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?

Allow the client to decline answering social questions.

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

Use the term illegal or illicit to describe street drugs.

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

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Allowing the client to decline answering social questions is inappropriate. This approach respects the client's autonomy and privacy by giving them the option to decline answering questions they may feel uncomfortable or unwilling to discuss. However, for the purpose of ensuring comprehensive care and assessing potential risks associated with substance use, it's important for the nurse to gather relevant information about the client's use of illegal drugs and alcohol.
Choice B Reason:
Obtaining a drug urine screen to verify legitimacy of client's stated history is inappropriate. While obtaining a drug urine screen may provide objective information about recent drug use, it may not be indicated during the initial health history and may not accurately reflect the client's past substance use history. Additionally, relying solely on laboratory testing without actively engaging the client in open communication may hinder the development of trust and rapport between the client and the healthcare provider.
Choice C Reason:
Using the term illegal or illicit to describe street drugs is inappropriate. Using the terms "illegal" or "illicit" may carry negative connotations and could potentially stigmatize the client's substance use. This approach may create barriers to open communication and may not accurately capture the client's experiences or perceptions regarding their substance use. Additionally, it's important to use language that is respectful and nonjudgmental when discussing sensitive topics such as substance use.
Choice D Reason:
Asking specifically about alcohol, marijuana, cocaine, heroin, and amounts is appropriate. This approach is the most appropriate because it directly addresses the substances of concern and allows for comprehensive assessment of the client's substance use history. By asking specifically about commonly used substances and their amounts, the nurse ensures that key information is gathered in a respectful and nonjudgmental manner, facilitating open communication and accurate assessment of the client's needs.

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Correct Answer is A

Explanation

Choice A Reason:
Observing pupil size when focusing on a near object and then a far object is correct. This choice is correct because it directly assesses the pupillary reaction to accommodation, which refers to the changes in pupil size that occur when the eyes shift focus between near and far objects. Observing the pupils while the client focuses on a near object and then a far object allows the nurse to assess how the pupils constrict (become smaller) or dilate (become larger) in response to changes in focus, providing valuable information about the client's accommodation reflex.
Choice B Reason:
Comparing the shape of each of the pupils bilaterally with normal room light is incorrect. While comparing the shape of each pupil bilaterally with normal room light is a valid assessment technique for evaluating pupillary size and symmetry, it does not specifically assess the pupillary reaction to accommodation. Therefore, this choice is not as directly relevant to assessing accommodation reflex as choice A.
Choice C Reason:
Noting the speed of pupil constriction when a penlight is shined into the eye is incorrect. This choice refers to assessing the pupillary light reflex, which involves observing the speed and extent of pupil constriction in response to a bright light stimulus. While this assessment is important for evaluating the pupillary response to light, it does not specifically assess accommodation, which involves changes in pupil size in response to changes in focus between near and far objects. Therefore, this choice is not directly relevant to assessing accommodation reflex.
Choice D Reason:
Determining if dilation of the pupils occurs when the room is darkened is incorrect. This choice involves assessing the pupillary response to changes in ambient light levels, which is known as the pupillary light reflex. While assessing pupil dilation in response to darkness is important for evaluating the pupillary response to changes in light, it does not specifically assess accommodation reflex. Therefore, this choice is not directly relevant to assessing accommodation reflex.

A. Nothing by mouth. B. Electrocardiogram. C. Monitor urinary output. D. Complete bed rest.

Correct Answer is A

Explanation

Choice A Reason:
During an abdominal assessment, the client's pain and abrupt cessation of inhalation during deep palpation, especially when accompanied by a high fever (103° F or 39.4° C), is indicative of potential peritonitis or an acute abdomen condition (e.g., appendicitis).Keeping the client NPO (nothing by mouth) is crucial to prepare them for potential emergency surgical intervention. Eating or drinking could complicate anesthesia and the surgical procedure.
Choice B Reason:
Electrocardiogram is incorrect. An electrocardiogram (ECG) may be indicated to assess cardiac function and rule out cardiac causes of chest pain or discomfort, particularly if there are associated symptoms such as shortness of breath or palpitations. However, in this scenario, the client's symptoms (abdominal pain, sudden cessation of inhalation during deep palpation, and elevated temperature) suggest a more immediate concern related to the abdominal condition rather than a primary cardiac issue.
Choice C Reason:
This is important for overall patient monitoring, but it is not the immediate priority for managing acute abdominal pain with suspected peritonitis.
Choice D Reason:
Complete bed rest is incorrect. Complete bed rest may be recommended in some cases of acute illness or injury to promote healing and prevent further exacerbation of symptoms. However, in this scenario, the client's symptoms suggest a potentially serious abdominal condition requiring further assessment and intervention beyond bed rest alone.

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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

To assess a client's pupillary reaction to accommodation, what action should the nurse take?

Correct Answer is A

Explanation

During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Correct Answer is A

Explanation

An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

Patient Data Exhibits During the assessment, the nurse notes that the areas are filled with a fluid-like substance. Which of the following primary skin lesions contain fluid? Select all that apply.

When entering a client's room, the nurse observes that the client is using pursed-lip breathing. It is most important for the nurse to monitor the client for which problem?

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm to the nurse that the client is experiencing an exacerbation of the HF? Select all that apply.