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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","F"]
Explanation
Choice A Reason:
Macule is incorrect. A macule is a flat, discolored spot on the skin that is less than 1 centimeter in diameter. It does not contain fluid; instead, it represents a change in the color of the skin, such as a freckle or a flat mole. Macules are not filled with fluid; they are characterized by alterations in skin pigmentation without any elevation or depression.
Choice B Reason:
Papule is incorrect. A papule is a small, raised bump on the skin that is less than 1 centimeter in diameter. Papules do not contain fluid; instead, they result from localized cellular infiltration, inflammation, or proliferation in the skin layers. Examples of papules include acne lesions and insect bites.
Choice C Reason:
While often confused with fluid-filled sacs, a wheal is an area of localized dermal edema. They are solid, itchy, and irregularly shaped (e.g., hives or insect bites).
Choice D Reason:
Vesicle is correct. A vesicle is a small, fluid-filled blister that appears on the skin. It contains clear fluid and can be caused by various factors such as infection, allergic reactions, or friction.
Choice E Reason:
Nodule is incorrect. A nodule is a solid, raised bump on the skin that is larger than 1 centimeter in diameter and extends into deeper layers of the skin. Similar to papules, nodules do not contain fluid; they are composed of tissue, such as fat, fibrous tissue, or tumors. Examples of nodules include lipomas and dermatofibromas.
Choice F Reason:
Pustule is correct. A pustule is a small, pus-filled blister that appears on the skin. It contains purulent fluid (pus) and is often associated with bacterial infections such as acne or folliculitis.
Correct Answer is D
Explanation
Choice A Reason:
Get the most difficult questions over with first is not the best approach because starting with the most difficult questions may put the client on the defensive or make them feel uncomfortable, hindering open communication. It's important to build rapport and establish trust with the client before addressing sensitive topics.
Choice B Reason:
Asking questions in a vague, non-specific format is not effective because vague and non-specific questions may result in ambiguous or incomplete responses, making it difficult to gather accurate information about the client's alcohol and substance use. Clear and specific questions are necessary to obtain relevant details.
Choice C Reason:
Sharing personal values to put the client at ease is not recommended as it can compromise the nurse's professional boundaries and may influence the client's responses. The focus of the interview should be on the client, and the nurse should maintain a neutral and non-judgmental stance.
Choice D Reason:
Begin with questions that are less sensitive in nature is the best approach because it allows the nurse to establish rapport and build trust with the client before addressing more sensitive topics such as alcohol and substance use. Starting with less threatening questions helps the client feel more comfortable and willing to disclose information, facilitating open communication and rapport-building.
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