The nurse is meeting a patient for the first time. The initial step in initiating a nurse-patient relationship is for the nurse to:

introduce her/himself

communicate trust

provide support

appear interested

Answer and Explanation

The Correct Answer is A

A. Introduce her/himself. – Introducing oneself establishes a professional relationship, sets the tone for communication, and makes the patient feel acknowledged and comfortable.

B. Communicate trust. – While trust is essential, it is built over time through consistent and reliable care rather than being the first step in the interaction.

C. Provide support. – Providing support is part of therapeutic communication, but it is not the initial step in forming a nurse-patient relationship.

D. Appear interested. – While showing interest is important, the first step is to introduce oneself to establish identity and professional presence.

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Correct Answer is C

Explanation

A. Bruits – Bruits are abnormal vascular sounds heard over arteries, often due to turbulence from a narrowed vessel.

B. Tympany – Tympany is a drum-like sound produced during percussion over areas filled with air, such as the stomach.

C. Crackles – Crackles (rales) are discontinuous, bubbling breath sounds often heard on inspiration. They are associated with conditions like pneumonia, heart failure, and pulmonary fibrosis.

D. Thrill – A thrill is a palpable vibration over an artery or heart valve, indicating turbulent blood flow.

A. After palpating the abdomen B. After checking for kidney tenderness C. Before percussing the abdomen D. Before inspecting the abdomen.

Correct Answer is C

Explanation

A. After palpating the abdomen – Palpation may alter bowel sounds by stimulating peristalsis, leading to inaccurate findings.

B. After checking for kidney tenderness – Checking for kidney tenderness (costovertebral angle tenderness) is unrelated to bowel auscultation and should not precede it.

C. Before percussing the abdomen – Auscultation should be done before percussion and palpation to avoid artificially stimulating bowel sounds.

D. Before inspecting the abdomen – Inspection should always come before auscultation to visually assess the abdomen for distension, symmetry, and discoloration before listening.

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The nurse is meeting a patient for the first time. The initial step in initiating a nurse-patient relationship is for the nurse to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Short, discrete, interrupted crackling or bubbling adventitious breath sounds heard most commonly on inspiration is termed:

Correct Answer is C

Explanation

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

Correct Answer is C

Explanation

An abnormal accumulation of fluid in the interstitial spaces is described as:

An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is called:

Discoloration of an area of the skin or mucous membranes caused by extravasation of blood into subcutaneous tissue is termed:

Which would be included in an assessment of the peripheral vascular system? (select all that apply)

Fluid, cells or other substances that have been slowly discharged from body cells or blood vessels, through small pores or breaks in the cell membrane are called:

When performing the nursing physical assessment, the nurse uses head-to-toe organization. When using this method, the nurse begins with a:

While conducting an assessment of the patient, the nurse recognizes that after verifying biographical data, the initial step is:

The protective response of body tissues to irritation, injury or pathogens is: