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 ["C","D","E"]

Explanation

C. Chronic obstructive pulmonary disease (COPD): COPD is a chronic respiratory condition characterized by airflow limitation, typically caused by chronic bronchitis and/or emphysema. In COPD, the airways become narrowed and inflamed, leading to difficulty breathing. Over time, chronic hypoxia (low oxygen levels in the blood) can develop due to impaired gas exchange in the lungs. Chronic hypoxia can trigger compensatory mechanisms in the body, including vascular changes that result in clubbing of the nails. Therefore, clubbed nails can often be seen in individuals with COPD as a consequence of chronic tissue hypoxia.

D. Lung cancer: Lung cancer is a malignant tumor that arises from the cells of the lungs. It is often associated with long-term smoking, as in the case of this client. Lung cancer can impair lung function and compromise gas exchange, leading to chronic hypoxia. As with COPD, chronic hypoxia can induce vascular changes that result in clubbing of the nails. Therefore, clubbed nails can be a manifestation of advanced lung cancer, particularly in cases where chronic hypoxia is present due to impaired lung function.

E. Chronic bronchitis: Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) characterized by inflammation and narrowing of the airways, leading to excessive mucus production and persistent cough. Similar to other forms of COPD, chronic bronchitis can result in chronic hypoxia due to impaired gas exchange in the lungs. The chronic hypoxia associated with chronic bronchitis can lead to vascular changes that cause clubbing of the nails over time. Therefore, individuals with chronic bronchitis may also exhibit clubbed nails as a consequence of chronic tissue hypoxia.

A. Assess conjunctival sacs of lower lids for pallor. B. Observe the client's urine for dark orange color. C. Examine client's sclera for icterus. D. Review recent serum bilirubin levels.

Correct Answer is C

Explanation

Choice A Reason:
Assessing conjunctival sacs of lower lids for pallor is incorrect. Pallor of the conjunctival sacs, or inner eyelids, may indicate anemia or decreased blood flow. While it can be a sign of various health conditions, it is not specific to jaundice. Jaundice is characterized by yellowing of the skin and sclerae (the white part of the eyes) due to elevated bilirubin levels in the blood, so assessing for pallor would not directly confirm jaundice.
Choice B Reason:
Observing the client's urine for dark orange color is incorrect. Dark orange urine may indicate concentrated urine or dehydration, but it is not specific to jaundice. Jaundice primarily manifests as yellowing of the skin and sclerae due to elevated bilirubin levels, rather than a change in urine color. While changes in urine color may occur in certain liver conditions, such as obstructive jaundice, it is not the most direct or reliable method to confirm jaundice.
Choice C Reason:
Examining client's sclera for icterus is correct. Icterus, or yellowing of the sclerae (the white part of the eyes), is a classic sign of jaundice. Elevated levels of bilirubin in the blood lead to the yellow discoloration of the sclerae, providing a direct visual confirmation of jaundice. Examining the sclerae for icterus is a quick and reliable method to confirm jaundice during a physical assessment.
Choice D Reason:
Reviewing recent serum bilirubin levels is incorrect. Reviewing recent serum bilirubin levels can provide objective data on bilirubin levels in the blood, which may support the diagnosis of jaundice. Elevated serum bilirubin levels are characteristic of jaundice. While this option provides valuable information, it may not be immediately available during a physical assessment and does not directly confirm jaundice visually, unlike examining the sclerae for icterus.

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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

Patient Data Exhibits The nurse reviews client data. Select the 3 possible conditions that could have the symptom of clubbed nails for this client.

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is C

Explanation

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