While interviewing a client, the nurse observes that the client ...

[lindiwe]

While interviewing a client, the nurse observes that the client is changing position frequently, wringing hands, and laughing at inappropriate times. Which would be appropriate for the nurse to include in the assessment based on this information?
 
  1. Anxiety assessment.
  2. Mental status testing.
  3. Attention deficit testing.
  4. Nutrition assessment.

Question 2

The nurse is admitting a client with a fractured hip. The client points to the painful hip and describes it as a constant throbbing. Which would the nurse include when continuing the pain assessment on this client?
 
  1. Intensity, precipitating and relieving factors, impact on ADLs, and coping strategies.
  2. Intensity, quality, location, and impact on ADLs.
  3. Intensity, quality, pattern, and precipitating factors.
  4. Intensity, quality, precipitating and relieving factors, and impact on ADLs.

[prumorgan]

Answer to Question 1

Correct Answer: 1

Body language and verbal responses can be key indicators of anxiety. If the patient exhibits anxiety during the interview it may be a reflection of anxiety related to the situation or a need for further assessment. One means used to further evaluate the anxiety is the use of an anxiety scale. Mental status testing would be indicated if the client demonstrates confusion. The nurse does not conduct attention deficit testing. This is beyond the nurse's scope of practice. The observations by the nurse do not provide clues to the client's nutritional state.

Answer to Question 2

Correct Answer: 1
Pain assessment should include data about the location, intensity, quality, pattern, precipitating factors, actions undertaken for relief of pain and effects, impact on ADLs, coping strategies, and emotional responses. The description of the client in the question already includes the quality, location, and pattern of the pain.

[lindiwe]

TYSM

[bigsis44]

Excellent