Advanced Assessment: Unit 1

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral?

A 50-year-old client newly diagnosed with diabetes Explanation: During the comprehensive assessment, the nurse identifies problems that require the assistance of other health care professionals. A client who is newly diagnosed with diabetes would benefit from a referral to a diabetes education program. Assistance from other health care professionals would not necessarily be required for the older adult client, the client wanting a vaccination, or the teenager seeking information.

Which observation would cause the nurse to suspect an abusive situation? Select all that apply.

A child is persistent in trying to please a parent. A caregiver of a cognitively intact older adult dominates the interview. A pre-schooler rubs her perineum and complains of it hurting. Explanation: Observations suggestive of possible abuse include a caregiver of a cognitively intact older adult dominating the interview, a child being persistent in trying to please a parent, and a pre-schooler rubbing her perineum and complaining of it hurting. Observations not suggestive of abuse include a parent allowing an adolescent to speak privately with the nurse and an explanation that is appropriate for an injury.

A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?

Adequate lighting Explanation: Adequate lighting is most important for the physical examination of the client with scabies. Sunlight (when available) would be preferable; however, even a portable lamp or a good overhead light is sufficient for illuminating the skin and for viewing shadows and contours. A warm and comfortable room, a quiet area free of disturbance, and a firm examination bed or table are subsequent preparations to the physical setting for the examination.

A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative?

Circle with a cross Explanation: The standard format for representing a deceased female relative in a genogram is using a circle with a cross. A simple circle indicates a living female relative. A simple square indicates a living male relative. A square with a cross indicates a deceased male relative.

A nurse receives report on a client admitted for new onset of lung cancer and reviews the initial comprehensive assessment. The nurse recognizes that which information is subjective and needs validation by further data collection?

Client denies any feelings of anxiety or distress over the diagnosis Explanation: Discrepancies between subjective and objective information or between subjective information; what a nurse observes should be validated by collection of further information. A nurse would expect a client newly diagnosed with cancer to express feelings of denial or anger. Pain and rust colored sputum are expected findings with lung cancer. A history of cigarette smoking is a risk factor for lung cancer.

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain?

Collecting data regarding the nature of the pain Explanation: The nurse's initial role in health assessment is to collect data. Teaching would occur later in the process. Planning care and identifying interventions are parts of the nursing process and not the health assessment.

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?

Correct response: Ask the client about the most recent experiences of pain. Explanation: Data are best validated by the client. Other sources are valid and useful, but the client is the ultimate source, especially in the case of subjective data.

The nurse is documenting information that uses alerts for specific problems assessed for the client. Which type of initial documentation form is the nurse using?

Cued

A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document?

Decreased range of motion in right shoulder

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?]

Determine if a structure is filled with air or fluid or is a solid structure Explanation: The nurse uses the percussion technique while performing a physical examination in order to determine whether the underlying structure is filled with air or fluid or is a solid structure. Palpation technique is used to feel deep organs or structures covered by thick muscles, and to determine tenderness, moisture, and surface of skin texture. The nurse uses the inspection technique to look for abnormalities on the skin's surface.

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?]

Dorsal surface Explanation: The dorsal (back) surface of the hand is the part most sensitive to temperature and thus is the correct part to use when palpating for temperature. The fingerpads are for fine discriminations, such as for palpating for pulses, texture, size, consistency, shape, and crepitus. The ulnar or palmar surface is used to palpate for vibrations, thrills, and fremitus.

The nurse would use what part of the hand when assessing temperature during palpation?

Dorsal surface Explanation: The dorsal surface is used for temperature. The fingerpads are used for fine discrimination such as pulses, texture and size. The ulnar or palmar surface is used for vibrations, thrills and fremitus.

A nurse is preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique?

Eliminate distracting noises from the environment. Explanation: The auscultation technique requires the use of a stethoscope. The nurse should eliminate any distracting or competing noises from the environment to ensure that the sounds heard are those of the client and not the environment. Using good lighting, preferably sunlight, looking and observing before touching the client, and comparing the appearance of symmetric body parts are some of the guidelines to perform the technique of inspection.

A patient arrives at the Emergency Department reporting shortness of breath. She is cyanotic with bilateral wheezing. The patient begins to gasp for air and cannot speak. The nurse begins to gather information so that interventions can resolve the immediate breathing problem. Her assessment and interventions are concurrent. The nurse is performing what type of health history?

Emergency Explanation: The nurse is performing an emergency health history, the purpose of which is to collect the most important information and defer obtaining details until the patient is stable. The focused health history involves questions that relate to the current situation. The comprehensive health history takes place during an annual physical examination. There is not a primary health history for patients.

For which client should a nurse perform a focused assessment?

Four-day history of sore throat and fever with enlarged lymph nodes Explanation: A client with a sore throat and fever with enlarged lymph nodes requires only a focused assessment by the nurse. A focused assessment consists of a thorough assessment of a particular client problem. An elevated blood pressure with no previous history of heart problems requires an initial or comprehensive assessment. Right upper abdominal pain that radiates into the groin area is an emergency situation and the nurse should collect only the data necessary to make a quick diagnosis for immediate treatment. A client with diabetes has a chronic, ongoing health problem that needs reassessment and possibly a change in treatment.

The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system?

Inspection Explanation: Inspection is the only technique that is used when assessing every body part and system. Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema. Percussion is used to illicit sound or determine tenderness. Auscultation is used to listen to sounds. Palpation, percussion and auscultation are not used to assess every body part or system.

A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client?

Inspection, palpation, percussion, auscultation Explanation: Four basic techniques must be mastered before you can perform a thorough and complete assessment of the client. These techniques are inspection, palpation, percussion, and auscultation. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected.

Examples of objective data include all the following except:

Itchy skin

Student nurses are learning about evidence-based practice. What would they learn is the final step in this process?

Justifying the selection of interventions Explanation: Evidence-based practice helps you solve common problems through these four steps: 1. Clearly identify the issue or difficulties based on an accurate analysis of current nursing knowledge and practice; 2. Search the literature for relevant research; 3. Evaluate the research evidence using established criteria regarding scientific merit; 4. Choose interventions and justify the selection with the most valid evidence.

A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information?

Lifestyle and health practices profile Explanation: By assessing the client with regard to nutritional habits, use of substances, education, and work and stress levels, the nurse expects to obtain a lifestyle and health practices profile. To determine the history of present health concerns, the nurse should ask questions relating to the onset, duration, and treatments, if any have been conducted on the client, for the present health concern. The questions related to personal health history assist the nurse in identifying risk factors that stem from previous health problems. Family health history helps the nurse to identify potential risk factors for the client.

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use?

Light Explanation: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin. Moderate palpation should be used to assess the size, shape, and consistency of abdominal organs. Pressure is firm enough to depress approximately 1 to 2 cm in depth. During deep palpation, the nurse uses a pressure to palpate 2 to 4 cm in depth. Intermediate palpation is a distracter for this question.

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?

Peripheral vascular Explanation: A tuning fork has two uses in the physical examination. The most common is to assess hearing however the tuning fork is also used to assess the sense of vibration when completing the neurologic or peripheral vascular assessment. A tuning fork is not used to assess the respiratory, genitourinary or gastrointestinal systems.

A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

Personal health history Explanation: The chief complaint is the abdominal pain. Any associated symptoms would be a part of the history of present illness. The information provided by the client about a past illness would be part of the personal health history. Review of systems provides specific questions about past illnesses that might still be impacting the client.

After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information as which of the following?

Subjective data and objective data

The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which nursing action would be most appropriate?

Try to minimize position changes. Explanation: Some positions may be very difficult or impossible for the older client to assume or maintain because of decreased joint mobility and flexibility. The nurse cannot omit intrusive parts of the exam or allow the client to remain dressed because essential information may be missed. The nurse can approach the client slowly, allow for rest periods, and provide clear explanations to the older adult client to help facilitate the exam and decrease anxiety. Dimming the lights would interfere with the nurse's ability to inspect the client.

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)

focused or problem-oriented assessment. Explanation: A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.

In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed

focused.

You are taking a health history on a new patient. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the significance of this information to the health history?

The patient may be at risk for developing diabetes. Explanation: Nurses incorporate a genetics focus into the health assessments of family history to assess for genetics-related risk factors. The information aids the nurse in determining if the patient may be predisposed to diseases that are genetic in origin.

Why is the nurse always reassessing the patient for changes?

To achieve the best results Explanation: The nurse or detective is always reassessing the patient or case for changes in order to achieve the best results. Each relies on both the science and art of his or her respective profession.

