Chapter 14: Assessing

Which are examples of subjective data? Select all that apply. Anxiety Light-headedness Nausea Edema Laceration

Anxiety Light-headedness Nausea Rationale: Subjective data are those that only the person experiencing them can perceive and report, such as anxiety, light-headedness, and nausea. Objective data are those that someone other than the person experiencing them can observe, such as edema and laceration.

Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist? Medical history Progress notes Consultation Laboratory reports

Consultation Rationale: The client's physician may invite a specialist to assess and treat the client. The focus of this part of the record is additional findings related to the client's medical diagnosis and treatment; it is found in the section called "Consultation." Laboratory reports are related to the laboratory values of the client. Progress notes are the part of a medical record where health care professionals describe details to document a client's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. The medical history or case history of a client is information gained by a physician by asking specific questions, either of the client or of other people who know the person and can give suitable information.

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? Hierarchy of Human Needs Functional Health Patterns Human Response Patterns Body Systems Model

Hierarchy of Human Needs Rationale:Maslow uses a hierarchy of five sets of human needs to organize data with basic physiological needs, such as the need for oxygen, being the most urgent. Gordon's (1994) framework identifies 11 functional health patterns and organizes client data into these patterns. The human response patterns organize data according to human responses to interventions. A medical model used to organize data collection, with which all nurses are familiar, is the body systems model. This method organizes data collection according to organ and tissue function in various body systems.

An 18-year-old client is brought to the urgent care clinic reporting severe left leg pain. Which assessment(s) should the nurse prioritize for this client? Select all that apply. Pedal pulses Skin color Temperature of skin Tenderness to palpation Blood pressure

Pedal pulses Skin color Temperature of skin Tenderness to palpation Rationale: The nurse should conduct a focused assessment and concentrate on the left calf, prioritizing the absence pedal pulse, erythema, warmth, and tenderness. The blood pressure is also important but the priority is the initial focused assessment.

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

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

While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, "The client's hearing may be impaired on the right side." This statement is an example of: a cue. an inference. duplicate data. erroneous data.

an inference. Rationale: The judgment a nurse makes about a cue is known as an inference. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. The nurse can observe a cue directly, but not an inference. The key is the verb used —"hearing may be impaired." The statement is not erroneous or duplicate data.

During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should: clarify the client's health status. review as much information as possible. identify existing and potential health problems. develop the nursing plan of care

review as much information as possible. Rationale: The preparatory or preinteraction phase occurs when the nurse meets the client. The nurse should review as much information as possible about the client during this phase. It would be premature for the nurse to attempt to clarify the client's health status, identify nursing diagnoses, or develop a nursing care plan without having completed the client interview, nursing history, and nursing assessment, all of which happen later in the assessment process.