While obtaining the health history of a client, the nurse learns the client's father was diagnosed with schizophrenia in his twenties, the same age the client is now. The client hesitates to discuss the topic and answer questions about the father. Which approach is best for the nurse to use to interview the client about mental health concerns?

Ask questions in a vague, nonspecific format.

Share personal values to put the client at ease.

Begin with questions that are less sensitive in nature.

Get the most difficult questions over with first.

Answer and Explanation

The Correct Answer is C

A.   While this approach may seem less intrusive, it can create confusion and may prevent the client from feeling fully understood. Asking vague questions could make it more difficult to get useful information about the client's health concerns.
B.   Sharing personal values is generally not appropriate in a clinical interview, as it could create boundaries that compromise the professional relationship. The nurse should maintain objectivity and empathy without sharing personal beliefs.
C.   Starting with less sensitive questions allows the nurse to build rapport and trust with the client before delving into more personal or difficult topics. This approach is helpful in easing the client into more sensitive discussions.
D.   Asking the most difficult questions right away can overwhelm the client, especially if they are hesitant or uncomfortable. It is better to establish a trusting relationship first and allow the client to open up at their own pace.

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Correct Answer is D

Explanation

A. This is not applicable in this case. A BMI of 14 kg/m² indicates severe malnutrition, not excess nutrition. The client is at risk for nutritional deficiencies, not an excess of nutrition.
B. While fluid volume might be a concern in severely malnourished clients, the primary issue in this scenario is related to nutrition rather than fluid imbalance. A low BMI suggests insufficient caloric intake.
C. Excess fluid volume is not typically associated with a low BMI. In fact, clients with a BMI this low may show signs of dehydration or fluid loss due to inadequate nutritional intake.
D. This is the most appropriate nursing diagnosis. A BMI of 14 kg/m² is indicative of severe malnutrition and the client is not meeting their nutritional needs, which could lead to further health complications.

A. "Refrain from eating or drinking for at least thirty minutes." B. "Lie in a prone position with slightly flexed knees." C. "Exhale slowly through your mouth then hold your breath." D. "Empty your bladder just prior to the examination."

Correct Answer is D

Explanation

A. The client should refrain from eating or drinking for other procedures but not specifically for an abdominal examination unless indicated for tests like ultrasounds.
B. A prone position is not necessary for an abdominal exam; lying on the back is preferred.
C. The client should not hold their breath during the abdominal exam unless asked to assist with specific maneuvers.
D. Having the bladder empty before the examination reduces discomfort and allows for better visualization of the abdominal organs.

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Naxlex Comprehensive Predictor Exams

In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m2. Which nursing problem should be included in this client's plan of care? Reference Range: Body mass index (BMI) [normal 18.0 to 24.9 kg/m2]

Correct Answer is D

Explanation

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

Correct Answer is D

Explanation

Patient Data Exhibits Nurse analyzes the assessment findings. Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?

The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?