Assessing - Chapter 15 - PrepU

The nurse auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding? a) "This is a normal finding and nothing of concern." b) "We need to validate the information obtained in this assessment." c) "Crackles indicate that your child may have an allergy." d) "We will share this assessment finding with the physical therapist."

b) "We need to validate the information obtained in this assessment." The assessment of a toddler should involve the parents, as they are the primary caretakers and most knowledgeable about their toddler's normal behavior and development, as well as the history of any presenting symptoms. The nurse will validate assessment data to verify information and clarify cues and inferences to determine if they are accurate and free of bias. Crackles indicate the presence of fluid in the airways. Client information is shared only with those caregivers who have a need to know the information. Nurses have a duty to teach the parents about their toddler's symptoms.

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? a) Document that the client refused the interview. b) Administer prescribed pain medication prior to conducting the interview. c) Use the information that is on the electronic health record and eliminate the need for the interview. Inform the client that the interview must proceed before getting anything that will alter sensorium

b) Administer prescribed pain medication prior to conducting the interview. The nurse should make every effort to make the client comfortable prior to interviewing, including obtaining an prescription for and administering pain medication; if the pain persists, obtain only vital data and defer the remainder of the interview until the client is more comfortable. The information on the electronic health record is not inclusive of the subjective data from the client. The client is not refusing the interview, and the nurse can always come back later to complete it.

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

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

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? a) At the end of the data-gathering process b) Both during the collection and at the end of the collection c) During the collection of data only d) In the middle of the data-gathering process

b) Both during the collection and at the end of the collection. Not all data need to be validated, but the nurse may validate data during the collection or at the end of the data-gathering process. When it is clear that the data are correct, the nurse may analyze the data and formulate nursing diagnoses.

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

b) Collection, validation, communication of client data. Assessing is the systematic and continuous collection, validation, and communication of client data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem-focused, time-lapsed, and emergency-based describe types of assessments. Assessments are nurse-focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are.

The nurse notices during an assessment interview that the client cannot stay focused and jumps from one topic to another. The client also is speaking very rapidly and at times incoherently. What should the nurse suspect is the main cause of this behavior? a) Sleepiness b) High anxiety c) Hunger d) Pain

b) High anxiety. When a client speaks rapidly or incoherently and jumps from one topic to another, the cause is usually high anxiety. The nurse should normalize the anxiety and approach the client gently, speak softly and slowly, and maintain a good relationship so that the client will share what the client is experiencing. Pain is whatever the client states it is and may be characterized by location, duration, and intensity. Sleepiness would be indicated by nodding off or staring in the distance and hunger by lips smacking, gastric movement, and the client expressing hunger.

Which nursing skill uses all five senses? a) caring b) observation c) documentation d) listening

b) observation. Observation is the conscious and deliberate use of the five senses (sight, smell, hearing, taste, and touch) to gather data. Documentation uses sight (seeing the client's chart) and touch (typing on a keyboard or writing with a pen). Listening involves just hearing what the client is saying. Caring need not involve any of the senses but is displaying kindness and concern for others.

A physical examination on a client should always include which components? Select all that apply. a) Identification of health problems b) Establishment of a database for interventions c) Appraisal of health status d) Identification of the religion of the client and client's family e) Determination of the economic status of the client

Appraisal of health status, Identification of health problems and Establishment of data base for interventions. When conducting a physical examination, the nurse should include appraisal of health status, identification of health problems, and establishment of a database for interventions. The nurse should collect information regarding the client's religious preference and socioeconomic status, which is used in developing the plan of care, during the client's interview, not during the physical examination.

Which comprehensive assessment findings will the nurse identify as objective data? Select all that apply. a) A client's report of being unable to breathe. b) Breath sounds on auscultation c) A client's temperature d) laboratory test results e) A client's report of pain

Laboratory test results, Breath sounds on ascultation and A client's temperature. Objective data are those that the nurse can gathered from observation (e.g., posture, skin color, behavior), health records (e.g., laboratory test results, reports from other health care team members), and physical assessment (e.g., breath sounds, strength of extremities, blood pressure, temperature). Subjective data are those that only the person experiencing them can perceive and report, such as pain and a feeling of being unable to breathe.

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

a) "Client states, 'I don't see the point in trying anymore." Subjective data should be recorded using the client's own words, using quotation marks as appropriate. Paraphrasing the client's words may lead to assumptions and misrepresentations.

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

a) Adds depth to existing information. 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.

A client is receiving home care due to complex needs involving orthostatic hypotension. Which nursing intervention is a priority? a) Assess the client's blood pressure. b) Assess the client's medication regimen. c) Assess the client's diet. d) Assess the client's activity level.

a) Assess the client's blood pressure. The priority intervention for the client with an unstable blood pressure is to first measure the blood pressure. Once the nurse is certain that this is within safe parameters, the nurse should assess the client's diet, activity level, and medication regimen.

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case? a) Obtaining data regarding the amount and frequency of drinking b) Interviewing friends to ascertain the client's exercise habits c) Asking the client to discuss social functioning d) Performing an abdominal assessment

a) Obtaining data regarding the amount and frequency of drinking. A focused assessment is information that provides more details about specific problems and expands the original database. Obtaining data regarding the amount and frequency of drinking qualifies as a focused assessment. The other actions do not relate to the client's drinking habits or potential for alcohol overuse and thus would not be included in a focused assessment of these issues.

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? a) Supplement the client's information by speaking with family or friends. b) Obtain the client's records from admissions to other institutions. c) Perform the assessment in several short episodes rather than at one sitting. d) Limit the assessment to objective data.

a) Supplement the client's information by speaking with family or friends. 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.

A nurse is interviewing a new client admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview? a) The nurse assesses the client's comfort and ability to participate in the interview. b) The nurse asks the client if there is anything else that needs to be divulged c) The nurse recapitulates the interview, highlighting important points. d) The nurse gathers all the information needed to form the subjective database.

a) The nurse assesses the client's comfort and ability to participate in the interview. During the introductory phase of the interview, the nurse determines if the client is going to be able to participate in the interview. The highlighting of important points occurs in the termination phase of the interview. Ensuring the environment is comfortable and private occurs during the preparatory phase, and the gathering of information occurs during the working phase. Asking the client if any other information needs to be divulged occurs in the termination phase.

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? a) The nurse b) The case manager c) The health care provider d) The nursing supervisor

a) The nurse. The question focuses on independent actions that nurses can perform. Interventions for which the nurse may be legally responsible include increasing the frequency of assessments and initiating necessary changes in the treatment regimen. Nurses are responsible for alerting the appropriate professional (e.g., the health care provider) whenever assessment data differs significantly from the baseline. The nursing supervisor would be alerted if the professional does not evaluate the client. The case manager would be alerted when the client was ready for discharge.

The nurse is performing an admission assessment. Which are considered objective data? Select all that apply. a) Weight: 195 lb (89 kg) b) Height: 6 ft (1.82 m) c) 38-year-old man d) "I am afraid something serious is wrong." e) "My leg hurts."

a) Weight: 195 lb (89 kg) b) Height: 6 ft (1.82 m) c) 38-year-old man. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person being assessed. Age, vital signs, height, and weight are objective data. Subjective data are data that the client reports or feels and are usually documented in the record with quotations. The client statements "My leg hurts" and "I am afraid something serious is wrong" are subjective data.

The nurse is caring for a 14-year-old client who has just gave birth. The client reports living with an aunt and having no other family around. The birth was uncomplicated, and the newborn is healthy. Which is the primary nursing concern the nurse will identify for this client's care planning? a) altered parenting risk b) ineffective feeding pattern in the newborn c) acute pain d) ineffective breastfeeding

a) altered parenting risk. 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 newborn's feedings are not discussed in the scenario.

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply. a) caring b) number of years in profession c) professionalism d) competence e) respect for client

a) caring c) professionalism d) competence e) respect for client. 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 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? a) Document the findings on the chart and recheck in 1 hour. b) Notify the health care provider of the change and document the finding. c) Recheck the client's pulse at the next scheduled assessment time and document the findings on the chart. d) Recheck the client's pulse in 2 hours. e) Notify the health care provider after the next scheduled assessment time if the pulse is unchanged.

b) Notify the health care provider of the change and document the finding. 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 health care provider 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 health care provider.

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? Select all that apply. a) Respirations 18 breath/min and regular b) Redness and blisters forming on both legs c) Crying and trying to scratch legs due to itching d) 4-year-old at 85 percentile of growth and development e) Stating "My legs feel like they are burning"

b) Redness and blisters forming on both legs c) Crying and trying to scratch legs due to itching e) Stating "My legs feel like they are burning" 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.

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. a) The nurse collects and organizes data related to human response patterns. b) The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality. c) The nurse explores the client's perception of the client's major roles and responsibilities in life. d) The nurse assesses and collects data on the major body systems. e) The nurse collects data regarding the client's health perception and health management. f) The nurse clusters or organizes data according to a hierarchy of basic human needs.

b) The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality. c) The nurse explores the client's perception of the client's major roles and responsibilities in life. e) The nurse collects data regarding the client's health perception and health management. 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.

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? a) Inform the unlicensed assistive personnel to document the finding. b) Verbally report the finding immediately to the client's health care provider. c) Verbally report the finding to the charge nurse at the change of shift. d) Reassess the client's temperature in 2 hours and chart this data.

b) Verbally report the finding immediately to the client's health care provider. The nurse should report any abnormal assessment findings or changes in the client's health status to the client's health care provider or the charge nurse immediately for prompt and appropriate treatment of the health alterations. The unlicensed assistive personnel should not document the findings as this is the nurse's responsibility. The nurse should not just reassess the client's temperature in 2 hours and chart that data; immediate reporting of the data to the health care provider or charge nurse is necessary.

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being: a) complete b) able to prioritize c) purposeful d) factual

b) able to prioritize. It is essential to get the most important information first when doing an assessment. This is prioritizing. Being purposeful is when a nurse completes a task that has meaning for the client. Complete means that the information obtained is comprehensive. Factual is concerned with what is actually the case rather than interpretations of or reactions to a situation (for example, a diagnosis as opposed to a hunch).

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? a) emergency b) focused c) time-lapse d) initial

b) focused. 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.

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? a) unreliable b) objective c) physical d) subjective

b) objective. Objective data are data that are observable and measurable and can be seen, heard, felt, or measured by someone other than the client. Subjective data are information perceived only by the affected person. Physical and unreliable are not types of data.

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) Conducting a thorough systems review to validate data on the client's record b) A full assessment of the urinary system c) A focused assessment of the specific problems identified d) Obtaining a detailed assessment of the client's sexual history

c) A focused assessment of the specific problems identified. 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 scenario is an example of a time-lapse reassessment? a) A nurse just coming on shift performs a focused physical assessment on each client, based on the client's diagnosis. b) A nurse in a long-term skilled nursing facility assesses a new resident's baseline health status. c) A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before. d) Seeing a client down on the floor, the nurse assesses the client's airway, breathing, and circulation, calls for help, and begins a quick neurological exam.

c) A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before. The four types of assessment a nurse may perform are initial, focused, time-lapse, and emergency. A time-lapse reassessment is performed to reevaluate any changes in the client's health from a previous assessment. It is used to monitor the status of an already identified problem for a client with whom the nurse is already familiar. In this question the only scenario that depicts these components is that of the client with mobility issues. The assessment of the client who is found down on the floor is an emergency assessment. The assessment of each client based on the client's specific diagnosis is a focused assessment. The baseline assessment of the new resident in the long-term care facility is an initial assessment.

Which statement is true regarding addressing a priority problem? a) Addressing priority problems involves skipping interventions. b) The priority of problems is established and continued according to the nursing plan of care. c) A priority problem requires a nursing intervention before another problem is addressed. d) Priority problems are identified at predetermined intervals throughout the shift.

c) A priority problem requires a nursing intervention before another problem is addressed. A priority problem requires a nursing intervention before another problem is addressed, but addressing priority problems does not entail skipping any interventions. The priority of problems can change as a client's condition changes. There are no predetermined times or intervals at which to identify priority problems. This is why critical thinking plays a central role in nursing.

The nurse delegates vital signs to be taken and recorded by the unlicensed assistive personnel (UAP). The UAP reports a blood pressure of 191/110 mm Hg on a client. Which is the nurse's priority action? a) Review the client's medication list and notify the nursing supervisor. b) Notify the health care provider of the blood pressure result. c) Asses the client and re-evaluate the vital signs d) Direct the UAP to take the blood pressure in the other arm with a large cuff.

c) Asses the client and re-evaluate the vital signs. The nurse is responsible for all delegated tasks. When the blood pressure is grossly elevated, the nurse should assess the client, re-evaluate the blood pressure, and notify the health care provider if findings are abnormal. The nurse should re-evaluate the blood pressure, not the UAP. The nurse should assess and re-evaluate the blood pressure before notifying the health care provider. The nurse's priority is to assess the client and provide interventions accordingly, not to notify the supervisor.

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

c) Assess blood pressure with a large cuff. 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 has obtained a new client's nursing history. This will primarily allow the nurse to perform which of the following? a) Assist the health care provider to establish a medical diagnosis b) Focus on objective physical data specific to the client c) Identify actual and potential health problems d) Minimize the time required to establish a nursing concern for care planning

c) Identify actual and potential health problems. The purpose of the nursing health history is to identify the client's strengths and weaknesses; health risks, such as hereditary and environmental factors; and potential and existing health problems. This interview does not typically include physical assessment of a client. As part of the nursing assessment and overall nursing process, its purpose is not to influence time within the process. The health care provider's medical work-up provides the data to develop the medical diagnoses.

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse will do which of the following? a) Review literature pertinent to the client's attributes b) Assess personal feelings regarding similar clinical situations c) Inform the client of the maintenance of confidentiality d) Implement supportive nursing interventions

c) Inform the client of the maintenance of confidentiality. During the introductory phase, the nurse should inform the client how the information will be used and that confidentiality will be maintained. The alternate responses are not associated with this specific phase.

What should the nurse do prior to performing an initial assessment on a newly admitted client? a) Tell the client that the nurse will do an assessment only if it's convenient. b) Report to the charge nurse what needs to be done for the client. c) Review the records available on the client. d) Introduce the members of the health care team to the client.

c) Review the records available on the client. Records prepared by different members of the health care team provide information essential to comprehensive nursing care. The nurse should review records early when gathering data before the first contact with the client. This review helps to focus the nursing assessment and to confirm and amplify information obtained already. The other actions are not appropriate prior to performing an assessment. An assessment must be done whether it is convenient or not, for the appropriate care to be given.

The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source? a) The health care provider prescribes medication to help the client void. b) The nurse tells the client to attempt to void. c) The client tells the nurse that there is a burning sensation when voiding. d) The client's spouse reports the client experienced incontinence a few days ago.

c) The client tells the nurse that there is a burning sensation when voiding. Subjective data consist of information that only the client can describe, such as feelings, sensations, or experiences. An example of subjective data is a client's report of pain or fatigue. Objective data are those that can be measured and observed by others, a fever or a broken bone. The primary source is the client. Secondary sources include family members, reports, test results, and other health care providers.

A nurse practitioner in private practice with a health care provider is providing care to a client with a history of domestic violence. 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? a) Complete b) Emergency c) Time-lapse d) Focused

c) Time-Lapse. The four types of nursing assessment include complete, focused, time-lapse, and emergency. In time-lapse assessments, the nurse reassesses a client and condition that is already known to re-evaluate the client's status. In this case the nurse is revisiting the client's feelings and plans to change her life situation by leaving her abusive husband. In emergency assessments, the nurse assesses the client for life-threatening problems which are acutely present.. In focused assessments, the nurse focuses on assessing a specific problem that is already known to exist to further refine planning interventions. In complete (general or initial) assessments, the nurse does a thorough assessment of all aspects of a client's health status on the client's admission to a health care facility.

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? a) Focused assessment b) Emergency assessment c) Time-lapsed assessment d) Developmental stage assessment

c) Time-lapsed assessment. A time-lapsed assessment is scheduled to compare 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 are scheduled for this type of check. An emergency assessment is conducted if the client is having an emergency such as chest pain or hemorrhaging from the hand. Focused assessment is performed on clients focusing on the system or systems involved in the client's problem. Developmental stage assessment is the process of mapping a child's performance compared with children of similar age.

The nurse is admitting a new client. What action will the nurse prioritize to identify actual or potential health problems? a) communicate with the primary health care provider b) evaluate care implemented c) gather data from sources d) collaborate with the family

c) gather data from sources. The nursing process includes: assessment, diagnosis, planning, implementation, and evaluation. The first phase, assessment, is the collection of data to identify actual or potential health problems for nursing interventions. Each of the other listed actions are appropriate and necessary aspects of sound nursing care, but gathering data is the key activity in identifying problems.

A client rates their leg pain at 8/10 on a 10-point pain scale. What type of cue is the client's description of pain in the right leg? a) severe b) explanatory c) subjective d) objective

c) subjective. Cues may be signs (objective) or symptoms (subjective). Objective cues, called signs, are observable, perceptible, and measurable by someone other than the person experiencing them. Subjective cues, called symptoms, are only observable, perceptible, and measurable by the person experiencing them. The pain described by the client in this question is a subjective cue, as only the client is able to perceive it. Explanatory suggests that the client would offer an explanation or comparison to describe the pain in the right leg. Severe is an adjective that might be the equivalent of 8/10 on the pain scale as reported by the client.

A nurse is asking questions about a client's sexual history. Which is the best question for the nurse to ask to determine the client's use of safer sexual practices? a) "How many sexual partners have you had in the past 6 months?" b) "Do you use condoms?" c) "Are you in a committed relationship?" d) "How do you protect yourself when having sex?"

d) "How do you protect yourself when having sex?" An open-ended question is the best type to use to gather the most information. Asking how the client uses protection during sex will obtain information about safer sex practices. Asking how many sexual partners the client has had or if the client is in a committed relationship will not help to ascertain the information. Asking, "Do you use condoms" is a closed-ended, yes or no question that will not provide comprehensive information.

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

d) Avoid the impulse to interrupt. When doing an interview with a client, the nurse must listen actively for feelings, in addition to the verbal comments made by the client. The nurse should demonstrate patience if the client has a memory block and should avoid the impulse to fill in words or interrupt the client. Pauses in the conversation should be allowed, as silence gives both parties time to gather thoughts.

Which is the best source of information for the nurse when collecting data for an assessment? a) Charge nurse b) Medical record c) Primary health care provider d) Client

d) Client. 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 health care provider 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.

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? a) Ask if the client would like the door opened or closed when finished b) Concentrate on a focused assessment of the abdomen and leave the rest of the assessment for a later time c) Point out potential nursing care plan goals while assessing d) Explain the nurse will need to touch the client during the assessment

d) Explain the nurse will need to touch the client during the assessment. Some people of Chinese descent are modest about having their bodies touched and may see touching as an invasion into their personal space. The nurse should explain what will be done as the assessment progresses and strive to help the client feel as comfortable as possible. However, asking if the client would like the door left closed or opened, is not a priority before starting the assessment. It would be inappropriate to discuss various goals before the assessment is complete. All the information is needed to determine which goals will be most appropriate for each client. It may also be inappropriate to only conduct a focused assessment at this time, depending on the situation and the client. If there are other issues, they should also be evaluated, so that appropriate nursing goals can be determined and the client can receive the best care possible.

During the interview component of the health assessment, how does the nurse convey to the client that the information is important? a) Limiting questions to those with yes or no answers b) Standing next to the client while interviewing c) Nodding frequently during the interview d) Sitting at eye level with the client

d) Sitting at eye level with the client. When the client responds to a question, the nurse conveys interest by maintaining eye contact, occasionally nodding, or verbally responding to the client's remarks. This is best accomplished by selecting a seat at eye level to allow direct engagement with the client during the interview. Standing during the interview can limit the interaction between nurse and client. Questions should be open-ended to elicit the most information and engage the client. Yes or no (close-ended) questions do not encourage the client to provide the level of detail the nurse is attempting to collect.

During admission, an adolescent client who has a diagnosis of anorexia informs the nurse of a 5-pound weight loss within the last 6 months. What should the nurse do with this data? a) inform the client that this cannot be correct b) record in the client's record c) Ignore this information completely and continue collecting data. d) Validate the weight loss with the client.

d) Validate the weight loss with the client. When a client reports data that appear to be distorted, either intentionally or unintentionally, the nurse—to ensure accuracy—needs to continually verify and validate all data. It would not be appropriate to tell the client the data are not correct or to ignore the data, as doing either could undermine the client's trust in the nurse and/or cause conflict with the client. The nurse should not just document this information, as it needs to be validated.

A client comes to the emergency department with a stab wound and is bleeding profusely. Which type of assessment should the nurse perform on this client immediately? a) head-to-toe b) focused c) time-lapsed d) emergency

d) emergency.

The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first? a) palpitation b) auscultation c) percussion d) inspection

d) inspection. When the nurse performs a physical assessment, four techniques: inspection, palpation, percussion, and auscultation will be used. In most cases the nurse will perform them in sequence. Because palpation and percussion can alter bowel sounds, the nurse will inspect, auscultate, percuss, then palpate an abdomen.

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

d) objective. Reports of laboratory studies and other diagnostic tests are considered objective data, which can either confirm or refute other data collected during the nursing exam and history. Subjective data are about a client's feeling or what the client states. Primary data are collected by an investigator conducting research. Common sources of secondary data for social science include censuses, information collected by government departments, organizational records, and data that were originally collected for other research purposes.

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

d) pain. Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief. Sleepiness would be observed if the client did not respond in a timely manner. A client with low anxiety is relaxed and would answer the question with intention and thoughtfulness. A hungry client would be short-tempered and angry.

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

d) uses broad, open statements to communicate with the client. 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 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? a) Ignore the client's nonverbal behavior. b) Ignore the client's answer. c) Chart the data. d) Validate the data

d) validate the data. Data need to be validated when there are discrepancies (e.g., the client says there is no pain but the nonverbal behavior indicates that the client is experiencing pain). The nurse should not ignore the client's answer or the client's nonverbal behavior. The nurse should chart the assessment, but the priority is to validate the differences in the verbal communication and nonverbal behavior.

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? a) Palpating the skin for pain and temperature b) Reviewing past records for ultrasound. c) Measuring the pedal pulse d) Watching the client walk into room.

d) watching client walk into room. Observation is the first step of a physical examination. This is when the nurse watches the client to observe any subtle indications of a problem, watches body language to see how it corresponds to the verbal communication, and determines possible areas which will need a focused assessment as the initial assessment develops. Review of past records should occur before the physical assessment is conducted. Assessing the area for pain, temperature and pulse are methods used during palpation.