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

To determine any changes from the baseline data Explanation: 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 (emergency assessment). Evaluation is done after an intervention to determine whether the outcomes have been achieved.

What is the primary purpose of health assessment?

To gather information about the health status of the client Explanation: Health assessment is "gathering information about the health status of the client, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings, and evaluating client care outcomes" (AACN, 2011). Health assessment is not making judgments about a client's lifestyle; it does not involve care based on the nurse's views and beliefs, nor does it help the physician diagnose illness without further testing.

A nurse is interviewing a man complaining of a pain in his shoulder. The nurse asks him where exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen similar cases in other clients and recognizes that is likely from prolonged work at a computer, particularly using a mouse. Which of the following is the most effective use of inferring that the nurse might implement in this situation?

"Do you perform any sustained or continually repetitive motions with that arm?" Explanation: Inferring information from what the client tells you and what you observe in the client's behavior may elicit more data or verify existing data. Be careful not to lead the client to answers that are not true. The question, "Do you perform any sustained or continually repetitive motions with that arm?" is open enough to not lead the client to an expected answer but narrow enough for the nurse to help elicit more information from the client about probable causes of his pain. Recommending that the client change his posture while working at the computer is premature, as the nurse has not confirmed that the computer work is the culprit. Likewise, "You work at a computer a lot, don't you?" is a leading question, as it encourages the client to answer in the affirmative. The question, "When did the pain start?" is a close-ended question; it will elicit more information from the client but is not an example of inferring.

Which of the following data entries follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

"How do you manage your stress?" Explanation: To investigate the amount of stress clients perceive they are under and how they cope with it, ask questions that address what events cause stress for the client and how they usually respond. In addition, find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive.

A client states, "My wife died two months ago today." Which of the following responses would be most appropriate?.

"How does that make you feel?" Explanation: The client's statement about his wife's death provides the nurse with an opportunity to gather information about the client's current state. Asking the open-ended question, "How does that make you feel?" would be most appropriate to obtain key information. Asking what the wife died from is a closed-ended question that ignores the client's feelings. Telling the client that he probably feels sad is imposing the nurse's personal values on the client. Asking the client the laundry list of feelings would be demeaning and doesn't allow the client to put his feelings into his own words.

The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply.

"I feel so tired sometimes." Client complains of a headache "My father died of a heart attack." Explanation: Subjective data include information obtained from the client through interviewing and therapeutic communication skills and are sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Feeling tired, complaints of a headache, and the statement about the client's father dying of a heart attack reflect subjective information. Weight, lung sounds, and pupil reaction are examples of objective data.

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?

"I'm going to assess the client now so that I can begin formulating the care plan." Explanation: 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 assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?

"I'm sorry, but assessment is ongoing and continuous." Explanation: Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ongoing and continuous throughout all the phases of the nursing process.

A nurse who is new to the health clinic and who recently graduated from a nursing program tells a client at the end of an interview that data the nurse has just collected from the client needs to be validated. The client, an elderly gentleman, gives the nurse a strange look and says, "Validate my data? What does that mean?" How should the nurse respond to this client?

"It means I need to make sure that all the information I gathered today is reliable and accurate." Explanation: Validation of data is the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate. Validation does not mean that the nurse must retake all of the client's vital signs, have the physician check the patient's chart, or have the client sign a statement.

A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time?

"What diseases did you have as a child?" Explanation: Information covered in the personal health history section includes questions about birth, growth, development, childhood diseases, immunizations, allergies, medication use, previous health problems, hospitalizations, surgeries, pregnancies, births, previous accidents, injuries, pain experiences, and emotional or psychiatric problems. The question, "How do you feel about having to seek health care?" would be asked during the reason for seeking health care section of the interview. The question regarding the status of the client's parents would be posed in the family health history section. The question regarding what the client usually eats in a typical day would be included in the lifestyle and health practices profile section.

Which of the following questions is most useful in the assessment of a client's diabetes management?

"What is your routine for checking your blood sugar these days?"

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?]

"What other symptoms occurred during the spell?" Explanation: Examples of questions related to associated factors include the following: "What other symptoms occur with it? How does it affect you? What do you think caused it to start? Do you have any other problems that seem related to it? How does it affect your life and daily activities?" The question, "How bad was the tingling and numbness?" relates to severity. The question, "How long did the spell last?" relates to duration. The question, "Where did the numbness and tingling occur?" relates to location.

Upon entering an exam room, the client states, "Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!" Which response by the nurse would be most appropriate?

"You're certainly justified in being upset, but I am ready to begin your exam now." Explanation: When the nurse encounters an angry client, it is best to acknowledge the feelings of the client in a calm, reassuring, and in-control manner. Telling the client that the schedule is busy and that no one is forcing him or her to be there do not acknowledge the client's feelings. Inviting the client to "report your complaints to someone with power" deflects the complaint inappropriately.

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of Ongoing or partial Explanation: An ongoing, follow-up or partial assessment of the client consists of data collection that occurs after the comprehensive database is established. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data. In addition, a brief reassessment of the client's body systems and holistic health patterns is performed to detect any new problems. An initial comprehensive assessment involves collection of subjective data about the client's perception of own health of all body parts or systems, past health history, family history, and lifestyle and health practices. A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern and consists of a thorough assessment of a particular client problem, and does not cover areas not related to the problem. An emergency assessment is a very rapid assessment performed in life-threatening situations.

The result of a nursing assessment is the

Formulation of nursing diagnoses. Explanation: Analysis of data (often called nursing diagnosis) is the second phase of the nursing process. Analysis of the collected data goes hand in hand with the rationale for performing a nursing assessment. The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment data.

The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data?

Appearance Explanation: Appearance is something that can be directly observed by the nurse and is considered objective data. Present concern, family history, and occupation are considered subjective.

On a very busy day in the office, Mrs. Donelan, 81 years old, comes for her usual visit to check her blood pressure. She has been on a low-dose diuretic for many years and denies any side effects. Today, her blood pressure is 118/78 today, which is well-controlled. The client mentions that it is hard not having her husband Bill around anymore. What would the nurse do next?

Ask why Bill is not there. Explanation: Sometimes, the client's greatest need is for support and empathy. It would be inappropriate to ignore this comment today. The client may have relied heavily upon Bill for care, and may be in danger. She may be depressed and even suicidal, but the nurse will not know unless the topic is explored. Most importantly, the nurse should empathize with the client by saying something like "It must be very difficult not to have him at home" and allow a pause for her to answer. The nurse may also ask "What did you rely on him to do for you?" Only a life-threatening crisis with another client should take the nurse out of her room at this point; the nurse may need to adjust the office schedule to allow adequate time for her.

What is the foundation of nursing practice?

Assessment

A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following?

Avoid biases and judgments Explanation: Once the nurse has gathered some basic data about a client, he or she needs to reflect on personal feelings to ensure keeping an open mind and avoiding premature judgments that may alter the ability to collect accurate data and maintain objectivity. The other listed actions may be necessary, but none is accomplished through reflection.

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam?

Ensuring client's privacy by providing an examination gown Explanation: The client is usually concerned about unnecessary body exposure. Explanation and reassurance that the nurse will protect the client's privacy decreases this anxiety. Providing a comfortable, warm room temperature is appropriate to prevent chilling, but is usually less important to the client than privacy. Arranging exam equipment on a bedside tray table if within the view of the client may add to the client's anxiety. However, arranging the exam equipment would facilitate organization. Explaining why standard precautions are being used may help alleviate some anxiety, but the client probably will not understand what standard precautions are.

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation Explanation: The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and the nursing care plan needs to be revised. The assessment stage involves collecting subjective and objective data. The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment. The implementation phase involves carrying out the plan to meet the determined outcome criteria.

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine whether the client has achieved the outcome criteria of the treatment?

Evaluation Explanation: The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and whether the nursing care plan needs to be revised. The assessment stage involves collecting subjective and objective data. The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment. The implementation phase involves carrying out the plan to meet the determined outcome criteria.

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?

Focused

A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?

Focused assessment Explanation: The nurse would most likely perform a focused assessment, which is done when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A comprehensive assessment would have been done for this client when he or she first visited the office. An ongoing assessment would be done to evaluate problems identified earlier, to determine any changes. This might be the type of assessment done when the client returns after receiving treatment for the current complaints. An emergency assessment would be done if the client came in with a life-threatening complaint or problem.

A nurse is working on a unit for clients with neurological conditions. Which assessment form would the nurse most likely use to document assessment data?

Focused assessment form

A client with a foot wound returns to the outpatient wound clinic for a weekly appointment and treatment. Which type of assessment should the nurse complete with this client?

Follow-up Explanation: A follow-up history is a form of a focused assessment. The client is returning to have a problem evaluated after treatment. Data is gathered to evaluate if the treatment plan was successful. A focused or problem-oriented assessment focuses on the client's current problem. The client's symptoms, age, and this history will determine the extent of the physical examination to perform. A comprehensive assessment is completed when admitting a client to a facility.

A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the patient's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?

Making incorrect nursing judgments or diagnoses Explanation: Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the nursing process. Interjection of the nurse's thoughts or feelings may lead to bias or the withholding of information but would not necessarily result from a lack of a thorough and accurate assessment of a client. Nursing judgments should rely on both objective and subjective information; thus this is not an error. Validating information that is correct makes more work for the nurse but will not be prevented by a thorough and accurate assessment of a client.

Which of the following is the best example of assessment in everyday life?

Measuring the remaining tread on a car tire to determine whether it is time to replace it Explanation: As a professional nurse, you will constantly observe situations and collect information to make nursing judgments. This occurs no matter what the setting: hospital, clinic, home, community, or long-term care. You conduct many informal assessments every day. For example, when you get up in the morning, you check the weather and determine what would be the most appropriate clothing to wear. Measuring the remaining tread on a car tire to determine whether it is time to replace it is an example of assessment, as it involves gathering information (the height of the tire tread) to make a decision (whether to buy new tires). The other answers do not involve gathering information to make a decision.

How does a nurse decide what health-promotion activities are necessary for a particular client?

Nurses collaborate with clients to identify areas in which clients are willing to make changes Explanation: Rather than addressing all areas associated with healthy behaviors and overwhelming clients, nurses collaborate with them to identify areas in which clients are willing to make changes. When caring for a client, a nurse does not address healthy behaviors only; nurses do not address only areas where clients are willing to make changes, nor do they construct their own theories to identify perceptions, barriers, and positive outcomes.

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?

Nursing intervention Explanation: Nursing interventions are used to monitor health status; prevent, resolve, or control a problem; assist with ADLs; or promote optimum health and independence. Nursing goals are the client's desired outcomes. Nursing evaluation is deciding whether the nursing goals have been reached. Nursing assessment is an overview of the patient's health status and current problems.

When performing an assessment, which of the following would be most helpful in validating a client's chief complaint?

Objective data

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

Obtain and check needed equipment. Identify ways to ensure patient privacy. Wash hands. Explanation: Prior to conducting a physical examination of a patient, the nurse should obtain and check needed equipment, identify how to maintain patient privacy during the examination, and wash hands before beginning the examination. Having any additional noise in the background will make it difficult to obtain an accurate assessment. All environmental noise should be removed as much as possible. Good lighting is needed to ensure an accurate assessment. Dim lights can prevent getting a good visual of the area being assessed.

The nurse is exhibiting critical thinking in which client care situation?

Performing a focused assessment on a client who is complaining of shortness of breath. Explanation: The nurse investigating a client problem by performing a focused assessment is exhibiting critical thinking. Transcribing orders, calling a healthcare provider, and answering a call bell are not examples of critical thinking that entail outcome-directed thinking based on the nursing process.

Prior to a client interview, the nurse collects information from the client's medical record, such as prior surgeries, home medications, allergies, and past treatments. What phase of the interview process is this?

Preinteraction Explanation: Before meeting with the client, the nurse collects data from the medical record, including the previous history of medical illnesses or surgeries, current medication list, and problem list. The nurse uses this information to conduct an interview, already knowing about some of the past problems and responses to treatments. The beginning phase of the interview process is when introductions are exchanged and the nurse explains the purpose of the interview process. The working phase of the interview process is when data is collected from the client, either in subjective or objective form. The closing phase of the interview process is when the nurse summarizes the interview, assessing for any issues or concerns that need to be addressed either at that time, or in the future.

When recording the patient's reason for seeking care (chief concerns) during the health history, it is recommended that the interviewer:

Quote the patient's words Explanation: When recording the patient's reason for seeking care (chief concern), it is preferable to quote the patient's exact words whenever possible.

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason?

Reassess previously detected problems Explanation: A periodic partial assessment consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes from the baseline data. In addition, a brief reassessment of the client's normal body system or holistic health patterns is performed whenever the nurse or another health care professional has an encounter with the client.

Following completion of the comprehensive health assessment, the nurse periodically performs a partial assessment primarily for which reason?

Reassess previously detected problems Explanation: A periodic partial assessment consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on his or her health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes from the baseline data. In addition, a brief reassessment of the client's normal body system or holistic health patterns is performed whenever the nurse or another health care professional has an encounter with the client.

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Reduce all environmental noise. Explanation: Auscultating bowel sounds can be difficult because of environmental noise. The nurse should reduce all environmental noise and auscultate the bowel sounds again. The steps used to assess the abdomen are inspection, auscultation, percussion, and palpation. The techniques of percussion and palpation will cause the patient to experience bowel sounds and, therefore, should be performed after bowel sounds are auscultated. Assessment of the abdomen is best performed with the patient in the lying position.

A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact?

Reflex hammer Explanation: A reflex is used to assess deep tendon reflexes which are under the control of the neurologic system. A penlight is used to assess pupillary reflexes and aids with tangential lighting. A scoliometer measures the degree of spinal curvature. A pulse oximeter measures oxygen level.

A nurse in the ED is assessing an adult client who, the nurse suspects, has been beaten by her husband. What is the nurse's legal obligation in this situation?

Report it to the nurse's supervisor Explanation: When abuse is suspected, nurses are obligated to report it to a supervisor and obtain assistance from social work for further assessment. It is not necessary to call the police or counsel the client, but it is necessary to pursue the situation even if the client does not ask for help.

What would be the expected tone elicited by percussion of a normal lung?

Resonance Explanation: Resonance is noted with a normal lung. Hyper-resonance is noted in a lung with emphysema. Tympany is heard over air. Dullness is noted over solid tissue.

An older adult client is brought to the ED. The client tells the nurse, "I feel like something really heavy is sitting on my chest." The nurse then says to the client, "You feel as if something heavy is sitting on your chest?" Of what type of nurse-client communication is this an example?

Restatement Explanation: Restatement relates to the content of the communication. The nurse makes a simple statement, usually using the words of client. The purpose is to ask client to elaborate. Active listening is a communication skill where the listener uses both verbal context and nonverbal signals to interpret the message. Encouraging elaboration, also known as facilitation, uses therapeutic response from the listener to encourage the client to respond in more detail. Reflection is the summarizing of the main themes of the communication that occurred.

Jason, a 41-year-old electrician, presents to the clinic for evaluation of shortness of breath, which occurs with exertion and improves with rest. The shortness of breath has been occurring for several months. Initially, it happened only a few times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than 12 times a day. The shortness of breath lasts for fewer than 5 minutes at a time. The client has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. Which of the following symptom attributes was not addressed in this description?

Severity Explanation: The interviewer did not record the severity of the symptom, so we have no understanding as to how bad the symptom is for this client. The client could have been asked to rate his pain on a 0 to 10 scale or according to one of the other standardized pain scales available. This allows the comparison of pain intensity before and after an intervention.

During the review of systems, a client reports having difficulty with urination and with establishing an erection. Which additional information should the nurse recognize as the highest priority to assess at this time?

Sexual history Explanation: If the chief complaint involves genitourinary symptoms, include questions about sexual health as part of "expanding and clarifying" the client's story. Lifestyle, medication, and substance use can be contributing factors but gathering a sexual history is the priority action at this time.

A nurse has gathered the necessary equipment for the physical assessment of an adult client. It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement?

Skin lesion size Explanation: A centimeter scale rule most likely would be used to measure the size of a skin lesion. A flexible tape measure would be appropriate to measure mid-arm circumference. A vertical scale in inches or meters would be appropriate to measure a client's height. Pupil size is measured in millimeters.

A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?

Snellen chart Explanation: To check the client's distant vision the nurse should use the Snellen chart. An ophthalmoscope is used to view the red reflex and examine the retina of the eye. An opaque card is used to test for strabismus. A penlight is used to test pupillary constriction.

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic? Primary Explanation: Primary prevention involves strategies aimed at preventing problems. Immunizations, health teaching, safety precautions, and nutrition counseling are examples. • Secondary prevention includes the early diagnosis of health problems and prompts treatment to prevent complications. Vision screening, Pap smears, BP screening, hearing testing, scoliosis screening, and tuberculin skin testing are examples. • Tertiary prevention focuses on preventing complications of an existing disease and promoting health to the highest level. Diet teaching for patients with diabetes, inhaler teaching for patients with lung disease, and exercise programs for those who have had myocardial infarction are examples. A holistic approach to health care may be applied to all levels of interventions but is not a "level" of intervention itself.

