get a different nurse to complete the physical assessment and interview

Continue with the physical assessment so the client can get treatment

Answer and Explanation

The Correct Answer is A

A. Explain the parts of the assessment and ask permission to move forward: Providing a clear explanation of the assessment process and asking for consent demonstrates respect for the client’s cultural values and personal boundaries. This approach helps reduce anxiety, promotes trust, and ensures the client feels in control of their care.

B. Return at a later time to complete the physical assessment and interview: Delaying the assessment may not address the client’s immediate health needs and does not actively engage the client in reducing their apprehension. It may also prolong anxiety without providing reassurance.

C. Get a different nurse to complete the physical assessment and interview: While changing nurses might help in some cases, it does not directly address the client’s apprehension or foster communication and trust. The underlying need is for explanation and consent, not just a change in personnel.

D. Continue with the physical assessment so the client can get treatment: Proceeding without consent disregards the client’s autonomy and may increase anxiety or distrust. It could violate ethical principles and negatively impact the nurse–client relationship.

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Inspection: Inspection is the first step in a respiratory assessment because it allows the nurse to observe the client’s overall respiratory effort, chest symmetry, use of accessory muscles, and breathing pattern. It is noninvasive and provides essential visual information about the client’s respiratory status before performing any physical manipulation.

• Percussion: Percussion is performed last because it involves tapping the chest to assess underlying tissue density and lung sounds, which can be uncomfortable for the client if done first. It provides additional information about areas of consolidation, fluid, or air in the lungs. Percussion is best completed after inspection, palpation, and auscultation, ensuring the assessment progresses from least to most invasive.

A. Covid-19 vaccine received in 2020 B. Cholecystectomy in 2017 C. Nausea after meals D. Skin color is appropriate to ethnicity with pink undertones E. Headache, rated as a 4 on a 0-10 scale F. Blood pressure 112/76 mmHg

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

• Covid-19 vaccine received in 2020: Vaccination history is obtained through interview questions about past immunizations. It cannot be observed or measured during the physical exam, making it part of the health history.

• Cholecystectomy in 2017: Surgical history is collected via client interview. The nurse relies on the client’s report or medical records rather than physical observation for this information.

• Nausea after meals: Nausea is a subjective symptom experienced by the client and must be reported during the health history. It cannot be directly observed during the physical exam.

• Headache, rated as a 4 on a 0-10 scale: Pain intensity is subjective and gathered from the client during the history interview. Numeric pain ratings reflect personal experience, not objective measurements.

• Skin color is appropriate to ethnicity with pink undertones: Skin color is observed directly during the physical assessment. Visual inspection allows the nurse to evaluate for pallor, cyanosis, or other abnormalities.

• Blood pressure 112/76 mmHg: Blood pressure is an objective measurement obtained using a sphygmomanometer during the physical exam. It reflects the client’s current physiological status.

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The nurse is caring for a client who is of a different culture than that of the nurse. When the nurse begins the physical assessment, the client seems apprehensive. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Complete the sentence using the drop-down lists. A nurse is completing a physical assessment of a client's respiratory system. The nurse should first use the dropdown technique and end with the dropdown technique.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The nurse is evaluating the client's assessment within their electronic health record. For each finding, click to specify whether the assessment finding was collected as part of the health history interview or the physical exam.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

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The nurse is caring for a client who is of a different culture than that of the nurse. When the nurse begins the physical assessment, the client seems apprehensive. What action should the nurse take?