Assessing Ch 14 (Fundamentals)

What must the nurse do to identify actual or potential health problems? meet with significant others evaluate care implemented call the physician gather data from sources

gather data from sources

The purpose of obtaining a nursing history is to: minimize the time required to establish a nursing diagnosis. assist the physician to establish a medical diagnosis. identify actual and potential nursing diagnoses. focus on objective physical data specific to the client.

identify actual and potential nursing diagnoses.

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. reassures the client of good outcomes. 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.

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 makes statements indicating a loss of hope." "Client states that his rehabilitation will be unsuccessful." "Client states, 'I don't see the point in trying anymore.'" "Client is demonstrating signs and symptoms of depression."

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

Which statement made by the nurse indicates data that would be documented as part of an objective assessment? "The client's right leg is cold to the touch, from the knee to the foot." "The client reports eating all of today's breakfast." "The client's sister reports that the client has unrelieved pain." "The UAP reports blood in the client's stool."

"The client's right leg is cold to the touch, from the knee to the foot."

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. Weight: 195 lb (89 kg) Height: 6' (1.82 m) "I am afraid something serious is wrong". 38-year-old man "My leg hurts."

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

Nurses collect objective and subjective data during the client interview. Which client data is subjective data? Select all that apply. A client's blood pressure is elevated following physical activity. A nurse observes a client wringing her hands before signing a consent for surgery. A client feels nauseated after eating his breakfast. A nurse observes redness and swelling at an IV site. A client reports being cold and requests an extra blanket. A client describes his pain as an 8 on the pain assessment scale.

A client describes his pain as an 8 on the pain assessment scale. A client feels nauseated after eating his breakfast. A client reports being cold and requests an extra blanket.

The nurse has identified a priority problem on her unit. Which statement is true regarding addressing a priority problem? Setting priorities involves skipping interventions. The physician is responsible for determining priority of client needs. Priority of problems is established and continued according to the nursing plan of care. Priorities are set at predetermined intervals throughout the shift. A priority problem requires a nursing intervention before another problem is addressed.

A priority problem requires a nursing intervention before another problem is addressed.

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 a focus assessment? Provides breadth for future comparisons Suggests possible problems Gives a comprehensive volume of data Adds depth to existing information

Adds depth to existing information

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview? Inform the client that the interview must proceed before getting anything that will alter sensorium Administer prescribed pain medication prior to conducting the interview Use the information that is on the electronic health record and eliminate the need for the interview Document that the client refused the interview

Administer prescribed pain medication prior to conducting the interview

Which client situation most likely warrants a time-lapse nursing assessment? The nurse has responded to the call light of a hospital client who is reporting shortness of breath and chest pain. An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. 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.

The nurse is conducting an interview with a newly admitted client. Which listening behavior guideline should the nurse implement in order to have a successful interview? Fill in quiet spaces and pauses. Avoid the impulse to interrupt. Fill in the words for the client. Focus mainly on verbal comments.

Avoid the impulse to interrupt.

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? At the end of the data-gathering process Both during the collection and at the end of the collection In the middle of the data-gathering process During the collection of data only

Both during the collection and at the end of the collection

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. Tell the client the questions will be quick. Carefully review the client's record.

Carefully review the client's record.

A nursing student is learning about how to perform a thorough assessment in a health assessment class. Which of the following is the best source of information for the student to learn data collection for an assessment? Medical record Client Charge nurse Primary physician

Client

An assessment involves gathering pieces of information about a client's health status. Which piece of information is subjective? Client has leukoplakia on her oral mucosa. Client has ptosis, a drooping of the eyelid, on his right side. Client has generalized myalgia or muscle pain. Client has a temperature of 102°F. Client is alert and oriented to person and place but not time or situation.

Client has generalized myalgia or muscle pain.

A nurse is assessing a client admitted to the hospital with reporting left-sided weakness and difficulty speaking. Which assessment contains the data that best represent a nursing assessment? Brain scan shows evidence of a clot in the middle cerebral artery. Client is unable to communicate basic needs and cannot perform hygiene measures with left hand. Neurologic examination reveals partial paralysis and aphasic speech. Left-sided weakness and speech deficit indicate probable stroke.

Client is unable to communicate basic needs and cannot perform hygiene measures with left hand.

