MESSY

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

Subjective A client has been discharged from an acute care facility with a referral for a home health nurse to make an assessment. What is the priority action by the home health nurse on the initial home visit? - establish the client's database. A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority? - Assess the client's blood pressure. A client reports to a health care facility with reporting abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data? - Client himself As the client is in a conscious state, he himself is the primary source of information since he can give firsthand information. The client's wife, friends, and test results would be secondary sources of data. A client who is bleeding profusely from a stab wound is brought to the emergency department. Which type of assessment is most appropriate for this client? - Emergency 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? - 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 whenever assessment data differ significantly from the baseline. A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of a focus assessment? - adds depth to existing information A focus assessment adds depth to existing information or the initial database gathered by the nurse. A database assessment provides breadth for future comparisons. A focus assessment does not suggest possible problems facing the client but rather rules out or confirms the client's problems. A focus assessment is not voluminous and comprehensive, like a database assessment, but limited and to the point. A nurse is assessing an energetic 80-year-old, admitted to the hospital with complaints of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this patient? - A focused assessment of the specific problems identified A nurse is beginning the preparatory phase of the nursing interview for a client who fractured the left leg in a fall. Which nursing actions occur in this phase of the nursing interview? Select all that apply. - -The nurse ensures that the interview environment is private and comfortable. -The nurse arranges the seating in the interview room to facilitate an easy exchange of information. -The nurse prepares to meet the client by reading current and past records and report Providing a private and comfortable environment, arranging seating, and reading current/past records about a client all take place during the preparatory phase of the nursing interview. The nurse states his/her name during the introductory phase. The nurse assesses the client's comfort and ability to participate during the introductory phase. The nurse recapitulates the interview during the concluding phase. A nurse is interviewing a hospitalized patient. Which nurse-patient positioning facilitates an easy exchange of information? - If the patient is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. 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 client's temperature is 39.4 C. What should be the nurse's priority action? - Verbally report the finding immediately to the client's physician Abnormal assessment findings or changes in the client's health status should be immediately reported to the client's physician or the charge nurse for prompt and appropriate treatment of client health alterations. A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: - uses broad, open statements to communicate with the client. A nurse practitioner has a private practice in conjunction with a physician. She is providing psychiatric care to a woman who has a past history of being abused by her husband. During the last visit, the client stated that she was planning to leave her husband. On the next visit in two weeks, the nurse practitioner will assess her client's commitment to changing her life situation and her ability to feel empowered. What type of assessment is the nurse practitioner implementing? - Time-lapse A nursing instructor teaching about assessment data identifies a need for further instruction when a student makes which of the following statements? - "The client is always the best source for collecting data." A nursing student is assisting with taking nursing, or health histories of all clients. The student identifies when is the best time to do a nursing/health history? - As soon as possible after a client presents for care A nursing student is learning about how to perform a thorough assessment in a health assessment class. Which of the following is the best source of information for the student to learn data collection for an assessment? - Client A woman has delivered a healthy newborn and is scheduled to go home today, her third post-partum day. Her vital signs are stable. How often would the nurse expect to take the vital signs of a stable in-patient? - Every 8 hours After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview? - "Is there anything else we should know in order to care for you better?" 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? - Objective An assessment involves gathering pieces of information about a client's health status. Which piece of information is subjective? - Client has generalized myalgia or muscle pain. 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 that afternoon to do some kind of check-up. Which type of check would be most appropriate for the nurse to perform on this client? - Time-lapsed assessment An older adult male with a history of benign prostatic hyperplasia (BPH) presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? - Focused assessment The nurse is performing a focused assessment that involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the client's health. An emergency assessment is performed to identify life-threatening problems. A time-lapse assessment compares a client's current status to baseline data obtained earlier. An unconscious client is brought to the emergency department. Which assessment should be implemented first? - The client's airway should be assessed. At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented? - Objective Before conducting a health assessment on a client, what should the nurse do first? - Introduce herself to the client. During the initial assessment of a newly admitted client, the nurse has clustered the client's range of motion (ROM) with his gait, his bowel sounds with his usual elimination pattern, and his chest sounds with his respiratory rate. The nurse is most likely organizing assessment data according to: - body systems During the interview component of the health assessment, how does the nurse convey to the client that