Chapter 1-3

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing

Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches). This allows you to feel very deep organs or structures that are covered by thick muscle.

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?

Determine any changes from the baseline data Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment. Evaluation is done after an intervention to determine if the outcomes have been achieved.

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?

Each person needs a complete health assessment. Ideally this is done on admission, but extenuating circumstances may prohibit its completion in detail at this time. The sooner the health assessment is completed fully, the better the nurse knows the client, and more holistic care can be provided to ensure health promotion and quality of life. The assessment should not be postponed until after the consult. The family should be informed of the need for the assessment and asked to leave until it is completed, unless their input with the history is needed. While pain may complicate the assessment process, it is not advisable to wait until the client is pain free to complete the assessment.

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?

Empathy Empathy is an intuitive awareness of what the client is going through; it helps the nurse to be effective in providing for the client's needs while remaining compassionately detached. Inspection and palpation are skills that help the nurse in collecting objective data of the client's physical characteristics. Sympathy is a feeling that would make the nurse as emotionally distraught as the client; this hampers the ability of the nurse to provide client care.

Revising the plan as needed occurs in what part of the nursing process?

Evaluation

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's

Flatness is a sound heard over very dense tissue like bone.

A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?

Making incorrect nursing judgments or diagnoses

When using an interpreter to facilitate an interview, where should the interpreter be positioned?

Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client

You should use the bell of the stethoscope when auscultating what type of sounds?

The bell is used with light skin contact to hear low-frequency sounds.

A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client?

The client may not want her sister to know her private information

An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?

The client's memory was cloudy but the adult daughter was able to provide the exact date based upon a life event that can be validated. This interaction does not indicate that the adult daughter is controlling the interview. The client was unable to recall the exact date of the surgery but with the daughter's help, the date was provided. The exact information about the surgical date and the person who provided the information should be documented. The client may have been confused, but that is not what needs to be documented.

While conducting a comprehensive health history the client says a few sentences about the current problem but then explains how her deceased mother used to have the same problem because of having diabetes. What action should the nurse take?

The health history does not always proceed in a set pattern. As the client provides information, the nurse should fill in the different parts of the assessment. There is no need for the nurse to refocus the client on the current problem. Expressing sympathy on the loss of the client's mother would encourage the client to focus on areas that are not related to the health history. Asking about the health of other family members would take the focus completely off of the client's current problem.

The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview?

The nurse should begin by asking a non-threatening open-ended question such as "have you ever had a problem with mental or emotional illness?" Asking specifically about medication for depression assumes the client has a history of depression. Asking about talking with a psychiatrist or counseling may cause the client to become defensive.

When making rounds, the RN should prioritize follow-up care for which client?

The nurse should prioritize care for the oncology client, because immunosuppression due to chemptherapy is a concern. The immunosuppressed client can still exhibit a respiratory infection without fever. The clients require routine assessments with no immediate concerns.

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

To establish a database against which subsequent assessments can be measured

When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using

blunt percussion. Blunt percussion is used to detect tenderness over organs by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface.

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?

cc The chief complaint is the reason for the person seeking care. Health patterns focuses on the client's social history. The review of systems is where the presence or absence of common symptoms related to each major body system are reviewed and documented. The history of present illness describes how each symptom developed. It includes the client's thoughts and feelings about the illness, relevant parts of the review of systems, and medications, allergies, and lifestyle habits that impact the present illness.

In which situation should a nurse perform an emergency assessment of a client?

An emergency assessment is a very rapid assessment performed in life threatening situations such as drowning, choking, or cardiac arrest. It is also used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. Shortness of breath requires an emergency assessment to promptly assess the client's ability to maintain an adequate airway. A broken arm, body rash, and ear pain require a focused assessment to gather information specific to the problem.

Which of the following is a general procedural rule when performing a complete physical examination?

Beginning examination on the right is the standard practice for the physical examination and has several advantages: it is more reliable to assess jugular veins from the right, the palpating hand rests more comfortably on the apical impulse, and the right kidney is more frequently palpable than the left. Draping provides examinee comfort, and symmetrical areas are not always identical. It is not necessary to begin with areas of pain but rather to proceed systematically.