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 B

Explanation

Choice A Reason:
Coronary heart disease is incorrect. Coronary heart disease is primarily associated with cardiovascular symptoms such as chest pain, shortness of breath, and fatigue. While some nail changes may occur in individuals with coronary heart disease due to decreased oxygenation, brittle, concave nails are not a typical manifestation of this condition. Therefore, this option is less likely to explain the appearance of the nails.
Choice B Reason:
Iron deficiency anemia is correct. Iron deficiency anemia is characterized by a lack of iron in the body, leading to decreased production of hemoglobin and red blood cells. One of the classic nail findings associated with iron deficiency anemia is koilonychia, which presents as brittle, concave nails with a spoon-like appearance. This is due to structural changes in the nails caused by the deficiency of iron. Therefore, this option is the most likely explanation for the observed nail changes.
Choice C Reason:
Diabetes mellitus is incorrect. Diabetes mellitus can lead to various dermatologic manifestations, including nail changes such as thickening, discoloration, and slow nail growth. However, brittle, concave nails with a spoon-like appearance are not typically associated with diabetes mellitus. Therefore, while diabetes mellitus may affect the nails, it is less likely to explain the specific appearance observed in this case.
Choice D Reason:
Recent candida infection is incorrect. Candida infections, particularly in the nail folds (paronychia), can lead to changes in the nails such as discoloration, thickening, or separation from the nail bed. However, brittle, concave nails with a spoon-like appearance are not typical findings of candida infections. Therefore, while recent candida infection may affect the nails, it is less likely to explain the specific appearance observed in this case.

A. Review the client's serum electrolytes. B. Evaluate client's muscle strength and hand grips. C. Check distal phalanges capillary refill. D. Observe skin for erythema, edema, and warmth.

Correct Answer is B

Explanation

Choice A Reason:
Reviewing the client's serum electrolytes is incorrect. While abnormalities in electrolyte levels can sometimes contribute to neurological symptoms, such as paresthesia, reviewing the client's serum electrolytes may not directly identify additional findings consistent with the client's reported paresthesia of the hands and legs. Therefore, this option is less relevant for assessing paresthesia and identifying additional consistent findings.
Choice B Reason:
This is the correct action to identify additional findings consistent with the client's paresthesia. Paresthesia, or abnormal sensations like burning or tingling, may indicate neurological dysfunction. Assessing the client's muscle strength and hand grips can provide valuable information about neurological function and help identify any weakness or changes that may be associated with the paresthesia.
Choice C Reason:
Checking distal phalanges capillary refill is incorrect. Checking distal phalanges capillary refill is important for assessing peripheral circulation, but it may not directly identify additional findings consistent with paresthesia. While impaired circulation could contribute to sensory disturbances, such as paresthesia, it is not always the primary cause. Therefore, this option may not fully capture the sensory aspect of the client's reported symptoms.
Choice D Reason:
While observing the skin for signs of inflammation or irritation is important in assessing for other conditions, such as infection or inflammation, it is not directly related to identifying additional findings consistent with paresthesia. Paresthesia primarily involves abnormal sensations and neurological function rather than changes in the skin.

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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

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

Correct Answer is B

Explanation

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?

Correct Answer is B

Explanation

The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?

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.

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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?

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