the information is important? - sitting at eye level with the client During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should: - inform the client of the maintenance of confidentiality. During the nursing examination, the nurse notices that the client, an older adult female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation? - Ask the client if it is okay to interview her husband for the answers to the interview questions During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should: - review as much information as possible. How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation? - "Client states, 'I don't see the point in trying anymore.'" In order for a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment? - Initial Nurses collect objective and subjective data during the client interview. Which client data is subjective data? Select all that apply. - -A client describes his pain as an 8 on the pain assessment scale. -A client feels nauseated after eating his breakfast. -A client reports being cold and requests an extra blanket. Nurses collect objective and subjective data when performing client assessments. What is an example of objective data? - The skin of a client who has liver failure has a yellowish tint. The night shift RN is caring for a hospitalized adult client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client? - Disturbed sleep pattern The nurse has identified a priority problem on her unit. Which statement is true regarding addressing a priority problem? - A priority problem requires a nursing intervention before another problem is addressed. The nurse is assessing a 3-week-old infant. Which of the following assessment findings would define the priority nursing diagnosis for this patient? The infant has not gained weight since birth. Bowel sounds are present in all quadrants. Breath sounds are clear to auscultation. Mom reports child cries much of the night but sleeps better in the daytime. Mom reports child only breastfeeds about four times in a 24-hour period and she doesn't seem to have much milk. - Ineffective Breastfeeding 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 count (WBC) lab value. The nurse is gathering which type of data when looking up the lab value? - Objective The nurse is assessing a male client with a diagnosis of vascular dementia. As a result of his cognitive deficit, the client is unable to provide many of the data that are required on the hospital's nursing admission history document. How should the nurse best proceed with this assessment? - Supplement the client's information by speaking with family or friends. The nurse is assessing a man in an outpatient setting. Which of the following assessment findings would lead to the priority nursing diagnosis for this client? Client states,"I don't want to live anymore. My family hates me and I am so tired of being sick. I have a gun and I am seriously thinking of killing myself." The patient reports a 30-year heavy smoking habit and having a cough for about six months. Ascultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminshed bowel sounds. His lips are slightly bluish in color. - Risk for Suicide The nurse is assessing the blood pressure of a young adult patient. The reading seems low in comparison the trend of other measurements. What might the nurse suspect is the cause of the abnormally low reading? Select all that apply. - the cuff is too large the arm is above the level of the heart There is too much background noise The stethoscope tubing is too long The nurse is assessing the spine of a 63-year-old woman who states, "I hope I don't end up with a big hump on my back like my mother did." The nurse knows the patient is referring to a condition known as: - kyphosis The nurse is caring for a 14-year-old adolescent who has just delivered her first baby girl. The adolescent states that she lives with an aunt and has no other family around her. The delivery was uncomplicated and the newborn is healthy. Which of the following would be the primary nursing diagnosis for this patient? - Risk for Impaired Parenting The nurse is caring for a patient for the third day in a row on the hospital unit. At his evening vital sign assessment, the nurse notices the radial pulse is much slower than his apical pulse. This finding is new. Which of the following would the nurse do next? - Notify the physician of the change and document the finding. The nurse is caring for a patient with an IV infusion and notes an elevated BP, increased pulse and respirations, dyspnea, crackles, and neck vein distention. Based on the assessment, the nurse suspects: - fluid overload The nurse is caring for an older adult client admitted to the hospital for a respiratory condition. What type of data should the nurse review prior to caring for this client? Select all that apply. - Consultations Lab reports Medical history Progress notes X-Ray reports The nurse is collecting data from a client during a complete assessment. What is the nurse demonstrating when the documentation of the assessment is performed in a timely precise manner? - Communication of data The nurse is conducting a client interview and notices that the client answers every questions with a "yes" or "no" response. What is mostly likely the cause of this action by the client? - Pain The nurse is conducting a health history on a newly admitted client. Which aspect of the client should the nurse include while doing the history? Select all that apply. - Health status Strengths Health problems Health risks The nurse is conducting an admission assessment on a client who informs the nurse that dyspnea follows the exertion the client is experiencing. What would be the best way for the nurse to chart this data? - The client reports feeling dyspneic after exertion The nurse is conducting an interview on a newly admitted client. Which of the following is recommended when conducting a client/nurse interview? - Focus full attention on the client. The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques? - "When did you first notice the rash on your leg?" The nurse is interviewing a client that is newly admitted to the unit. Which techniques used by the nurse will facilitate communication during the interview? Select all that apply. - Use broad opening statements. Share observations. Use silence. The nurse is performing a physical assessment of a newly admitted client. During the assessment the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client is there is any pain the answer is, "No." What is the best thing for the nurse to do next? - Validate the data. The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? Select all that apply. - 38-year-old man Height: 6' (1.82 m) Weight: 195 lb (89 kg) The nurse is planning to do a physical assessment on a newly admitted client.The assessment will be a review of systems (ROS). This means the nurse plans to do which of the following? - Complete an exam of all body systems The nurse is preparing to perform an assessment on a newly admitted client. What should the nurse do prior to performing this initial assessment? - Review the records available on the client Records prepared by different members of the healthcare team provide information essential to comprehensive nursing care. The nurse should review records early when gathering data before the first contact with the client The nurse is reviewing information about a client and notes the following assessment data. Which data cue does the nurse recognize as subjective data? - Pain rating is 7 The nurse is reviewing the laboratory report section of a client's record. For what reason is this important for the nurse to review? Select all that apply. - To confirm previous collected data To conflict with previous collected data To help to establish a diagnosis To monitor clients' responses to treatment The nurse must be familiar with the client record in order to provide care effectively. Which parts of the client record include only the findings of physicians? Select all that apply. - Medical history Physical exam Progress notes The nurse notices during an assessment interview that the client cannot stay on focus and jumps from one topic to another. The client also is speaking very rapidly and at time incoherently. What should the nurse suspect is the main cause of this behavior? - High anxiety The nurse observes the client as he walks into the room. What information will this provide the nurse? - information regarding the client's gait The nurse records the name, age, and genetic background of the client after obtaining this data. This data are components of which action? - Health history The nurse working at a local community hospital understands the importance of having a client database for continuous data collection. What does the nurse identify as the the primary reason for collecting data continuously? - It is because the client's health status can change quickly The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side". This statement is an example of which of the following? - A cue The nursing instructor is teaching about collecting data for an assessment and informs the students about the importance of validation. Which of the following statements made by a nursing student indicates a need for further instruction? - All data collected needs to be validated The nursing instructor is teaching the students about assessments. Which of the following does the instructor list as being most important in order for an assessment to be successful? - Trust and confidence The nursing instructor is teaching the students about the proper techniques for conducting a client interview. A student asks the instructor the reason for asking the client what he or she would like to be called. What explanation provided by the instructor is most appropriate? - It communicates respect for the client The nursing instructor is teaching the students how to do an interview on a client. Which statement made by a student indicates a need for further instruction? - The nurse should show her name badge to the client so he can identify the nurse. Some clients cannot read and they should not be expected to know a nurse's name and position by reading a name badge. The nursing student demonstrates accurate application of the assessment phase of the nursing process by performing which action? - asking the client whether the client has cultural preferences Assessing the client involves gathering information about the client's physical and emotional health; cognition; spiritual, cultural, or religious preferences; and sociodemographics. Developing a plan to manage the client's health problems falls within the planning phase of the nursing process. Coming up with the nursing diagnosis falls within the diagnosing phase of the nursing process. Determining if the client's goals for wellness have been met occurs at the evaluation phase of the nursing process. The nursing student has learned that when doing an assessment on any client, it is essential to get the most important information first. By doing so the nurse's action is an example of which of the following? - Being able to prioritize The purpose of obtaining a nursing history is to: - identify actual and potential nursing diagnoses. The RN is interviewing an 80-year-old woman admitted to the hospital for evaluation of her diabetes. The client states she enjoys being in the hospital because she lives alone and does not have many friends. She states her husband died 1 year ago and she is no longer able to drive. She relies on her daughter who lives one hour away to shop for her once a week. The client states, "My daughter can never stay long, she is just in and out in no time." Which nursing diagnoses would be appropriate for this client? Select all that apply. - Risk for Loneliness Powerlessness What must the nurse do to identify actual or potential health problems? - gather data from sources 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? - Assess blood pressure with a large cuff. When assessing an infant, it is important to involve the: - parents. When performing an assessment on an older client the nurse discovers that the client needs a cane when walking and has problem seeing in the night. Under which of the following stages of Maslow's Human Needs Theory should the nurse cluster this data? - Safety and Security When performing an assessment, the nurse should focus on the developmental stage for which client? - Toddler Which client situation most likely warrants a time-lapse nursing assessment? - An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. Which cultural group may interpret touch by another as an invasion of privacy? - Chinese Which of the following are examples of objective data? - laboratory results breath sounds a client's temperature Which of the following is an example of a time-lapse reassessment? - Natalia is a visiting nurse who has an appointment with Donald, an 85-year-old man with mobility issues. Natalia has worked with Donald in the past on the ways in which he can prevent falls. Today she wants to assess how he is doing with the fall prevention strategies they practiced before. Which quality does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply. - Respect for client Competence Professionalism Caring How long the nurse has practiced does not influence this. Which statement made by the nurse indicates data that would be documented as part of an objective assessment? - "The client's right leg is cold to the touch, from the knee to the foot." Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? - Focused assessment Which would be considered examples of subjective data? Select all that apply. - Comments made by the client's family. Description of a symptom by a client. A mother telling a nurse what the baby looked like when he was very ill. While caring for a client who has a problem related to digestion, a nurse has been referred by the primary care provider to be seen by a gastroenterologist. Which of the following parts of the client record should the nurse look at to see the recommendations made by the gastrointestinal specialist? - Consultation While performing an assessment, the nurse recognizes that his own personal biases may be interfering with the collection of data. What step should the nurse take to assure the information is factual and accurate? - The nurse should consult with another nurse for that colleague's description of the assessment or observations. While studying methods of data collection, a nursing student learns that there are many different skills involved. Which of the following is a key nursing skill that uses all five senses? - Observation - A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source? - Secondary A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client? - Focused 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? - Emergency A client is admitted for removal of a cancerous tumor of the lung. The client expresses concern to the nurse about how the cancer and the treatment will affect the client's family. The client explains that the client's spouse has never worked outside the home and that the client is concerned that their financial situation will be compromised by this illness. Which would be the best nursing diagnosis for this client? - Risk for Interrupted Family Processes A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition? - The nursing and medical literature A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority? - Assess the client's blood pressure. A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? - Focused A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method? - Presence of peristalsis A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which source? - The client 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? - The nurse A nurse has just taken vital signs on a newly admitted client. Vital signs would be entered on the client record as which type of data? - Objective A nurse is asking questions about a client's sexual history. It is important for the nurse to: - collect data in a quiet, private environment. A nurse is assessing a client admitted to the hospital with reporting left-sided weakness and difficulty speaking. Which documented statement best represents the data that should be collected in a nursing assessment? - Client is unable to communicate basic needs and cannot perform hygiene measures with left hand. 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 focused assessment of the specific problems identified A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information? - If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information? - If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. 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? - Verbally report the finding immediately to the client's physician. A nurse is performing an assessment on a client in which the nurse categorizes the data according to various categories of functions. Which assessment model is the nurse using? - Gordon's functional health patterns A nurse is performing an assessment on a client. Which should the nurse record as subjective data? Select all that apply. - "My leg hurts when I move." "I am so afraid of what my diagnosis is." "I am always anxious." A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: - uses broad, open statements to communicate with the client. A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being: - able to prioritize. A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. 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? - Time-lapse A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrintestinal symptoms or should be reported to the physician. Which action should the nurse perform next? - Consult with another nurse. 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 After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview? - "Is there anything else we should know in order to care for you better?" 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? - Objective 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? - Time-lapsed assessment During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficent data for planning care. Which action by the nurse would be most appropriate in this situation? - Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions. During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to: - body systems. During the interview component of the health assessment, how does the nurse convey to the client that the information is important? - Sitting at eye level with the client During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should: - inform the client of the maintenance of confidentiality. 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. - The nurse collects data regarding the client's health perception and health management. The nurse explores the client's perception of the client's major roles and responsibilities in life. The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality. For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment? - Initial 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? - "Client states, 'I don't see the point in trying anymore.'" The night shift nurse is caring for a hospitalized client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client? - Disturbed sleep pattern The nurse is admitting a client to a medical unit. The nurse delegates the measurement of the vital signs to an unlicensed assistive person (UAP) while the nurse collects data. After completing the admission process, the client reports a severe headache, so the nurse reassesses the vital signs and find the client's blood pressure extremely elevated. Whose responsibility is the accuracy of the blood pressure measurement? - The nurse The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client? - Ineffective Breastfeeding 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? - Objective 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? - Supplement the client's information by speaking with family or friends. 