Chapter 14: Assessing

Which statement is true regarding addressing a priority problem?

A priority problem requires a nursing intervention before another problem is addressed. A priority problem requires a nursing intervention before another problem is addressed, but addressing priority problems does not entail skipping any interventions. The priority of problems can change as a client's condition changes. There are no predetermined times or intervals at which to identify priority problems. This is why critical thinking plays a central role in nursing.

Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training?

All data collected need to be validated. Validation is the act of confirming or verifying. The purpose of validation is to keep data as free from error as possible. It is an important part of assessment. However, it is neither possible nor necessary to validate all data; nurses should decide which items need verification.

What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall?

Assess blood pressure with a large cuff. When assessing an obese client, a larger blood pressure cuff will likely be needed to prevent false high readings. It is not in the nurse's scope of practice to determine when and if cholesterol levels and an electrocardiogram are ordered. Diet education may or may not be warranted depending on the cause of the obesity.

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment Some people of Chinese descent are modest about having their bodies touched and may see touching as an invasion into their personal space. The nurse should explain what will be done as the assessment progresses and strive to help the client feel as comfortable as possible. However, asking if the client would like the door left closed or opened, is not a priority before starting the assessment. It would be inappropriate to discuss various goals before the assessment is complete. All the information is needed to determine which goals will be most appropriate for each client. It may also be inappropriate to only conduct a focused assessment at this time, depending on the situation and the client. If there are other issues, they should also be evaluated, so that appropriate nursing goals can be determined and the client can receive the best care possible.

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. If the client is in bed, the nurse sitting in a chair placed at a 45-degree angle to the bed ensures the nurse is sitting at eye-level with the client, which promotes communication. If the nurse is standing at the foot or at the side of the client's bed, an authoritative position is established, which does not promote good communication. If both the nurse and the client are seated, being 30 cm apart intrudes upon personal space; ideally the nurse and client should be about 1 m apart.

For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

Initial The Joint Commission has mandated that each client have a documented nursing admission (initial) assessment that follows institutional policies. An initial assessment is comprehensive and covers both a client's physical and psychosocial health. A focused assessment is one that addresses one specific problem that has already been identified; this type of assessment is not mandated by the Joint Commission.

The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment?

Supplement the client's information by speaking with family or friends. Family and friends can be an invaluable source of assessment data, especially in the care of clients who have cognitive deficits. It would be inappropriate to limit an assessment to solely objective data. Using previous medical records and breaking up the assessment are appropriate measures, but they do not supersede the importance of using family and friends as data sources.

A nurse is beginning the preparatory phase of the nursing interview for a client who fractured the left leg in a fall. Which nursing actions occur in this phase of the nursing interview? Select all that apply.

The nurse ensures that the interview environment is private and comfortable. The nurse arranges the seating in the interview room to facilitate an easy exchange of information. The nurse prepares to meet the client by reading current and past records and reports. Providing a private and comfortable environment, arranging seating, and reading current and past records about a client all take place during the preparatory phase of the nursing interview. The nurse states the nurse's name during the introductory phase. The nurse recapitulates the interview during the concluding phase.

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?

The nursing and medical literature In addition to information about medical diagnoses, treatment, and prognosis, a literature review of nursing and medical references offers nurses important information about nursing diagnoses, developmental norms, and psychosocial and spiritual practices that are helpful when assessing and caring for clients. Consulting with the client, physician, or client's chart would not give as comprehensive of a review.

A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing?

Time-lapse The four types of nursing assessment include complete, focused, time-lapse, and emergency. In time-lapse assessments, the nurse reassesses a client and condition that is already known to re-evaluate the client's status. In this case the nurse is revisiting the client's feelings and plans to change her life situation by leaving her abusive husband. In emergency assessments, the nurse assesses the client for life-threatening problems which are acutely present.. In focused assessments, the nurse focuses on assessing a specific problem that is already known to exist to further refine planning interventions. In complete (general or initial) assessments, the nurse does a thorough assessment of all aspects of a client's health status on the client's admission to a health care facility.

The nurse is reviewing the laboratory report section of a client's record. For what reason is this important for the nurse to review? Select all that apply.

To confirm previously collected data To reveal changes from previously collected data To help establish a diagnosis To monitor clients' responses to treatment Reports of laboratory data are used to either confirm or reveal changes from data previously collected. The diagnostic studies also help physicians establish a diagnosis and monitor the client's response to treatment. The labs are not used to make the client feel better.

The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side." This statement is an example of:

a cue. Cues and inferences describe the early analysis of data. "The client does not respond when I speak while standing on the client's right side," is a cue that something may be wrong. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. A nurse can observe a cue directly but not an inference. The information in this case is based on the nurse's direct observation, not interpretation or inference, and thus cannot be a misinterpretation. There is no evidence that the nurse's observation duplicates other data collected.

During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to:

body systems. The categorization of assessment findings according to systems (in this case, musculoskeletal, gastrointestinal, and respiratory) is characteristic of a body systems model for organizing data. Although systematic, this strategy tends to ignore spiritual and psychosocial considerations. Human needs are based on food, water, and shelter. Human response patterns involve the subjective awareness of information. The functional health patterns model is used to provide a more comprehensive nursing assessment of the patient focusing on sleep, roles, exercise, relationships, etc.