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply. Ecchymosis on upper left arm Clothes unkempt and hair greasy Blood pressure 140/82 mm Hg Client states, "I feel so sad all of the time." Client states, "I am in pain."

Client states, "I feel so sad all of the time." Client states, "I am in pain."

Which group of terms best defines assessing in the nursing process? Collection, validation, communication of client data Nurse-focused, establishing nursing goals Problem-focused, time-lapsed, emergency-based Design a plan of care, implement nursing interventions

Collection, validation, communication of client data

A client who is bleeding profusely from a stab wound is brought to the emergency department. Which type of assessment is most appropriate for this client? Emergency Time-lapse Initial Focused

Emergency

An older adult male with a history of benign prostatic hyperplasia (BPH) presents to the emergency room with reports of urinary retention. The nurse collects data related to the client'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? Initial Focused Emergency Follow up

Focused

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

Focused assessment

The nursing instructor is teaching about the different models used in nursing to assist in clustering data. Which models should the instructor include during the teaching session? Select all that apply. Change Theory Model Functional Health Patterns Model Body Systems Model Human Needs Model Human Response Model

Functional Health Patterns Model Body Systems Model Human Needs Model Human Response Model

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

The nurse is assessing a 3-week-old infant. Which of the following assessment findings would define the priority nursing diagnosis for this patient? The infant has not gained weight since birth. Bowel sounds are present in all quadrants. Breath sounds are clear to auscultation. Mom reports child cries much of the night but sleeps better in the daytime. Mom reports child only breastfeeds about four times in a 24-hour period and she doesn't seem to have much milk. Ineffective Breastfeeding Risk for Impaired Parenting Readiness for Enhanced Parenting Disturbed Sleep Pattern Impaired Comfort

Ineffective Breastfeeding

A 50-year-old male is admitted for removal of a cancerous tumor of his lung. He tells the RN he is worried about how the cancer and the treatment will affect his family. He explains his wife has never worked outside the home and he is concerned their financial situation will be compromised by his illness. Which of following would be the best nursing diagnosis for this patient? Risk for Loneliness Death Anxiety Chronic Low Self-Esteem Interrupted Family Processes Impaired Social Interaction

Interrupted Family Processes

The nurse must be familiar with the client record in order to provide care effectively. Which parts of the client record include only the findings of physicians? Select all that apply. Laboratory values Progress notes Care plan Physical exam Medical history

Medical history Physical exam Progress notes

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? Subjective Unreliable Physical Objective

Objective

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

Observation

The nurse is conducting a client interview and notices that the client answers every questions with a "yes" or "no" response. What is most likely the cause of this action by the client? Low anxiety Hunger Pain Sleepiness

Pain

When assessing the client's pulse, the nurse should us which assessment technique? Palpation Inspection Auscultation Percussion

Palpation

The nurse is caring for a 14-year-old adolescent who has just delivered her first baby girl. The adolescent states that she lives with an aunt and has no other family around her. The delivery was uncomplicated and the newborn is healthy. Which of the following would be the primary nursing diagnosis for this patient? Acute Pain Ineffective Breastfeeding Risk for Impaired Parenting Risk for Loneliness Ineffective Infant Feeding Pattern

Risk for Impaired Parenting

A client 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? Objective Subjective Explanatory Severe

Subjective

The 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? The client's health status can change quickly. Most facilities require it for reimbursement. It makes the client feel as if the nurse is spending more time with him or her. It gives the nurse more information to document on the client.

The client's health status can change quickly.

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 nursing supervisor The nurse The case manager The physician

The nurse

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 mm Hg. This is a significant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the physician? The charge nurse The client The nurse The supervisor

The nurse

While performing an assessment, the nurse recognizes that his own personal biases may be interfering with the collection of data. What step should the nurse take to assure the information is factual and accurate? The nurse should inform the client of these potential biases and obtain the client's opinion. The nurse should verify the information with one or two family members without informing the client. The nurse should consult with another nurse for that colleague's description of the assessment or observations. The nurse should document on the client's chart that the assessment data may be biased.

The nurse should consult with another nurse for that colleague's description of the assessment or observations.

The nursing instructor is teaching the students how to do an interview on a client. Which statement made by a student indicates a need for further instruction? The nurse should verify the client's name. The nurse should sit on eye level with the client. The nurse should introduce herself and give name and position. The nurse should ask the client what name they would like to be called. The nurse should show the name badge to the client so they can identify the nurse.

The nurse should show the name badge to the client so they can identify the nurse.

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, the client 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? Complete Time-lapse Emergency Focus

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 Developmental stage assessment Focused assessment Emergency assessment

Time-lapsed assessment

While doing an assessment, the nurse identifies questionable data. Which of the following should the nurse do first? Disregard the questionable data. Inform the physician of the questionable data. Inform the client that the data are not correct. Validate the questionable data.

Validate the questionable 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 39.4°C (103°F). What should be the nurse's priority action? Reassess the client's temperature in 2 hours and chart this data. Inform the unlicensed assistant personnel to document the finding. Verbally report the finding immediately to the client's physician. Verbally report the finding to the charge nurse at the change of shift.

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

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 39.4°C (103°F). What should be the nurse's priority action? Verbally report the finding to the charge nurse at the change of shift. Inform the unlicensed assistant personnel to document the finding. Reassess the client's temperature in 2 hours and chart this data. Verbally report the finding immediately to the client's physician.

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

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: being complete. being factual. being able to prioritize. being purposeful.

being able to prioritize.

A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method? presence of peristalsis pupil reaction skin temperature size of the liver

presence of peristalsis

During the interview component of the health assessment, how does the nurse convey to the client that the information is important? standing next to the client while interviewing nodding frequently during the interview limiting questions to those with yes or no answers sitting at eye level with the client

sitting at eye level with the client

During the interview component of the health assessment, how does the nurse convey to the client that the information is important? limiting questions to those with yes or no answers nodding frequently during the interview standing next to the client while interviewing sitting at eye level with the client

sitting at eye level with the client

A nursing student is assisting with taking health histories of all clients. The student identifies when is the best time to do a health history? As soon as possible after a client presents for care After the client is settled and feels ready WIthin 24 hours of admission Anytime before the client is discharged

As soon as possible after a client presents for care

During the nursing examination, the nurse notices that the client, an older adult 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? Wait until the next day to obtain the answers to the interview questions. Ask the client if it is okay to interview her husband for the answers to the interview questions. Ask the client to wake up and try to answer the interview questions. Ask the client's husband to come in and answer the interview questions.

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

During the nursing examination, the nurse notices that the client, an older adult 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 client to wake up and try to answer the interview questions. Ask the client if it is okay to interview her husband for the answers to the interview questions. Wait until the next day to obtain the answers to the interview questions. Ask the client's husband to come in and answer the interview questions.

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

Which quality does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply. Number of years in profession Competence Caring Professionalism Respect for client

Competence Caring Professionalism Respect for client

After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data? Body Systems Model Functional Health Patterns Hierarchy of Human Needs Human Response Patterns

Hierarchy of Human Needs

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 side of the bed. If the client is in bed, the nurse stands at the foot of the bed. If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to 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.

The nurse is caring for a 14-year-old adolescent who has just delivered her first baby girl. The adolescent states that she lives with an aunt and has no other family around her. The delivery was uncomplicated and the newborn is healthy. Which of the following would be the primary nursing diagnosis for this patient? Ineffective Infant Feeding Pattern Risk for Loneliness Risk for Impaired Parenting Ineffective Breastfeeding Acute Pain

Risk for Impaired Parenting

The nurse is assessing a man in an outpatient setting. Which of the following assessment findings would lead to the priority nursing diagnosis for this client? Client states,"I don't want to live anymore. My family hates me and I am so tired of being sick. I have a gun and I am seriously thinking of killing myself." The patient reports a 30-year heavy smoking habit and having a cough for about six months. Ascultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminshed bowel sounds. His lips are slightly bluish in color. Ineffective Health Maintenance Impaired Gas Exchange Risk-Prone Health Behavior Risk for Suicide Stress Overload

Risk for Suicide

When performing an assessment, the nurse should focus on the developmental stage for which client? Young adult Toddler Adolescent Middle-age adult

Toddler

The nursing instructor is teaching the students about assessments. Which traits does the instructor list as being most important in order for an assessment to be successful? Trust and confidence Competence and forceful Enthusiastic and aggressive Low-key and timid

Trust and confidence

During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should: assess personal feelings regarding similar clinical situations. inform the client of the maintenance of confidentiality. review literature pertinent to the client's attributes. implement supportive nursing interventions.

inform the client of the maintenance of confidentiality.