Ch. 1 + 5

"It determines your health status, risk factors and educational needs to develop a plan of care."

A client asks why a health assessment needs to be done. What should the nurse respond to this client?

Place on cardiac monitor.

A client presents to the emergency department complaining of new onset chest pain. What is the priority action of the nurse?

subjective data

A client with a 5-day history of constipation describes a sensation of "burning" in the perianal area. This information is considered which part of the assessment data?

continuous

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is

Nursing intervention

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?

Mental

As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife. How did you get into my house?". Based upon the client's behavior, which assessment will the nurse now focus upon?

Assessment

Data collection occurs where in the nursing process?

environmental

During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?

Nurses collaborate with clients to identify areas in which clients are willing to make changes

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

Shortness of breath

In which situation should a nurse perform an emergency assessment of a client?

validate information and judgments.

One characteristic of a nurse who is a critical thinker is the ability to

True

Subjective and objective data are both important parts of an assessment. Subjective data are things the patient or his or her family tells the nurse.

Primary

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

Subjective

The client has a headache. What type of data is this?

Objective

The client has a murmur. This is what type of data?

Review the client's prescribed medication orders.

The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action?

Increase in psycho-social stress

The nurse is completing an assessment of a patient who reports two episodes of fainting in the late afternoon. Which data would the nurse categorize as subjective?

seeing things as only right or wrong

The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning.

review the client's health care record.

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first

Assessing

Using both verbal and nonverbal clues given by the patient, what is the nurse constantly doing?

Clinical experience.

What can the nurse use to learn new information and add to their knowledge base?

Assessment

What is the foundation of nursing practice?

Collecting data regarding the nature of the pain

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

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings

Which of the following is the best example of holistic data collection by a nurse?

To achieve the best results

Why is the nurse always reassessing the patient for changes?

Actual Nursing Diagnosis

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a patient who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered?

Actual nursing diagnosis

The nurse has clustered assessment data on a patient with cirrhosis of the liver that has altered mental status due to the accumulation of ammonia toxins. What type of priority nursing diagnosis would be indicated for this patient?

Ask the client for opinions and willingness to proceed with the interventions.

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan?

discuss the plan with the patient

The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to

Analyze the data

The nurse has learned that after completing the assessment phase of the nursing process, the next step is the diagnostic phase. What does the diagnostic phase allow for the nurse to do?

Reassess blood pressure

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?

A focused assessment is more in-depth on specific issues, unlike a comprehensive assessment

The nurse is admitting a client to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment?

Objective

The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable?

Weight gain of 3 pounds (1.5 kilograms) over 1-2 days

The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client?

Performing a focused assessemt on a client who is complaining of shortness of breath.

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

Physical examination

The nurse is following a structured head-to-toe approach to identify changes in a patient's body systems. Which component of the health assessment is the nurse completing with the patient?

headaches began 3 days ago

The nurse is grouping subjective and objective data. Which data would the nurse list as subjective?

Wellness

The nurse is working with a 14-year-old girl who has told the nurse that she would like to try getting to bed a little sooner to get a full night's sleep and have more energy at school. The nurse diagnoses her with the following: Readiness for enhanced sleep related to client's expressed desire to go to bed earlier. Which type of nursing diagnosis is this?

Step Three--Draw Inferences

The nurse is writing down hunches about the patient that presents with a cluster of subjective and objective data. Which step of the diagnostic reasoning process is the nurse presently in?

Diagnostic reasoning skills are required to interpret data accurately.

The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step?

- Collection and organization of data - Validation of data - Documentation of data

The nurse recognizes the following to be a necessary component of performing an accurate assessment. (Select all that apply.)

Follows a Kosher diet

The nurse reviews data collected while completing a comprehensive assessment with a client. Which information should the nurse identify as being subjective data?

take a complete health history

The nurse tells a newly admitted patient that she is going to do a health assessment to help in planning care and educational needs during the patient's hospital stay. Before the physical examination, the nurse should first

Functional

The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students know that this type of information is assessed in what type of assessment?

- Be nonjudgmental and keep an open mind. - Use rationale to support opinions or decisions. - Acquire an adequate knowledge base that continues to build.

The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.)

Patients do not need to understand their problems.

The nursing student demonstrates a need for further teaching when she states which of the following?

Head-to-toe

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

formulation of nursing diagnoses.

The result of a nursing assessment is the

Assess the growth and development chart that provides the standards.

The school nurse is assessing height and weights for the 4th grade students. She is unsure if one of the students meets the standard for growth. What should the nurse do to validate the information she obtained?

Comprehensive

This type of assessment includes a health history and physical assessment.

check for the presence of defining characteristics.

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next

To gather information about the health status of the client

What is the primary purpose of health assessment?

a healthy lifestyle

When answering questions about health during a presentation at a women's club luncheon, the nurse emphasizes that prevention of disease is multifaceted but is connected directly to

A nursing diagnosis handbook

When checking defining characteristics to choose the most accurate nursing diagnosis, the best reference text for the nurse to use is which of the following?

Identify in what areas the patient needs the most care

When doing an overall assessment of a patient, the nurse is able to utilize findings and do what?

collaborative problem

When the nurse knows after drawing an inference that there is a need for both medical and nursing interventions, the patient's problem is which type?

Body functions

Which assessment finding should the nurse document as objective data?

timing

Which factor would assist the nurse in determining how to cluster clinical data into a single problem for a 65-year-old male client with a chief report of lower back pain?

Measuring the remaining tread on a car tire to determine whether it is time to replace it

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

Collect subjective and objective data related to overall function.

A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility?

The client's pain level

A nurse is working with a client who has AIDS. Which of the following is an example of subjective data that might be gathered for this client?

intuition

A nurse is working with a patient who has a history of chronic obstructive pulmonary disease (COPD). While bathing the patient, the nurse senses that something is not quite right and takes the patient's vital signs and obtains an oxygen saturation reading. The nurse is acting on which of the following?

Ongoing

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?

perform a physical examination

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history?

nursing diagnosis

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following?

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

What is one way nurses use critical thinking in regard to the nursing process?

"It was done to validate the reading."

A client asks why a nurse measured the blood pressure after the nursing assistant completed the measurement a few minutes ago. What should the nurse respond to the client?

Make a referral to the dietician.

A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse?

"It's acceptable for a client to admitted for observation."

A client is admitted for observation after complaining of chest pain. A 12-lead electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge about whether the client can be observed or should be sent home because the ECG is normal. What is the charge nurse's best response?

"I'm going to assess the client now so that I can begin formulating the care plan."

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?

- Who will be there to help the client with ADLs? - How will the client get home from the hospital? - How will the client cook and eat?

A client on the orthopedic unit is being discharged home. The client is elderly and has a broken right humerus; the client is right handed. The client's closest family member lives 50 miles away. What should the nurse consider before discharging the client? Select all the apply. (select all that apply.)

Itchy feeling

A client presents to the clinic with reports of an itchy rash all over the body. The nurse observes lesions on the client's arms and legs as well as the presence of a dry, hacky cough and sneezing. Which data collected from the client can be classified as a subjective abnormal finding?

Unable to feel his leg

A client presents to the emergency department following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states he cannot feel his leg. The nurse notes that the client is lethargic and mildly confused. What subjective data should the nurse document on this client?

Comprehensive

A client presents to the health care facility with reports of new onset of chest pain of 3 days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse to perform for this client?

Medication reconciliation

A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission?

A referral

A community health nurse provides information to a patient with newly diagnosed multiple sclerosis for a support group at the local hospital for patients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following?

An elderly woman who needs daily therapy sessions to help her walk again after a hip fracture

A nurse interacts with four different clients one afternoon at the health clinic. The nurse is able to directly assist three of them and makes a referral for the fourth. Which of the following patients should the nurse refer to another professional?

Objective

A nurse is admitting a client, having completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data?

"I'm sorry, but assessment is ongoing and continuous."

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?

Hospice

A nurse is assessing the social and spiritual needs of a client who is terminally ill with pancreatic cancer and living at home. This nurse most likely works in which of the following settings?

Making incorrect nursing judgments or diagnoses

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?

The client's range of motion in her right arm

A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data?

Exploring many alternatives before making a decision

A nurse is performing a self-assessment of ability to think critically, making a list of characteristic behaviors. Which of the following behaviors would indicate critical thinking?

Formation of judgments that may interfere with the interview

A nurse is preparing to interview a client who is a Seventh Day Adventist. The nurse does not agree with this religion's view of modern medicine. Reflection of the nurse on her personal feelings regarding this patient and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation?

Empathy

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?

Schedule a dietary consult.

A nurse is teaching a patient newly diagnosed with diabetes about diet and the exchange list. After several teaching sessions, the patient continues to be confused and not sure about what to eat. The nurse's next best action is which of the following?

Complete health history

A nurse performs a comprehensive assessment on a client. Which is included only in a comprehensive assessment?

Overlooking consideration of the clients cultural background

A nurse provided dietary counsel for a client who recently immigrated to the United States from Japan. During the initial interview, the client had his eyes lowered and did not make eye contact with the nurse. In analysis of the data, the nurse wrote down the following hunch: "risk for imbalanced nutrition related to client's unwillingness to listen to dietary advice." At the next meeting with the client a month later, however, the nurse was surprised to find that the client had adopted all recommended changes from their initial interview. Which error did the nurse commit in this case?

Evaluation

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?

To determine any changes from the baseline data

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?

Ongoing or partial

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?

To establish a database against which subsequent assessments can be measured

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

"All patients have the same defining characteristics."

A nursing instructor is teaching about diagnostic reasoning and the importance of culture. The student needs further explanation when making which statement?

wellness diagnosis

A nursing student demonstrates understanding of the different types of nursing problems when choosing the following to indicate that the patient has the opportunity for an enhanced health state:

Anxiety related to lesions on body

A patient comes to the clinic for a yearly physical examination. The assessment reveals multiple lesions on the face, neck, arms, and legs. The patient appears upset, starts to cry when questioned about the skin abnormalities, and asks the nurse if the problem is skin cancer. What would be the best nursing diagnosis for this patient?

Collaborative problem

A patient has 3+ pitting edema, crackles in lungs, and dyspnea. The nurse is monitoring the patient's vital signs and O2 saturations, and the physician has prescribed 40 mg of intravenous Furosemide (Lasix). What type of problem is this considered?

Airway

A patient is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the patient?

the statement of feeling "hot"

A patient who is 2 days postoperative reports feeling "hot." The nurse takes vital signs and the patient's temperature is 100 degrees F. The other vital signs are as follows: BP 120/80, pulse 82, respirations 18, oxygen saturation 100%. Which of the following is subjective?

implementation

A patient who is 2 days postoperative reports pain and requests pain medication. After assessing the patient's pain level, the nurse decides to give the patient oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process?

A baseline for comparison with future findings

A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides?

"Basic care and comfort assessments are included in nursing practice."

A student nurse tells the clinical instructor that a staff nurse suggested not focusing on the basic care assessments, only on the registered nurse scope of practice. What the nursing instructor's best response to the student?