Lab Manual Chapter 4 Pretest/Posttest

Subjective or Objective: reddened, raised, indurated area on deltoid area of left arm

objective

The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write a- "bilateral lung sounds clear" b- "the client's lung sounds were clear on both sides" c- "client's lung sounds were auscultated with stethoscope and are clear on both sides" d- "after listening to client's lung sounds, both lungs appeared clear"

a- "bilateral lung sounds clear"

An assessment form commonly used in long-term care facilities is the nursing minimum data set. One primary advantage to this type of assessment for is that it a- establishes comparability of nursing data across clinical populations b- clusters all the nursing and medical diagnoses in one place c- allows for individualization for each client in the health care setting d- uses a flowchart format for easy documentation of objective data

a- establishes comparability of nursing data across clinical populations

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should a- validate all data before documentation of the data b- document the data after the entire examination process c- record the nurse's understanding of the client's problem d- use medical terms that are commonly used in health care settings

a- validate all data before documentation of the data

The nurse is preparing to document assessment finding in a client's record. The nurse should a- write in comets sentences with few abbreviations b- avoid slang terms or labels unless they are direct quotes c- record how the data were collected d- use the term "normal" to describe non-pathological findings

b- avoid slang terms or labels unless they are direct quotes

One advantage for an institution to use an integrated cued/checklist type of assessment data form is that it a- allowed a comprehensive and thorough picture of the client's symptoms b- may be easily used by different levels of caregiver, which enhances communication c-provides for easy and rapid documentation across clinical settings and populations d- includes the 11 health care patterns in an easily readable format

b- may be easily used by different levels of caregiver, which enhances communication

One disadvantage of the open-ended assessment form is that is a- does not allow for individualization b- asks standardized questions c- requires a lot of time to complete d- does not provide a total picture of the client

c- requires a lot of time to complete

If the nurse makes an error while documenting findings on a client's record, the nurse should a- erase the error and make the correction b- obliterate the error and make the correction c- draw a line through the error and have it witnessed d- draw a line through the error, writing "error" and initialing

d- draw a line through the error, writing "error" and initialing

In some health care settings, the institution uses an assessment form that assesses only one part of a client. There types of forms are termed a- progressive b- specific c- checklist d- focused

d- focused

While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and the a- cause of the pain b- client's caregiver c- client's occupation d- pain relief measures

d- pain relief measures

An example of an objective finding in an adult client is a- a client's symptom of pain b- family history data c- genetic disorders d- vital signs

d- vital signs

Subjective or Objective: bowel sounds present in all four quadrants

objective

Subjective or Objective: emesis of 200 mL light beige thin liquid

objective

Subjective or Objective: pale, clammy, and diaphoretic

objective

Subjective or Objective: passing flatus

objective

Subjective or Objective: patterns of request for pain medication every 2 hours

objective

Subjective or Objective: Describes sever right sided headache

subjective

Subjective or Objective: cannon eat seeds or uncooked grains without abdominal discomfort

subjective

Subjective or Objective: complains of lower back pain on movement

subjective

Subjective or Objective: feels nauseated and dizzy

subjective