health assessment I (nursing data collection, documentation and analysis)

Identify the following items as subjective (S) or objective (O). 1. Describes severe right-sided headache 2. Reddened, raised, indurated area on deltoid area of left arm 3. Cannot eat seeds or uncooked grains without abdominal discomfort 4. Passing flatus 5. Bowel sounds present in all four quadrants 6. Complains of lower back pain on movement 7. Pattern of request for pain medication every 2 hours 8. Pale, clammy, and diaphoretic 9. Feels nauseated and dizzy 10. Emesis of 200 mL light beige thin liquid

1. S 2. O 3. S 4. O 5. O 6. S 7. O 8. O 9. S 10. O

. A nursing diagnosis that indicates the client is currently experiencing the stated problem or has a dysfunctional pattern

Actual nursing diagnosis

. Diagnostic phase of the nursing process

Analysis of data

Smaller end of the stethoscope used to detect low-pitched sounds (abnormal heart sounds and bruits)

Bell of stethoscope

. The fact or condition of knowing something with familiarity gained through experience or association

Cognitive abilities

. Certain physiologic complications that nurses monitor to detect their onset or change in status

Collaborative problem

. The way in which one processes information using knowledge, past experience, intuition, and cognitive abilities to formulate conclusions or diagnoses

Critical thinking

Larger end of the stethoscope used to detect breath sounds, normal heart sounds, and bowel sounds

Diaphragm of stethoscope

Part of the examiner's hand used to feel for temperature

Dorsal surface of hand

Part of the examiner's hand used to feel for fine discriminations: pulses, texture, size, consistency, shape, and crepitus

Fingerpads

. Quick and ready insight

Intuition

. Aptitude involving the act or process of knowing, including both awareness and judgment

Knowledge

Back-lying position with hips at the edge of the examining table and feet supported in stirrups; used for examination of female genitalia, reproductive tract, and rectum

Lithotomy position

Client lies on the abdomen with the head turned to the side; may be used to assess back and mobility of the hip joint

Prone position

. A nursing diagnosis that indicates the client does not currently have a problem but is at high risk for developing it

Risk nursing diagnosis

Side-lying position used during the rectal examination

Sims' position

Position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities

Sitting position

Position used to examine male genitalia and to assess gait, posture, and balance

Standing position

Back-lying position used for examination of the abdomen (with one small pillow under the head and another under the knees); this position also allows easy access for palpation of peripheral pulses

Supine position

Part of the examiner's hand used to feel for vibration, thrills, or fremitus

Ulnar surface or palm of hand

. A nursing diagnosis that indicates the client has an opportunity to enhance a health status

Wellness nursing diagnosis

. An assessment form commonly used in long-term care facilities is the nursing minimum data set. One primary advantage to this type of assessment form is that it a. establishes comparability of nursing data across clinical populations. b. clusters all the nursing and medical diagnoses in one place. c. allows for individualization for each client in the health care setting. d. uses a flowchart format for easy documentation of objective data.

a

. The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write a. "Bilateral lung sounds clear." b. "The client's lung sounds were clear on both sides." c. "Client's lung sounds were auscultated with stethoscope and were clear on both sides." d. "After listening to client's lung sounds, both lungs appeared clear."

a

. The nurse is caring for an adult client who tells the nurse "For weeks now, I've been so tired. I just can't get to sleep at night because of all the noise in my neighborhood." An actual nursing diagnosis for this client is a. fatigue related to excessive noise levels as manifested by client's statements of chronic fatigue. b. sleep deprivation related to noisy neighborhood and inability to sleep. c. chronic fatigue syndrome related to excessive levels of noise in neighborhood. d. readiness for enhanced sleep related to control of noise level in the home.

a

. The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should a. validate all data before documentation of the data. b. document the data after the entire examination process. c. record the nurse's understanding of the client's problem. d. use medical terms that are commonly used in health care settings.

a

. The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form a. prevents missed questions during data collection. b. covers all the data that a client may provide. c. clusters the assessment data with nursing diagnoses. d. establishes comparability of data across populations.

a

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's a. physiologic status. b. holistic wellness status. c. developmental history. d. level of functioning.

a

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is a. continuous. b. completed on admission. c. linear. d. performed only by nurses.

a

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to a. arrive at conclusions about the client's health. b. document any physical symptoms the client may have. c. contribute to the medical diagnosis. d. validate the data collected.

