While conducting a rapid assessment for a client who has ...

[sheilaspns]

While conducting a rapid assessment for a client who has diabetes, the student nurse notes that the client is experiencing emotional stress following the recent death of the spouse.
 
  When discussing the client with the nurse preceptor, which statement by the student nurse student indicates the need for further education?
  1. Emotional stress can negatively impact the immune system's ability to function.
  2. The client has probably not been eating well recently.
  3. I should not ask about the use of drugs or alcohol at this time.
  4. The client may be hyperglycemic.

Question 2

The nurse is conducting an initial respiratory assessment on the client recently admitted to the unit. Rank the following steps in the correct sequence. Select the correct choice from the list.
 
  1. The nurse percusses the client's thorax.
  2. The nurse unties the client's gown to better visualize the client's thorax.
  3. The nurse warms his stethoscope and listens to the client's lung sounds in each lung field.
  4. The nurse gently palpates the client's thorax.

[l.stuut]

Answer to Question 1

Correct Answer: 3
Some individuals use alcohol, tobacco, or drugs to feel better. The nurse must assess the client's use of drugs or alcohol at this time. Emotional stress affects the immune system, resulting in increased susceptibility to infection. During periods of stress or change, individuals are less likely to attend to habits that promote health such as eating nutritious meals or following an exercise routine. The client who is experiencing emotional stress is more likely to develop an increased serum glucose level due to the increased level of circulating stress hormones.

Answer to Question 2

Correct Answer: 2, 4, 1, 3
When performing a physical assessment, the nurse utilizes four basic techniques to obtain objective and measurable data. These techniques are inspection, palpation, percussion, and auscultation and are performed in an organized manner. This pattern of organization varies when assessing the abdomen. The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation.