The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol?

Obtain a drug urine screen to verify legitimacy of client's stated history.

Use the term illegal or illicit to describe street drugs.

Allow the client to decline answering social questions.

Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts.

Answer and Explanation

The Correct Answer is D

A. Obtain a drug urine screen to verify the legitimacy of the client's stated history. This may be necessary but is not the initial approach for obtaining a health history.

B. Use the term illegal or illicit to describe street drugs. Using stigmatizing terms may make the client uncomfortable and less likely to disclose information.

C. Allow the client to decline answering social questions. The nurse should encourage open communication, but also respect the client's right to privacy.

D. Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts. This is the correct approach. Specific questions about substances and quantities help obtain accurate information.

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Correct Answer is B

Explanation

A. Sternum. Auscultating directly over the sternum does not provide optimal lung sounds.

B. Lung apex. This is the best choice as auscultation should begin at the lung apex to systematically cover all lung fields.

C. Clavicle. Auscultating over the clavicle does not provide optimal lung sounds.

D. Aortic site. The aortic site is for heart sounds, not lung sounds.

A. ever had problems with your blood sugar?" B. been sleeping well?" C. been depressed lately?" D. had anything to eat in the last 24 hours?"

Correct Answer is D

Explanation

A. ever had problems with your blood sugar?" This question is relevant for assessing potential hypoglycemia or hyperglycemia, which can cause slurred speech, but does not directly address all the symptoms.

B. been sleeping well?" Poor sleep can contribute to slurred speech and expressionless affect but does not explain the red conjunctivae.

C. been depressed lately?" Depression can cause an expressionless affect but is less likely to cause slurred speech and red conjunctivae.

D. had anything to eat in the last 24 hours?" This is the best choice because it addresses the potential for hypoglycemia, which can cause slurred speech, expressionless affect, and possibly red conjunctivae due to poor overall health. This is because these symptoms could be indicative of alcohol intoxication or substance use, and assessing recent food intake can help determine if this is the case. The other questions are also important, but addressing potential substance-related issues takes precedence in this situation.

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The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Correct Answer is B

Explanation

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you

Correct Answer is D

Explanation

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