a

Before beginning a physical assessment of a client, the nurse should first a. wash both hands with soap and water. b. determine whether the client is anxious. c. ask the client to remove all clothing. d. request a family member to be present.

a

During a client interview, the nurse uses nonverbal expressions appropriately when the nurse a. avoids excessive eye contact with the client. b. remains expressionless throughout the interview. c. uses touch in a friendly manner to establish rapport. d. displays mental distancing during the interview.

a

During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit a. hyperresonance. b. tympany. c. dullness. d. flatness.

a

During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client's a. perception of pain. b. height. c. weight. d. temperature.

a

The nurse has interviewed a Hispanic client with limited English skills for the first time. The nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. The nurse should a. indicate acceptance of the client's cultural differences. b. request a family member to interpret for the client. c. use slang terms to identify certain body parts. d. remain in a standing position during the interview.

a

The nurse is beginning a health history interview with an adult client who expresses anger at the nurse. The best approach for dealing with an angry client is for the nurse to a. allow the client to ventilate his or her feelings. b. offer reasons why the client should not feel angry. c. provide structure during the interview. d. refer the client to a different health care provider.

a

The nurse is interviewing a 78-year-old client for the first time. The nurse should first a. assess the client's hearing acuity. b. establish rapport with the client. c. obtain biographic data. d. use medical terminology appropriately.

a

The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to a. use very basic lay terminology. b. have a family member present during the interview. c. use standard medical terminology. d. show the client pictures of different symptoms, such as the "faces pain chart."

a

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should a. maintain eye contact while asking the questions from the form. b. read the questions verbatim from the form. c. ask the client to complete the form. d. ask leading questions throughout the interview.

a

. One advantage for an institution to use an integrated cued/checklist type of assessment data form is that it a. allows a comprehensive and thorough picture of the client's symptoms. b. may be easily used by different levels of caregivers, which enhances communication. c. provides for easy and rapid documentation across clinical settings and populations. d. includes the 11 health care patterns in an easily readable format.

b

. The nurse is preparing to document assessment findings in a client's record. The nurse should a. write in complete sentences with few abbreviations. b. avoid slang terms or labels unless they are direct quotes. c. record how the data were collected. d. use the term normal for normal findings.

b

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a a. 1-inch bell. b. 1½-inch diaphragm. c. 15-inch flexible tubing. d. 1-inch diaphragm.

b

During an interview with an adult client for the first time, the nurse can clarify the client's statements by a. offering a "laundry list" of descriptors. b. rephrasing the client's statements. c. repeating verbatim what the client has said. d. inferring what the client's statements mean.

b

During the interview of an adult client, the nurse should a. use leading questions for valid responses. b. provide the client with information as questions arise. c. read each question carefully from the history form. d. complete the interview as quickly as possible.

b

The depth and scope of nursing assessment has expanded significantly over the past several decades primarily because of a. the growing elderly population with chronic illness. b. rapid advances in biomedical knowledge and technology. c. an increase in the number of baccalaureate programs in nursing. d. an increase in the number of nurse practitioners.

b

The nurse is planning to interview a client who has demonstrated manipulative behaviors during past clinic visits. During the interview process, the nurse should plan to a. give the client rules with which he must agree to comply. b. provide structure and set limits with the client. c. tell the client that the nurse is aware of his past behaviors. d. approach the client in an authoritative manner.

b

To alleviate a client's anxiety during a comprehensive assessment, the nurse should a. begin with intrusive procedures first to get them completed quickly. b. explain each procedure being performed and the reason for the procedure. c. remain in the examination room while the client changes into a gown. d. ask the client to sign a consent for the physical examination.

b

While interviewing an adult client about her nutrition habits, the nurse should a. ask the client for a 3-day recall of food intake. b. review the food pyramid with the client. c. ask the client about limitations to activity. d. encourage the client to drink three to four glasses of water daily.

b

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's a. lungs. b. bone. c. liver. d. abdomen.

b

. One disadvantage of the open-ended assessment form is that it a. does not allow for individualization. b. asks standardized questions. c. requires a lot of time to complete. d. does not provide a total picture of the client.

c

During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed a. introductory. b. ongoing. c. working. d. closure.

c

During examining a client, the nurse plans to palpate temperature of the skin by using the a. fingertips of the hand. b. ulnar surface of the hand. c. dorsal surface of the hand. d. palmar surface of the hand.

c

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing a. light palpation. b. moderate palpation. c. deep palpation. d. very deep palpation.

c

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have a. advanced preparation in this area. b. experience in dealing with these types of clients. c. knowledge of his or her own thoughts and feelings about these issues. d. personal experiences with death, dying, and sexuality.

c

The most commonly used method of percussion is a. direct percussion. b. mild percussion. c. indirect percussion. d. blunt percussion.

c

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should a. analyze data that have already been collected. b. review any past collaborative problems. c. avoid premature judgments about the client. d. consult with the client's family members.

c

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first a. discuss the client's symptoms with other team members. b. plan for potential laboratory procedures. c. review the client's health care record. d. determine potential health care resources.

c

. A common error for beginning nurses who are formulating nursing diagnoses during data analysis is to a. formulate too many nursing diagnoses for the client and family. b. include too much data about the client in the history. c. obtain an insufficient number of cues and cluster patterns. d. quickly make a diagnosis without hypothesizing several diagnoses.

d

. An example of an objective finding in an adult client is a. a client's symptom of pain. b. family history data. c. genetic disorders. d. vital signs.

d

. Before the nurse analyzes the data collected, the nurse should a. determine collaborative problems with the health care team. b. group the data into clusters or groups of problems. c. generate possible hypotheses for the client's problems. d. perform the steps of the assessment process accurately.

d

. If the nurse makes an error while documenting findings on a client's record, the nurse should a. erase the error and make the correction. b. obliterate the error and make the correction. c. draw a line through the error and have it witnessed. d. draw a line through the error, writing "error" and initialing.

d

. In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed a. progressive. b. specific. c. checklist. d. focused.

d

. One characteristic of a nurse who is a critical thinker is the ability to a. form an opinion quickly. b. offer advice to clients. c. be right most of the time. d. validate information and judgments.

d

. While performing a physical examination on an older adult, the nurse should plan to a. complete the examination as quickly as possible. b. ask the client to change positions frequently. c. provide only minimal teaching related to health care. d. use minimal position changes.

d

. While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and the a. cause of the pain. b. client's caregiver. c. client's occupation. d. pain relief measures.

d

An adult client visits a clinic and tells the nurse that she suspects she has a urinary tract infection. To detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing a. moderate palpation. b. deep palpation. c. indirect percussion. d. blunt percussion.

d

An ongoing or partial assessment of a client a. focuses on a specific problem of the client. b. includes a comprehensive overview of all body systems. c. is usually performed by another health care worker. d. includes a brief reassessment of the client's normal body system.

d

During a client interview, the nurse asks questions about the client's past health history. The primary purpose of asking about past health problems is to a. determine whether genetic conditions are present. b. summarize the family's health problems. c. evaluate how the client's current symptoms affect his or her lifestyle. d. identify risk factors to the client and his or her significant others.

d

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is a. palpation. b. percussion. c. auscultation. d. inspection.

d

During an interview with an adult client, the nurse can keep the interview from going off course by a. using open-ended questions. b. rephrasing the client's statements. c. inferring information. d. using closed-ended questions.

d

The nurse is planning to interview a client who is being treated for depression. When the nurse enters the examination room, the client is sitting on the table with shoulders slumped. The nurse should plan to approach this client by a. providing the client with simple explanations. b. offering to hold the client's hand. c. using a highly structured interview process. d. expressing interest in a neutral manner.

d

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should a. allow the client time to calm down. b. avoid discussing sensitive issues. c. set time limits with the client. d. explain the role and purpose of the nurse.

d

The result of a nursing assessment is the a. prescription of treatment. b. documentation of the need for a referral. c. client's physiologic status. d. formulation of nursing diagnoses.

d

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 a. cluster the data collected. b. draw inferences and identify problems. c. document conclusions. d. check for the presence of defining characteristics.

d

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed a. entry. b. exploratory. c. focused. d. comprehensive.

d

When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using a. firm percussion. b. direct percussion. c. indirect percussion. d. blunt percussion.

d

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is a. "Do you feel stress at work?" b. "How often do you feel stressed?" c. "Is stress a problem in your life?" d. "How do you manage your stress?"

d

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using a. inspection. b. palpation. c. Doppler magnification. d. percussion.

d

The nurse is interviewing a client in the clinic for the first time. When the client tells the nurse that he smokes "about two packs of cigarettes a day," the nurse should a. look at the client with a frown. b. tell the client that he is spending a lot of money foolishly. c. provide the client with a list of dangers associated with smoking. d. encourage the client to quit smoking.

d (indicated in the lab manual) but i argue it's c