Exam 1 - Module 1 (Nurse's Role)

Amplitude of pulses: 0: 1+: 2+ 3+

0: Absent 1+ :Weak, diminished 2+ Normal 3+ Bounding (unable to obliterate because it is so strong)

The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first? A) Review the client's medical record. B) Obtain basic biographic data. C) Consult clinical resources explaining the client's diagnosis. D) Validate information with the client.

A) Review the client's medical record

A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify? A) The client's feelings of happiness B) The client's posture C) The client's affect D) The client's behavior

A) The client's feelings of happiness

What are nurses able to detect through the health assessment? Areas that need continuous care Areas that need in-hospital care Areas that need referral to a specialist Areas in need of health adjustments

Areas in need of health adjustments

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption? Review the client's medication administration record for analgesic use. Ask the client about the most recent experiences of pain. Meet with the client's spouse and daughter to discuss the client's pain. Collaborate with the physician who is treating the client.

Ask the client about the most recent experiences of pain

What is the first and most critical phase of the nursing process?

Assessment

What does the A in COLDSPA stand for? What questions would we ask?

Associated factors - What other symptoms occur with it? How does it affect you? What do you think caused it to start?

What does COLDSPA stand for?

C-character O- onset L- location D-duration S- severity P- Pattern A- Associated factors/how it affects the patient

While examining a client, the nurse plans to palpate temperature of the skin by using the... A. Palmar surface of hand B. Fingertips of hand C. Ulnar surface of hand D. Dorsal surface of hand

D - Dorsal surface of hand

What does the D in COLDSPA stand for? What questions would we ask?

Duration - E.g. How long does the pain last?

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? Initial Focused Ongoing Emergency

Ongoing - the initial report was already established when the patient came in given they arrived a day before

Equation for pulse pressure

SBP-DBP

What does the S in COLDSPA stand for? What questions would we ask?

Severity - How severe is the pain, rate it on a scale of 1-10

______________ data are sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified by the client

Subjective

T/F: Body function is an example of objective data directly observed by the examiner

True

What is considered light palpation?

less than 1cm

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? A. Body System B. Head to Toe C. Functional D. Focused

B - Head to Toe

Which of the following client situations would the nurse interpret as requiring an emergency assessment? A) A pediatric client with severe sunburn B) A client needing an employment physical C) A client who overdosed on acetaminophen D) A distraught client who wants a pregnancy test

C) A client who overdosed on acetaminophen

A nurse on the hospital's subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice? A) The focused assessment should be done before the physical exam. B) The focused assessment replaces the comprehensive database. C) The focused assessment addresses a particular client problem. D) The focused assessment is done after gathering subjective data.

C) The focused assessment addresses a particular client problem.

A nurse on a postsurgical unit is admitting a client following the client's cholecystectomy (gall bladder removal). What is the overall purpose of assessment for this client? A) Collecting accurate data B) Assisting the primary care provider C) Validating previous data D) Making clinical judgments

D) Making clinical judgments

What does the L in COLDSPA stand for? What questions would we ask?

Location - Where is the symptom located?

What does the O in COLDSPA stand for? What questions would we ask?

Onset - when did this symptom start?

Subjective vs. Objective Data

Subjective: Anything the patient states Objective: Anything we observe, measure

T/F: Family history gathered by the nurse during assessment is a major part of subjective data

True

What is the difference between a focused assessment and an initial comprehensive assessment?

A focused assessment focuses on one particular client problem/body system and doesn't cover areas NOT related to that specific area. An initial comprehensive assessment is more thorough and includes data about all their body parts, their PMH, family history, etc.

After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases? A) Assessment B) Planning C) Implementation D) Evaluation

A) Assessment

A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify? A) Expansion of health care networks B) Decrease in client participation in care C) The shrinking cost of medical care D) Public mistrust of physicians

A) Expansion of health care networks

A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is ìa bit sporadic. How should the nurse best respond to this assessment finding? A) Identify a nursing diagnosis of Ineffective Health Maintenance. B) Identify a collaborative problem that should involve the occupational therapist. C) Make a referral to the unit's social work department. D) Reassess the client's blood glucose level.

A) Identify a nursing diagnosis of Ineffective Health Maintenance.

An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession? A) Natural senses B) Biomedical knowledge C) Simple technology D) Critical pathways

A) Natural senses

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason? A) Reassess previously detected problems B) Provide information for the client's record C) Address areas previously omitted D) Determine the need for crisis intervention

A) Reassess previously detected problems

The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following? A) The client's motivation for change B) The client's medical comorbidities C) The client's learning style D) The client's prognosis for recovery

A) The client's motivation for change

Which actions should a nurse perform before beginning the initial shift assessment of a client? Select all that apply A. Gather assessment tools (thermometer, otoscope, stethoscope). B. Review the client's record C. Revise nursing care plans to reflect any change in the client's condition. D. Check the client's status with the nurse of the previous shift. E. Understand the client's knowledge of self-care based on documented age, education, and background. F. Educate yourself about the client's diagnosis or any prior tests performed.

A, B, D, F

The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply. A) "I feel so tired sometimes" B) Weight: 145 lbs C) Lungs clear to auscultation D) Client complains of a headache E) "My father died of a heart attack" F) Pupils equal, round, and reactive to light

A,D,E

The result of a nursing assessment is the A. Formulation of nursing diagnoses B. Client's physiological status C. Documentation or need for a referral D. Prescription of treatment

A. Formulation of nursing diagnoses

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen? Ask the client to bring all the medications and supplements to an interview. Ask the caregiver whether the client is taking prescribed medications. Ask the client to identify which medications taken every day. Ask the client about the use of any over-the-counter medications.

Ask the client to bring all the medications and supplements to an interview.

ADPIE

Assessment - collecting subjective AND objective data Diagnosis - analyzing subjective and objective data to make a judgment Planning - SMART goals Implementation - implement your plan Evaluation - what went well, what could be improved

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment? A) A 14-year-old girl who is crying because she thinks she is pregnant B) A 45-year-old man with chest pain and diaphoresis for 1 hour C) A 3-year-old child with fever, rash, and sore throat D) A 20-year-old man with a 3-inch shallow laceration on his leg

B) A 45-year-old man with chest pain and diaphoresis for 1 hour

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral? A) An 80-year-old client who lives with her daughter B) A 50-year-old client newly diagnosed with diabetes C) An adult presenting for an influenza vaccination D) A teenager seeking information about contraception

B) A 50-year-old client newly diagnosed with diabetes

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption? A) Review the client's medication administration record for analgesic use. B) Ask the client about the most recent experiences of pain. C) Meet with the client's spouse and daughter to discuss the client's pain. D) Collaborate with the physician who is treating the client.

B) Ask the client about the most recent experiences of pain.

A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment? A) Gastroenterologist B) ED nurse C) Admissions clerk D) Diagnostic technician

B) ED Nurse

In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation? A) Current physiologic status B) Effect of health on functional status C) Past medical history D) Motivation for adherence to treatment

B) Effect of health on functional status

The nurse is performing a health assessment on a community-dwelling client who is recovering from hip replacement surgery. Which of the following actions should the nurse prioritize during assessment? A) Focus the assessment on the client as a member of her age group. B) Interpret the information about the client in context. C) Corroborate the client's statements with trusted sources. D) Gather information from a variety of sources.

B) Interpret the information about the client in context.

The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process? A) Each step is independent of the others. B) It is ongoing and continuous. C) It is used primarily in acute care settings. D) It involves independent nursing actions.

B) It is ongoing and continuous.

The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data? A) Family history B) Occupation C) Appearance D) History of present health concern

C) Appearance

A nurse has documented the findings of a comprehensive assessment of a new client. What is the primary rationale that the nurse should identify for accurate and thorough documentation? A) Guaranteeing a continual assessment process B) Identifying abnormal data C) Assuring valid conclusions from analyzed data D) Allowing for drawing inferences and identifying problems

C) Assuring valid conclusions from analyzed data

A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following? A) Determine if pertinent data has been omitted B) Identify the need for referral C) Avoid biases and judgments D) Construct a plan of care

C) Avoid biases and judgments

A nurse has received a report on a client who will soon be admitted to the medical unit from the emergency department. When preparing for the assessment phase of the nursing process, which of the following should the nurse do first? A) Collect objective data. B) Validate important data. C) Collect subjective data. D) Document the data.

