1. A nurse is conducting an admission interview with a client. Which of the following pieces of

assessment information should the nurse collect during the introductory phase of the

interview?

A. Clients level of comfort and ability to participate in the interview

-The nurse should assess the client’s level of comfort and establish a rapport during the

introductory or orientation phase. The nurse should engage in active listening and present a

relaxed attitude to place the client at ease and encourage client participation. This will assist the

nurse in gaining the necessary data to formulate appropriate nursing diagnoses and outcomes.

B. Previousillnesses and surgeries

-incorrect: The nurse should assessthe client’s health history, including previous illnesses and

surgeries, during the working phase of the interview.

C. Eventssurrounding the client’srecent illness

-incorrect: The nurse should assessthe client’s health history, including eventssurrounding the

recent or current illness, during the working phase of the interview.

D. Sociocultural history

-incorrect: The nurse should assessthe client’s sociocultural history during the working phase of

the interview.

2. A nurse is performing an abdominal assessment of a client. Which of the following positions

should the nurse tell the client to assume for this examination?

A. Lithotomy

-incorrect: The lithotomy position is useful for gynecological examinations.

B. Lateral

-incorrect: The lateral recumbent, or side-lying position, limits access to the abdomen. This

position is useful when auscultating the heart to detect murmurs.

C. Supine

-The nurse should tell the client to assume the supine position to promote relaxation of the

abdominal muscles. Having the client bend the knees enhances relaxation of the stomach

muscles.

D. Sims

-incorrect: The Sims’ position limits access to the abdomen. This position is useful for rectal and

vaginal examinations.

3. A nurse is caring for a client who is postoperative following an abdominal surgery. Which of

the following actions should the nurse perform first after discovering the client’s wound has

eviscerated?