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 the legitimacy of the client's stated history.

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

Use the term illegal or illicit to describe street drugs.

Allow the client to decline answering social questions.

Answer and Explanation

The Correct Answer is B

A. While a drug urine screen may be part of preoperative testing, it is not appropriate as the primary method for gathering a client's substance use history. Trust and accuracy in self-reporting should be encouraged.
B. Asking specifically about alcohol, marijuana, cocaine, heroin, and amounts helps the nurse gather detailed information on the client's substance use, which is critical for safe anesthesia and surgical planning. Using specific terms rather than general or stigmatizing language promotes open communication.
C. The terms "illegal" or "illicit" might carry stigma, potentially leading the client to withhold information. Using neutral, non-judgmental language is more effective.
D. While clients can decline to answer, the nurse should explain the importance of accurate health information for their safety and care. Encouraging open dialogue is better than allowing clients to skip important questions without understanding the implications.

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Correct Answer is B

Explanation

A. A positive Homan's sign indicates potential deep vein thrombosis (DVT) but is not a common or reliable indicator for chronic swelling of the feet. Bilateral swelling is less likely related to DVT and more likely to be due to systemic issues.
B. 2+ pitting edema of the ankles bilaterally directly indicates chronic swelling. This finding supports the client's statement of persistent swelling, which is characteristic of fluid retention or systemic issues affecting both feet.
C. Capillary refill greater than 3 seconds may indicate poor peripheral circulation but does not directly assess or confirm chronic swelling of the feet.
D. Weak and thready pedal pulses suggest poor blood flow but are not directly related to the symptom of chronic swelling. They indicate possible circulatory issues rather than swelling alone.

A. Clavicle B. Lung apex C. Sternum D. Aortic site

Correct Answer is B

Explanation

A. The clavicle is a bony structure, and placing the stethoscope over it is not ideal for auscultating breath sounds. Breath sounds are best heard over areas where lung tissue is present, so starting at the clavicle would not provide the most accurate assessment.
B. The lung apex, located just above the clavicle, is the correct starting point for auscultating anterior breath sounds. This location allows the nurse to systematically assess the lung fields from the top down, ensuring that all areas are evaluated.
C. The sternum is located centrally and anteriorly on the chest, but it is not the ideal location to begin auscultation of breath sounds. Breath sounds should be auscultated over lung tissue, not over bone, which can obscure or alter the sounds.
D. The aortic site is used for auscultating heart sounds rather than breath sounds. Starting at this location would be inappropriate for a systematic assessment of the lungs and could lead to missing important breath sounds.

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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

Which assessment finding supports the client statement, "My feet swell all the time?"

Correct Answer is B

Explanation

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

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