The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

"The care team needs to cross-reference your diagnostic testing with your medical history."

"In general, it's necessary for us to gather as much information about each client as possible."

"We do not want to focus solely on the medical problem that brought you here."

"This information will help me to plan individualized nursing care with you."

Answer and Explanation

The Correct Answer is D

A. While diagnostic testing and medical history are important, this response does not acknowledge the client’s frustration or emphasize the purpose of the assessment.
B. This response is too general and does not provide reassurance to the client.
C. While this statement is true, it does not clearly explain why the history is necessary in a way that involves the client.
D. "This information will help me to plan individualized nursing care with you" is correct because it directly explains the purpose of the assessment and involves the client in their care.

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Correct Answer is C

Explanation

A. "You are probably sad about that" assumes the client’s emotions rather than allowing them to express their own feelings.
B. "Are you feeling sad, depressed, angry, or upset?" is a closed-ended question that may limit the client’s ability to fully express emotions.
C. "How does that make you feel right now?" is correct because it is an open-ended question that encourages the client to explore and express their emotions in their own words.
D. "What was the cause of your wife's death?" shifts the focus away from the client’s emotions and may come across as insensitive.

A. Pneumonia B. Chronic emphysema C. Pneumothorax D. Congestive heart failure

Correct Answer is B

Explanation

A. Pneumonia typically presents with fever, productive cough, and crackles rather than wheezing and tripod positioning.
B. Chronic emphysema is correct. The tripod position (leaning forward, hands on knees) is a classic sign of severe obstructive lung disease, such as emphysema or COPD. Wheezing and dyspnea at rest suggest air trapping and difficulty exhaling, which are hallmarks of this condition. The oxygen saturation of 91% is common in COPD patients due to chronic hypoxemia.
C. Pneumothorax presents with sudden onset chest pain, absent breath sounds on one side, and tracheal deviation (if severe) rather than wheezing.
D. Congestive heart failure can cause dyspnea but typically presents with crackles due to pulmonary edema rather than wheezing and tripod positioning.

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The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

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Naxlex Comprehensive Predictor Exams

During the interview the client states, "Is today the 12th? My wife died two months ago today." Which of the following responses would be most appropriate?

Correct Answer is C

Explanation

The nurse is assessing an older adult client in the emergency room. Upon assessment, the nurse notes that the client is in the tripod position, has dyspnea at rest, wheezing upon auscultation, and an oxygen saturation level of 91%. What significant health problem might the nurse suspect?

Correct Answer is B

Explanation

The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, why does the nurse periodically perform a partial assessment of the client?

A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

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