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?

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.

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

Answer and Explanation

The Correct Answer is A

Choice A rationale
Asking specifically about alcohol, marijuana, cocaine, heroin, and amounts provides a clear and direct approach to obtaining accurate information about the client’s substance use. This method helps in identifying potential health risks and planning appropriate care.
Choice B rationale
Using the term “illegal” or “illicit” to describe street drugs may cause the client to feel judged or defensive, which can hinder open communication. It is better to ask about specific substances directly.
Choice C rationale
Allowing the client to decline answering social questions may result in incomplete health history, which can affect the quality of care provided. It is important to encourage clients to share relevant information while ensuring confidentiality.
Choice D rationale
Obtaining a drug urine screen to verify the legitimacy of the client’s stated history is not an appropriate initial assessment technique. Trust and rapport should be established first through direct questioning.

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Correct Answer is A

Explanation

Choice A rationale
Describing the client’s exact words, “body-wracking dry cough” of 6 weeks duration, provides a clear and specific account of the client’s symptoms and concerns.
Choice B rationale
Expressing concern of “lung cancer” symptoms for the last 6 weeks is less specific and does not accurately capture the client’s primary symptom, which is the dry cough.
Choice C rationale
Presenting with a hacking nonproductive cough of 6 weeks duration is a clinical interpretation and does not use the client’s own words, which is important for accurate documentation.
Choice D rationale
An adult male presents with fears that he has “lung cancer” is a subjective interpretation and does not accurately describe the client’s primary symptom.

A. Document the presence of borborygmi. B. Auscultate the remaining quadrants. C. Elevate the head of the client’s bed immediately. D. Use the bell of the stethoscope to auscultate again.

Correct Answer is B

Explanation

A. Document the presence of borborygmi.Loud, high-pitched, and almost continuous gurgling sounds can indicate borborygmi.However, the nurse should not immediately document without fully assessing all four quadrants to ensure a comprehensive evaluation of bowel sounds.

B. Auscultate the remaining quadrants.A complete assessment of bowel sounds involves auscultating all four quadrants to determine if the sounds are generalized, localized, or absent in other areas. This provides a more accurate assessment of the client’s gastrointestinal function.

C. Elevate the head of the client’s bed immediately.The client’s position does not typically affect bowel sounds, and elevating the head of the bed is unnecessary unless the client has difficulty breathing or other non-gastrointestinal concerns.

D. Use the bell of the stethoscope to auscultate again.Using the bell, which is intended for low-pitched sounds like bruits or heart murmurs, would not provide any additional relevant information.

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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

Correct Answer is A

Explanation

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement first?

Correct Answer is B

Explanation

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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?