PrepU Chapter 14: Assessing

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse:

uses broad, open statements to communicate with the client.

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

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

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview?

"Is there anything else we should know in order to care for you better?"

Which statement by a nurse best indicates an accurate understanding of the different types of assessments? -"It is up to the nurse to decide which assessment to perform." -"How much time the nurse has and how the client is feeling determine which type of assessment to perform." -"The purpose for the assessment offers guidance for which type and how much data to collect." -"The physician informs the nurse of which type of assessment to perform for each client."

-"The purpose for the assessment offers guidance for which type and how much data to collect." Explanation: The purpose for which the assessment is being performed offers the best guidance for what type and how much data to collect. The type of nursing assessment the nurse should conducted should not depend on (a) the nurse's preference, (b) how much time the nurse has, or (c) what the physician wants. It is important to take into account how the client is feeling when preparing to assess, but the client's feelings should not dictate which assessments the nurse performs.

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.

Which scenario is an example of a time-lapse reassessment?

A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.

Which is the purpose of a focused assessment?

Adds depth to existing information

Which is the purpose of a focused assessment? -Provides breadth for future comparisons -Suggests possible problems -Adds depth to existing information -Gives a comprehensive volume of data

Adds depth to existing information Explanation: A focused assessment adds depth to existing information or the initial database gathered by the nurse. A database assessment provides breadth for future comparisons. A focused assessment does not suggest possible problems facing the client but rather rules out or confirms the client's problems. A focused assessment is not voluminous and comprehensive, like a database assessment, but limited and to the point.

Nurses understand the problem that clients have when they are repeatedly asked the same questions. To best avoid this problem, which intervention should nurses perform when beginning to collect assessment data? -Organize all questions into categories. -Make the questions short. -Carefully review the client's record. -Tell the client the questions will be quick.

Carefully review the client's record. Explanation: Before beginning to collect data on a client, the nurse should review the client's record for data. Then the nurse can identify lower-priority data that are not important for the client's assessment. The nurse should avoid telling the client the questions will be quick or making the questions shorter, as proper assessment may not be quick and may necessitate longer questions. A nurse could organize the questions into categories, but reviewing the client's record would be more effective for avoiding duplication of information and ensuring that the assessment is efficient and comprehensive.

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

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

Focused

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? -Initial -Focused -Emergency -Time-lapse

Focused. Explanation: The nurse conducts a focused assessment of the client with a specific identified problem. An initial assessment is conducted by the nurse to establish a baseline database and identify current health problems. The nurse performs an emergency assessment during a crisis to identify life-threatening problems. A time-lapse assessment is one in which the nurse reassesses a client to evaluate the client's progress since a previous assessment for the same condition.

The nurse is conducting a health history on a newly admitted client. Which aspects of the client should the nurse include while doing the history? Select all that apply.

Health status Strengths Health problems Health risks

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.

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

Initial. Explanation: 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.

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply.

Respect for client Competence Professionalism Caring

The nurse is interviewing an 80-year-old client admitted to the hospital for evaluation of diabetes. The client reports enjoying being in the hospital because the client lives alone and does not have many friends. The client reports having a spouse die 1 year ago and no longer being able to drive. The client relies on a daughter, who lives one hour away, to shop for the client once a week. The client states, "My daughter can never stay long and is just in and out in no time." Which nursing diagnoses would be appropriate for this client? Select all that apply.

Risk for Loneliness Powerlessness

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

Secondary

The nurse is summarizing the key points of the interview. This nursing activity occurs during which phase? -Preparatory phase -Introductory phase -Working phase -Termination phase

Termination phase. Explanation: The nurse highlights the key points of the interview during the termination phase. During the preparatory phase the nurse prepares the setting for the interview and reviews any available information about the client. Introductions take place during the introductory phase, and the nurse outlines expectations for the interview. The nurse collects subjective data during the working phase.

Other than the client, what sources of client information should the nurse consider when assessing a client? Select all that apply.

The client's support people The client's health record Family members accompanying the client Other health care professionals

The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "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 nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?

Verbally report the finding immediately to the client's physician.

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. -functional health patterns. -human response patterns. -human needs.

body systems. Explanation: 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.

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?

functional assessment

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

inform the client of the maintenance of confidentiality.

During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:

review as much information as possible.

Which client situation most likely warrants a time-lapse nursing assessment? -An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. -The nurse has responded to the call light of a hospital client who is reporting shortness of breath and chest pain. -A client is being admitted to a general medicine unit after spending several days in the intensive care unit. -A nurse is auscultating the lungs and measuring the oxygen saturation of a client who has pulmonary edema.

-An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. Explanation: A time-lapse assessment is often indicated in the care of a stable client whose current status is being compared to earlier baseline data. Shortness of breath and chest pain necessitate an emergency assessment, while a new admission to a unit or institution requires an initial assessment. Following up a known health problem most often requires a focused assessment.

Which is the best source of information for the nurse when collecting data for an assessment? -Primary physician -Client -Charge nurse -Medical record

-Client Explanation: The client is the primary, and usually best, source of information when doing an assessment. The medical record may also provide information, but only if the client has been at the health care facility before; even then, the client is likely to have more current information than the medical record. Although the charge nurse is responsible for the care of all clients on the unit, the charge nurse is not likely to know the details of any one client's information. The primary physician would provide medical care based on the medical assessment and would not have more information than the client about the client's current health status.

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 stands at the foot of the bed. -If both the nurse and client are seated, their chairs are at right angles to each other, 30 cm apart. -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 stands at the side of the bed.

-If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. Explanation: 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.

The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next? -Recheck the client's pulse in 2 hours. -Recheck the client's pulse at the next scheduled assessment time and document the findings on the chart. -Document the findings on the chart and recheck in 1 hour. -Notify the physician of the change and document the finding. -Notify the physician after the next scheduled assessment time if the pulse is unchanged.

-Notify the physician of the change and document the finding. Explanation: When a pulse deficit is present, the radial pulse rate is always lower than the apical pulse rate. The nurse should document and report to the physician any new finding of a pulse deficit immediately so that evaluation and follow-up can occur. The nurse should not wait until after rechecking the pulse to document the finding or report it to the physician.

A nurse is preparing to interview a client who is newly admitted to the unit. Which strategies will help establish a quiet, relaxed, and comfortable environment during the interview? Select all that apply. -Leaving the door to the room open -Leaving the television on -Keeping the heat on high -Providing a proper seating arrangement -Maintaining a proper distance from the client

-Providing a proper seating arrangement -Maintaining a proper distance from the client Explanation: In the interview of the client, both the seating arrangement and the distance from the client are important in establishing a relaxed and comfortable environment for data collection. Leaving the door opened, leaving the television on, and keeping the heat high will cause distractions for the client.

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next? -Cover the infant. -Ask the parent whether the child has been exposed to cold temperatures. -Assess the skin for signs of cyanosis. -Recheck the temperature, paying close attention to technique.

-Recheck the temperature, paying close attention to technique. Explanation: Tympanic membrane thermometers are noninvasive and fast to use, but studies show discrepancies between their readings and those of oral thermometers, resulting in both false-positive and false-negative readings. The nurse can minimize these discrepancies by using the same ear and device for measurement each time and by using proper technique. The other actions listed would be appropriate for the nurse to take after rechecking the infant's temperature and confirming that it actually is lower than normal.

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply. -Respect for client -Competence -Professionalism -Number of years in profession -Caring

-Respect for client -Competence -Professionalism -Caring Explanation: The nurse's interpersonal competence is critical beginning with the very first assessment. The client's initial impression is crucial. The nurse's competence, professionalism, and interpersonal qualities of caring and respect invite confidence and assure the client that help is available. The length of time as a nurse does not influence competence and professionalism.

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client? -Risk for Loneliness -Acute Pain -Risk for Impaired Parenting -Ineffective Breastfeeding -Ineffective Infant Feeding Pattern

-Risk for Impaired Parenting Explanation: A 14-year-old parent with little family support is at risk for difficulties with the expanded role of parent. The client has not stated feeling loneliness or pain. The infant's feedings are not discussed in the scenario.

A family presents to the emergency room with a 4-year-old child who is crying and reporting that the skin on the legs are itching and hurting. The parent explains that they were out walking in the woods when the child went running off the path and into some tall weeds. Which finding(s)s should the nurse prioritize in this assessment? -4-year-old at 85 percentile of growth and development -Stating "My legs feel like they are burning" -Redness and blisters forming on both legs -Respirations 18 breath/min and regular -Crying and trying to scratch legs due to itching

-Stating "My legs feel like they are burning" -Redness and blisters forming on both legs -Crying and trying to scratch legs due to itching Explanation: This client needs an emergency assessment to ensure the child did not encounter any poisonous vegetation such as poison ivy. Reports of burning, redness, blisters, and itching all indicate a possible reaction to poisonous foliage and require immediate attention and care. The other findings will be assessed after the emergent situation is stabilized.

The nurse identifies which types of data when performing an assessment? Select all that apply. -Subjective -Intuition -Objective -Critical thinking -Hunches

-Subjective -Objective There are two types of data used when doing an assessment: subjective and objective. The others are not types of data but tools that nurses can use while collecting data. Intuition is the ability to understand something immediately, without the need for conscious reasoning. A hunch is a feeling or guess based on intuition rather than known facts. Critical thinking is a systematic, logical, disciplined way of thinking that carefully evaluates evidence and assumptions.

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. -Limit the assessment to objective data. -Obtain the client's records from admissions to other institutions. -Perform the assessment in several short episodes rather than at one sitting.

-Supplement the client's information by speaking with family or friends. Explanation: 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.

Following a client interview, the nurse is organizing data obtained according to Gordon's functional health patterns model. Which statements reflect the focus of this model? Select all that apply. -The nurse clusters or organizes data according to a hierarchy of basic human needs. -The nurse collects data regarding the client's health perception and health management. -The nurse explores the client's perception of the client's major roles and responsibilities in life. -The nurse assesses and collects data on the major body systems. -The nurse collects and organizes data related to human response patterns. -The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality.

-The nurse collects data regarding the client's health perception and health management. -The nurse explores the client's perception of the client's major roles and responsibilities in life. -The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality. Explanation: Gordon's framework identifies 11 functional health patterns and organizes client data within these patterns, including one's own perception of health and health promotion activities. Self-perception/self-concept attitudes is one of the functional health patterns identified with this model. The perception of the major roles and responsibilities in the client's life falls into this category. Gordon also identifies assessment of areas such as elimination, activity, sleep, and sexuality as part of the model. Clustering data according to a hierarchy of basic needs describes Maslow's model. The body systems model organizes the assessment into categories of the major body systems, such as cardiovascular and respiratory systems, and follows most medical models. Data related to human response patterns describe the human response patterns (unitary person) model.

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training? -The nurse sits on eye level with the client. -The nurse verifies the client's name. -The nurse asks the client what name the client would like to be called. -The nurse introduces oneself to the client by pointing to the nurse's name badge.

-The nurse introduces oneself to the client by pointing to the nurse's name badge. Explanation: When conducting an interview, the nurse should sit at eye level with the client, verbally introduce oneself, and state one's position. This sends the message that the nurse accepts responsibility and is willing to be accountable. The nurse should not simply point to the nurse's name badge in introducing oneself. The nurse should verify the client's name and ask what the client would like to be called.

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing? -comprehensive assessment -database assessment -focused assessment -functional assessment

-functional assessment Explaantion: The nurse is performing a functional assessment that focuses on areas that relate to the physical performance of activities, such as how the client is able to meet activities of daily living, demonstration of cognitive abilities, and social functioning. A comprehensive assessment encompasses all of the assessment data for the client. The focused assessment relies on one area of functioning such as the respiratory system if a client is having an asthma attack. The database assessment is performed during the initial history and physical portion of the client's illness and represents a comprehensive and all inclusive initial collection of data.