An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary?

The client Explanation: Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client is considered the primary source and all others (including the client's medical record) are secondary sources. In some cases, the client's immediate family or caregiver may be a more accurate source of information than the client. An example would be an older adult client's wife who has kept the client's medical records for years or the legal guardian of a mentally compromised client. In any event, validation of the information by a secondary source may be helpful.

A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify?

The client's feelings of happiness Explanation: Subjective data are sensations, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Happiness is a feeling and therefore subjective. Posture, affect, and behavior are observable and are thus considered objective data.

During a health assessment, the nurse learns that an adolescent is sexually active. What information can the nurse provide the client in order to support the Healthy People 2020 indicator of responsible sexual behavior?

The importance of using a condom when engaging in sexual activity Explanation: An objective to support the Healthy People 2020 indicator of responsible sexual behavior is to increase the proportion of sexually active persons who use condoms. The nurse should instruct the patient about condom use with sexual activity. The objectives of Healthy People 2020 do not include promoting sexual abstinence. While diagnostic testing and reducing the percentage of adolescents diagnosed with HIV may be worthwhile goals, they are not identified as such by Healthy People 2020

Before beginning a physical assessment of a client, the nurse should first

Wash both hands with soap and water. Explanation: A general principle to keep in mind while performing a physical assessment includes washing hands before beginning the examination. If possible, wash hands in the examining room in front of the client. This assures the client that you are concerned about his or her safety.

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing what action?

Wearing gloves to palpate the tongue and buccal membranes Explanation: When adhering to standard precautions, the nurse would wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur. Safety pins should be disposed of in the sharps container. Gowns and masks are appropriate only if anticipated patient interaction indicates that contact with blood or body fluids may occur. Hand hygiene need not be performed between assessments of each system or body part.

A client comes to the office for evaluation of fatigue. He has come to the office many times in the past with various injuries, and the nurse suspects that the client has a problem with alcohol. Which of the following questions will be most helpful in diagnosing this problem?

When was your last drink? Explanation: "When was your last drink?" is a good opening question that is general and neutral in tone; depending on the timing, the nurse will be able to ask for more specific information related to the client's last drink. The other questions may close the conversation down because they are close-ended. Asking "Do you drink alcohol when you are supposed to be working?" implies negative behavior and may also keep the person from sharing freely.

During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved?

Working Explanation: During the working phase, the nurse collects data by asking specific questions. Two types of questions are closed-ended and open-ended. Each type has a purpose; the nurse chooses which type will help solicit the appropriate information. The pre-interaction phase is prior to meeting with the client. The nurse review the client's medical records to collect important data. The beginning phase is the phase when introductions are exchanged and the purpose of the interaction is explained to the client. The closing phase is a time for summarizing information shared with the client and assessing any learning deficits.

During a health history a client recalls the date when being first diagnosed with hypertension. Which term should the nurse use to categorize the quality of the client's data?

reliable Explanation: The client's memory is intact and would be considered reliable. The terms puzzling, concerning, and questionable would not apply because the client was able to provide an exact date.

An elderly patient arrives in the Emergency Department with nonspecific symptoms. When the nurse attempts to take the health history, the patient appears not to understand and does not answer the questions. The nurse realizes that this might be because of a common problem in the elderly, which is:

sensory deficits Explanation: Sensory deficits, such as loss of vision or hearing, might alter the history taking. Anorexia is loss of appetite, decubitus is an ulcer, and altruism is a true concern for the welfare of others. Only sensory deficits is a term that explains why the older patient cannot answer the questions during the health history.

The nurse conducts a health history with a client who reports having a dull headache over the past month. The client tells the nurse that using aromatherapy scents have helped manage the pain sometimes. This information is belongs to which attribute of a symptom?

treatment Explanation: The nurse should include any client reports of self treatment, such as alternative therapies, that the client has tried to alleviate the symptoms. This is captured within treatment. Associated manifestations refers to any other symptoms that accompany the chief report. The onset refers to when the headache started. Duration refers to the length of time the headaches last each time.

During an interview with an adult client, the nurse can keep the interview from going off course by

using closed-ended questions. Explanation: Use closed-ended questions to obtain facts and to focus on specific information. Closed-ended questions are useful in keeping the interview on course.