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 legitimacy of client's stated history.

Use the term illegal or illicit to describe street drugs.

Allow the client to decline answering social questions.

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

Answer and Explanation

The Correct Answer is D

A. Obtain a drug urine screen to verify the legitimacy of the client's stated history. This may be necessary but is not the initial approach for obtaining a health history.

B. Use the term illegal or illicit to describe street drugs. Using stigmatizing terms may make the client uncomfortable and less likely to disclose information.

C. Allow the client to decline answering social questions. The nurse should encourage open communication, but also respect the client's right to privacy.

D. Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts. This is the correct approach. Specific questions about substances and quantities help obtain accurate information.

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Correct Answer is C

Explanation

A. Recently had dental surgery. While relevant, dental surgery is less likely to explain multiple areas of ecchymosis.

B. Works in a day care center. This is not directly related to the presence of ecchymosis and does not require immediate follow-up.

C. Takes an oral anticoagulant. Anticoagulants can increase the risk of bleeding and bruising, which requires follow-up to ensure the client is not experiencing excessive anticoagulation or bleeding complications.

D. Adheres to a gluten-free diet. This is less likely to be related to the presence of ecchymosis unless there is a concern for nutritional deficiencies, which is less immediate than anticoagulant use.

A. Determine if client can recall what he ate for breakfast. B. Instruct the client to follow a three-step task. C. Tell the client to repeat a series of unrelated numbers. D. Ask the client if he knows the year he married his wife.

Correct Answer is A

Explanation

A. Determine if client can recall what he ate for breakfast. This is the best choice as it assesses short-term memory, which is often affected early in memory loss conditions.

B. Instruct the client to follow a three-step task. This assesses the client’s ability to follow instructions and executive function, not specifically memory loss.

C. Tell the client to repeat a series of unrelated numbers. This assesses immediate memory and attention span but not recent memory.

D. Ask the client if he knows the year he married his wife. This assesses long-term memory, which is not typically affected in early stages of memory loss.

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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

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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