C) Collect subjective data.

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

C) Focused assessment

A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable? A) The client's age B) The unit's protocols C) The client's acuity D) The nurse's potential for liability

C) The client's acuity

The nurse has been applying the nursing process in the care of an adult client who is being treated for acute pancreatitis. Place the nurse's actions in their proper sequence from first to last. A) Identifying outcomes B) Determining client's nursing problem C) Collecting information about the client D) Determining outcome achievement E) Carrying out interventions

C,B,A,E,D

What does the C in COLDSPA stand for? What questions would we ask?

Characteristic- Describe the sign or symptom (feeling, appearance, sound, smell, or taste)

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment? A) Identify the most appropriate forms of medical intervention for the client. B) Determine the most likely prognosis for the client's health problem. C) Identify the status of the client's airway, breathing, and circulation. D) Establish a baseline for the comparison of future health changes.

D) Establish a baseline for the comparison of future health changes.

An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem? A) Encourage the client to increase oral fluid intake. B) Provide the client with a bedtime protein snack. C) Assist the client with personal hygiene. D) Measure the client's blood glucose four times daily.

D) Measure the client's blood glucose four times daily.

When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force? A) Documentation B) Informatics C) Diversification D) Technology

D) Technology

A nurse reviews the vital signs of a client... 800am: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air 1200pm: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air 1230pm: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next? A. Identify client concerns B. Implement an intervention C. Cluster client cues D. Evaluate the outcome

D. Evaluate the outcome because the nurse has already implemented an intervention

What is an ongoing or partial assessment?

Data collection that occurs AFTER the comprehensive database is established. Determines if there are any changes from the baseline data

A nurse completes an initial assessment and discusses findings with the client. What is the next best action of the nurse? Discuss lifestyle and health practices with the client. Develop a plan of care with the client. Perform a review of systems. Validate the client's biographical data

Develop a plan of care with the client.

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? Assessment Diagnosis Implementation Evaluation

Evaluation

T/F: An initial comprehensive assessment of the client consists of data collection that occurs after a comprehensive database is established

False -

It is important for the nurse to maintain a __________________on each client's context of their culture, family, and community when providing care

Focus

A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity. Which pieces of personal protective equipment should the nurse wear? Gloves, mask, protective eye goggles, gown Gloves, gown Mask, protective eye goggles, gown Mask, protective eye goggles

Gloves, mask, protective eye goggles, gown

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data? A) Inspection B) Therapeutic communication C) Interviewing D) Active listening

Inspection

What is the order of assessment in nursing?

Inspection, Palpation, Percussion, Auscultation

What does the P in COLDSPA stand for? What questions would we ask?

Pattern - Does anything relieve your symptoms, does anything make your symptoms worse?

In a hospital setting, who usually performs a total physical examination when the client is admitted?

Physician

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment? To collect subjective data related to the client's overall health To evaluate whether outcomes of treatment are met To determine any changes from the baseline data To perform a rapid assessment for prompt treatment

To determine any changes from the baseline data

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? To establish a database against which subsequent assessments can be measured To establish rapport with the client and family To gather information for specialists to whom the client might be referred To quantify the degree of pain a client may be experiencing

To establish a database against which subsequent assessments can be measured

T/F: The purpose of data analysis is to reach a conclusion on the client's health

True

T/F: The purpose of health assessment is to collect subjective and objective data to determine client's overall functioning

True

What is considered bimanual palpation?

Using two hands - one to apply pressure and the other to feel the structure

What is considered moderate palpation?

between 0.5-0.75 in

What is considered deep palpation?

between 2.5-5 cm (between 1-2 in)

What assessment is a very rapid assessment performed in life-threatening situations

emergency assessment