Prep U Chapter 11

How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation?

"Client states, 'I don't see the point in trying anymore.'"

An unlicensed staff member asks the nurse what the difference is between a medical assessment and a nursing assessment. Which of the following is the nurse's best response?

A nursing assessment focuses on the client's response to health problems.

A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of focus assessment?

Adds depth to existing information

Which of the following patient situations most likely warrants a time-lapsed nursing assessment?

An elderly resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

During the nursing examination, the nurse notices that the patient, an elderly female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation?

Ask the patient if it is okay to interview her husband for the answers to the interview questions.

The nursing student has learned that when doing an assessment on any client, it is essential to get the most important information first. By doing so the nurse's action is an example of which of the following?

Being able to prioritize

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data?

Both during the collection and at the end of the collection

A client reports to a health care facility with complaints of abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data?

Client himself

The nurse is planning to do a physical assessment on a newly admitted client.The assessment will be a review of systems (ROS). This means the nurse plans to do which of the following?

Complete an exam of all body systems

A 50-year-old female patient is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information?

Consult nursing and medical literature.

An older adult male with a history of benign prostatic hyperplasia presents to the emergency room with complaints of urinary retention. The nurse collects data related to the patient's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing?

Focused assessment

The nurse notices during an assessment interview that the client cannot stay on focus and jumps from one topic to another. The client also is speaking very rapidly and at time incoherently. What should the nurse suspect is the main cause of this behavior?

High anxiety

When charting the assessment of a client, the nurse writes,"Client is depressed." This documentation is an example of which of the following?

Interpretation of data

he nurse working at a local community hospital understands the importance of having a client database for continuous data collection. What does the nurse identify as the the primary reason for collecting data continuously?

It is because the client's health status can change quickly

The nurse records the name, age, and race of the client. These data are components of which of the following?

Nursing or health history

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

Objective

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood count (WBC) lab value. The nurse is gathering which type of data when looking up the lab value?

Objective

The nurse is assessing the client's abdominal wound and notes yellow-green purulent wound drainage. The nurse recognizes that the drainage is an example of what?

Objective data

While studying methods of data collection, a nursing student learns that there are many different skills involved. Which of the following is a key nursing skill that uses all five senses?

Observation

The nursing instructor is teaching the students how to do an interview on a client. Which of the following statements made by a student indicates a need for further instruction?

Show your name badge to the client so they can read who you are

During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

Sitting at eye level with the client

A patient describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

Subjective

After suffering a wrist fracture in a recent fall, a female client 77 years of age is strongly suspected of having osteoporosis. Which of the following data best demonstrates the nursing focus of assessment?

The client claims her mobility and independence have declined in recent years.

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that which of the following is the best place to get baseline data?

The initial comprehensive nursing assessment

The nurse is performing an assessment on an older adult client and notices that the blood pressure has increased from 140/82 to 198/120. This is a significant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the physician?

The nurse

A nurse is interviewing a new patient admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview?

The nurse assesses the patient's comfort and ability to participate in the interview.

The nurse is performing a physical assessment of a client admitted with emphysema. How will the nursing physical assessment differ from a medical physical assessment?

The nurse's physical assessment will focus on the client's functional abilities.

A nurse practitioner has a private practice in conjunction with a physician. She is providing psychiatric care to a woman who has a past history of being abused by her husband. During the last visit, she stated that she was planning to leave her husband. On the next visit in two weeks, the nurse practitioner will assess her client's commitment to changing her life situation and her ability to feel empowered. What type of assessment is the nurse practitioner implementing?

Time-lapsed

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming that afternoon to do some kind of check-up. Which type of check would be most appropriate for the nurse to perform on this client?

Time-lapsed assessment

When performing an assessment, the nurse should focus on the developmental stage for which of the following clients?

Toddler

The nursing instructor is teaching the students about assessments. Which of the following does the instructor list as being most important in order for an assessment to be successful?

Trust and confidence

The nurse is performing a physical assessment of a newly admitted client. During the assessment the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client is there is any pain the answer is "no." What is the best thing for the nurse to do next?

Validate the data

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs the client's temperature is 102. 9 F. What should be the nurse's priority action

Verbally report the finding immediately to the client's physician

The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? Select all that apply.

• 38 year-old man • Height: 6' • Weight 195 pounds

Nurses collect objective and subjective data during the patient interview. Which patient data is subjective data? (Select all that apply.)

• A patient describes his pain as an 8 on the pain assessment scale. • A patient feels nauseated after eating his breakfast. • A patient complains of being cold and requests an extra blanket.

Which of the following qualities does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply.

• Respect for client • Competence • Professionalism • Caring