While performing a focused interview with a healthy adult client, ...

[future617RT]

While performing a focused interview with a healthy adult client, the nurse notes frequent position changes, wringing of hands, lack of eye contact, incomplete sentences, and rapid speech.
 
  The vital signs are BP 160/88 mmHg, apical pulse 102 beats per minute, respiratory rate 26 per minute. Which responses by the nurse are appropriate in this situation?
  Select all that apply.
  1. I'm going to take your temperature now.
  2. Have you ever experienced chest pain?
  3. Are you feeling any anxiety right now?
  4. Are you experiencing any pain at this time?
  5. Have you ever been diagnosed with hypothyroidism?

Question 2

The nurse is performing a focused interview with a client who was recently diagnosed with varicose veins. Which statements by the client will the nurse document as risk factors for varicose vein development? Select all that apply.
 
  1. My mother had big veins on her legs from the time I was little.
  2. My father is of Japanese descent.
  3. I'm a hair stylist.
  4. I was pregnant once and have a son.
  5. I know I weigh a lot more than I should.

[dlook33]

Answer to Question 1

Correct Answer: 2, 3, 4
The client's actions may indicate that the client is experiencing pain. The client may be experiencing chest pain. The nurse should determine whether the client is experiencing chest pain prior to continuing the focused interview. Pain can result in increased blood pressure, pulse, and respiratory rate. The nurse should determine if the client is experiencing pain and seek to treat the pain prior to continuing with the focused interview. The client's actions are also consistent with anxiety. Anxiety stimulates the sympathetic nervous system, which can result in vasoconstriction, high blood pressure, increased heart rate, and respiratory rate. It will be appropriate to assess the client's temperature, but the nurse should first determine whether the client is in pain or is experiencing anxiety. The client's vital signs and actions are more likely associated with hyperthyroidism.

Answer to Question 2

Correct Answer: 1, 3, 4, 5
A client who has a family history of varicose veins has an increased risk for developing them. Hair stylists are more likely to be on their feet while they are working and this does result in an increase in their risk of developing varicose veins. People who have been pregnant multiple times have an increased risk for developing varicose veins. People who are obese have an increased risk for developing varicose veins. Risk factors for varicose veins include people who are of Irish or German descent. People of Japanese descent do not necessarily have an increased risk of developing varicose veins.

[future617RT]

Excellent

[emsimon14]

TYSM