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: -agrees with each of the client's statements. -attempts to write down everything the client says. -uses broad, open statements to communicate with the client. -reassures the client of good outcomes.

-uses broad, open statements to communicate with the client. Explanation: The nurse should use broad, open statements to facilitate communication during an interview. Using close-ended questions, which prompt yes or no answers, should be avoided, as it does not provide the level of the detail the nurse is seeking. The nurse should pay full attention to the client; paying too much attention to note-taking or making computer entries will interfere with good communication. The nurse should avoid providing false reassurance and agreeing with every statement the client makes.

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. -an inference. -a misinterpretation. -duplicate data.

A cue. Explanation: 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.

A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client? -A full assessment of the urinary system -A focused assessment of the specific problems identified -Obtaining a detailed assessment of the client's sexual history -Conducting a thorough systems review to validate data on the client's record

A focused assessment of the specific problems identified. Explanation: The priority assessment at this time is a focused assessment of the client's primary concern. A focused assessment may be performed during the initial assessment if the client's health problem is apparent. A full assessment of the urinary system may be appropriate but is not the priority. A detailed assessment of the client's sexual history is not warranted, and although a thorough systems review is conducted, it is not the priority at this time.

Which client situation most likely warrants a time-lapse nursing assessment?

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

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

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 cholesterol levels. -Obtain an electrocardiogram daily. -Assess blood pressure with a large cuff. -Begin client education regarding a low-fat diet.

Assess blood pressure with a large cuff. Explanation: 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 conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview?

Avoid the impulse to interrupt.

A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrointestinal symptoms or should be reported to the physician. Which action should the nurse perform next? -Call the family. -Consult with another nurse. -Chart the information. -Wait and see whether the pain subsides.

Consult with another nurse. Explanation: A nurse who is unsure of the significance of a particular finding should consult with another nurse. In some instances, years of experience are needed to distinguish significant from insignificant findings. Calling the family is not appropriate at this point as there is no information to report to them. Charting the information is important after the consultation with another nurse. Waiting to see whether the pain subsides is not appropriate; a timely assessment is needed for this client.

The nurse is performing an admission assessment. Which are considered objective data? Select all that apply.

Height: 6 ft (1.82 m) Weight: 195 lb (89 kg) 38-year-old man

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments?

The nurse

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

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 to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?

Time-lapsed assessment

The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment?

Time-lapsed assessment

The nurse is comparing a client's current status to baseline data obtained upon admission to a long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment? -Emergency assessment -Patient centered assessment method (PCAM) -Time-lapsed assessment -Initial assessment

Time-lapsed assessment. Explanation: A nurse is comparing a client's current status to the baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses, are scheduled for periodic time-lapsed assessments to reassess their health status and to make necessary revisions in the care plan. This assessment can be comprehensive or focused. An initial assessment would be performed on admission. An emergency assessment is generally focused on any life-threatening client issues. PCAM is a tool health care providers can use to assess client complexity using the social determinants of health. These determinants may explain why some clients engage and respond well in managing their health while others with the same or similar health conditions do not experience the same outcomes.

Which traits of the nurse are most important for an assessment to be successful?

Trustworthy and confident

The nurse watches a 43-year-old client walk into the room and notes the client is slightly limping on the left foot when walking. The nurse also notes the client has difficulty sitting in the chair and sits down carefully with the left leg slightly held forward. The client notes having had difficulty walking for the past year and it is getting worse. A previous ultrasound of the foot revealed a Morton neuroma. The client reports continued pain in the left foot when walking or standing for long periods of time. A physical examination reveals pain and tenderness on palpation of the upper left foot, skin is cool to touch with no redness noted, pedal pulse is 78 beats/min and regular. Which action by the nurse demonstrates the observation phase of an assessment?

Watching client walk into room