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

Explanation

Choice A Reason:
Observing for jugular vein distention while the client is flat in bed is incorrect because jugular vein distention is not directly related to orthopnea. Jugular vein distention may indicate increased central venous pressure, which can occur in conditions such as heart failure, but it is not specific to orthopnea, which is difficulty breathing while lying flat.
Choice B Reason:
Measuring the client's blood pressure when he is lying and standing is incorrect because measuring blood pressure in different positions (lying and standing) is used to assess for orthostatic hypotension, not orthopnea. Orthostatic hypotension refers to a drop-in blood pressure upon standing and is not directly related to difficulty breathing while lying flat.
Choice C Reason:
Asking the client how many pillows he sleeps on at night is correct because orthopnea is characterized by difficulty breathing while lying flat, often relieved by sitting up or propping oneself with pillows. Asking the client how many pillows he sleeps on at night provides valuable information about his sleeping position and potential orthopnea. Clients with orthopnea often need to sleep in a semi-upright position or with multiple pillows to alleviate breathing difficulties.
Choice D Reason:
Auscultating the client's breath sounds while he is supine is incorrect because auscultating the client's breath sounds while he is supine may provide information about lung sounds, but it does not specifically assess for orthopnea. Orthopnea refers to difficulty breathing while lying flat, and the assessment of breath sounds may not directly indicate this condition.

A. Have the client lay flat while listening to the anterior surface of the chest. B. Use the bell of the stethoscope to listen to the lung fields over lower lobes. C. Shave all chest hair that may distort sounds heard through the diaphragm. D. Press the stethoscope's diaphragm firmly on the skin over each lung field.

Correct Answer is D

Explanation

Choice A Reason:
Having the client lay flat while listening to the anterior surface of the chest is incorrect because having the client lay flat may not be the most optimal position for auscultating lung sounds. While auscultation of the anterior surface of the chest is important, particularly for assessing the upper lobes of the lungs, having the client lay flat may not provide the best positioning for detecting all lung sounds, especially those located in the posterior lung fields.
Choice B Reason:
Using the bell of the stethoscope to listen to the lung fields over lower lobes is incorrect because using the bell of the stethoscope is more suitable for detecting low-frequency sounds such as heart murmurs or bruits. Adventitious lung sounds, such as crackles (rales) or wheezes, are typically high-pitched sounds that are best heard using the diaphragm of the stethoscope. Therefore, using the bell may not be the most effective technique for assessing adventitious lung sounds.
Choice C Reason:
Shaving all chest hair that may distort sounds heard through the diaphragm is incorrect because while removing chest hair may improve sound transmission for certain auscultatory findings, such as heart sounds, it is not specifically indicated for assessing adventitious lung sounds. Chest hair removal is not necessary for auscultation of lung sounds with the diaphragm of the stethoscope, as the sound transmission through chest hair is minimal and unlikely to significantly distort lung sounds.
Choice D Reason:
Pressing the stethoscope's diaphragm firmly on the skin over each lung field is correct because using the diaphragm of the stethoscope and pressing it firmly on the skin over each lung field ensures good contact with the chest wall, allowing for optimal transmission of lung sounds. Adventitious lung sounds, such as crackles or wheezes, are best heard using the diaphragm, particularly when it is applied firmly to the chest wall to minimize external noise and enhance sound transmission. Therefore, this technique is the most appropriate for assessing adventitious lung sounds during auscultation.

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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 D

Explanation

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