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. Recent over-the-counter infection cures. This is less immediately relevant unless directly related to lymph node changes.

B. Nontender, firm lymph nodes. This is the correct choice. Nontender, firm lymph nodes can indicate a more serious underlying condition such as malignancy or chronic infection and require further investigation.

C. Number of indoor cats at home. This might be relevant if there is a concern for cat scratch disease, but it is less critical than the nature of the lymph nodes.

D. Amount of daily caffeine consumption. This is not related to the palpation of lymph nodes and is not immediately relevant to the findings.

A. Benign variation. B. Cardiac atrophy. C. Expected finding. D. Cardiac enlargement.

Correct Answer is D

Explanation

A. Benign variation. This finding is not typically considered a benign variation and warrants further evaluation.

B. Cardiac atrophy. Cardiac atrophy would likely present differently and is not typically diagnosed via percussion findings alone.

C. Expected finding. This finding is within normal limits for the size and location of the heart's borders on percussion.

D. Cardiac enlargement. Cardiac enlargement might present with percussion dullness extending beyond normal limits, but the described findings do not indicate enlargement beyond expected borders.

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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

The nurse is examining a female client who states, she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

Correct Answer is B

Explanation

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is D

Explanation

The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

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