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 Impaired Parenting 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? - Notify the physician of the change and document the finding. 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? - The client tells the nurse that there is a burning sensation when voiding. The nurse is collecting data from a client during a complete assessment. Which skill is the nurse demonstrating when documenting the assessment data? - Communication The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is most likely the cause of this action by the client? - Pain The nurse is conducting a health history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next? - Continue the health history with questions focusing on respiratory function. The nurse is conducting a health history on a newly admitted client. Which aspects of the client should the nurse include while doing the history? Select all that apply. - Health status Strengths Health problems Health risks The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview? - Avoid the impulse to interrupt. The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply. - Client states, "I feel so sad all of the time." Client states, "I am in pain." 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? - Validate the data. The nurse is performing an admission assessment on a young client admitted to the unit. Which are considered objective data? Select all that apply. - 38-year-old man Height: 6 ft (1.82 m) Weight: 195 lb (89 kg) 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? - Both during the collection and at the end of the collection The nurse is performing an assessment on an older adult client and notices that the blood pressure has increased from 140/82 to 198/120 mm Hg. This is a significant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the physician? - The nurse The nurse is planning on doing a nursing/health history on a new client by performing an interview. Which elements are considered phases of the nursing interview? Select all that apply. - Preparatory phase Introduction phase Working phase Termination phase The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to: - complete an exam of all body systems. 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? - Administer prescribed pain medication prior to conducting the interview. 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? - High anxiety The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side." This statement is an example of: - a cue. The purpose of obtaining a nursing history is to: - identify actual and potential health problems. What must the nurse do to identify actual or potential health problems? - Gather data from sources What should the nurse do prior to performing an initial assessment on a newly admitted client? - Review the records available on the client. When assessing the firmness of a client's abdomen, the nurse should use which assessment technique? - Palpation When is the best time for a nurse to take a client's health history? - As soon as possible after a client presents for care When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? - Safety and security When performing an assessment, the nurse should focus most on the developmental stage for which client? - Toddler Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training? - The nurse introduces oneself to the client by pointing to the nurse's name badge. Which action would the nurse perform in the assessment phase of the nursing process? - Asking the client whether the client has cultural preferences Which are examples of objective data? Select all that apply. - Laboratory test results Breath sounds on auscultation A client's temperature Which are examples of subjective data? Select all that apply. - A client describes pain as an 8 on the pain assessment scale. A client feels nauseated after eating breakfast. A client reports being cold and requests an extra blanket. Which are models used in nursing to assist in clustering data? Select all that apply. - Human Needs Functional Health Patterns Human Response Body Systems Which assessment data cue does the nurse recognize as subjective data? - A pain rating of 7 Which client situation most likely warrants a time-lapse nursing assessment? - An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. Which group of terms best defines assessing in the nursing process? - Collection, validation, communication of client data Which is the best source of information for the nurse when collecting data for an assessment? - Client Which is the most appropriate reason for a nurse to ask a client what the client would like to be called? - It communicates respect for the client. Which is the primary reason for a nurse collecting data continuously on a client? - The client's health status can change quickly. Which is the purpose of a focused assessment? - Adds depth to existing information Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply. - Respect for client Competence Professionalism Caring Which nursing skill uses all five senses? - Observation Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist? - Consultation Which piece of client information is subjective? - Generalized myalgia or muscle pain Which scenario is an example of a time-lapse reassessment? - A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before. Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training? - All data collected need to be validated. Which statement by a nurse best indicates an accurate understanding of the different types of assessments? - "The purpose for the assessment offers guidance for which type and how much data to collect." Which statement made by the nurse indicates data that would be documented as part of an objective assessment? - "The client's right leg is cold to the touch, from the knee to the foot." Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? - Focused While doing an assessment, the nurse identifies questionable data. Which should the nurse do first? - Validate the questionable data. While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate? - Consult with another nurse for that colleague's description of the assessment or observations. Who or what is the primary source of information for a nursing history? - The client A 45-year-old client has presented to the emergency department with a report of nausea and vomiting and severe pain just under the right rib cage. Which response(s) should the nurse prioritize? Select all that apply. - "Can you tell me more about the nausea and vomiting?" "I am going to apply some pressure to your abdomen to see just exactly where the pain is." "How long have your eyes had the yellow tinge?" A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source? - Secondary A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg? - Subjective A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority? - Assess the client's blood pressure. A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? - Focused 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? - The nurse 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? - "How do you protect yourself when having sex?" 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 focused assessment of the specific problems identified A nurse is beginning the preparatory phase of the nursing interview for a client who fractured the left leg in a fall. Which nursing actions occur in this phase of the nursing interview? Select all that apply. - The nurse ensures that the interview environment is private and comfortable. The nurse arranges the seating in the interview room to facilitate an easy exchange of information. The nurse prepares to meet the client by reading current and past records and reports. A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information? - If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. 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? - The nurse assesses the client's comfort and ability to participate in the interview. 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? - Verbally report the finding immediately to the client's physician. A nurse is performing an assessment on a client in which the nurse categorizes the data according to various categories of functions. Which assessment model is the nurse using? - Gordon's functional health patterns A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being: - able to prioritize. A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. 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? - Time-lapse A physical examination on a client should always include which components? Select all that apply - Appraisal of health status Identification of health problems Establishment of a database for interventions After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview? - "Is there anything else we should know in order to care for you better?" 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? - Objective An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver? - The nurse uses open-ended questions when working with a crying client. 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? - Time-lapsed assessment During admission, a teenage 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? - Validate the weight loss with the client. During the interview component of the health assessment, how does the nurse convey to the client that the information is important? - Sitting at eye level with the client During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should: - inform the client of the maintenance of confidentiality. 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. - The nurse collects data regarding the client's health perception and health management. The nurse explores the client's perception of the client's major roles and responsibilities in life. The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality. 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? - "Client states, 'I don't see the point in trying anymore.'" The nurse delegates vital signs to be taken and recorded by the unlicensed assistive personnel (UAP). The UAP reports a blood pressure of 230/120 mm Hg on a client. Which is the nurse's priority action? - Assess the client and re-evaluate the vital signs. The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment? - Time-lapsed assessment The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment? - Time-lapsed assessment The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is most likely the cause of this action by the client? - Pain The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply. - Client states, "I feel so sad all of the time." Client states, "I am in pain." 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? - Validate the data. The nurse is performing an admission assessment on a young client admitted to the unit. Which are considered objective data? Select all that apply. - 38-year-old man Height: 6 ft (1.82 m) Weight: 195 lb (89 kg) 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? - Both during the collection and at the end of the collection 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? - Administer prescribed pain medication prior to conducting the interview. 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? - Watching client walk into room The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is: - the initial comprehensive client assessment. What must the nurse do to identify actual or potential health problems? - Gather data from sources When performing an assessment, the nurse should focus most on the developmental stage for which client? - Toddler Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training? - The nurse introduces oneself to the client by pointing to the nurse's name badge. Which are examples of objective data? Select all that apply. - Laboratory test results Breath sounds on auscultation A client's temperature Which are examples of subjective data? Select all that apply. - A client describes pain as an 8 on the pain assessment scale. A client feels nauseated after eating breakfast. A client reports being cold and requests an extra blanket. Which group of terms best defines assessing in the nursing process? - Collection, validation, communication of client data Which is the primary reason for a nurse collecting data continuously on a client? - The client's health status can change quickly. Which is the purpose of a focused assessment? - Adds depth to existing information Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply. - Respect for client Competence Professionalism Caring Which piece of client information is subjective? - Generalized myalgia or muscle pain Which statement is true regarding addressing a priority problem? - A priority problem requires a nursing intervention before another problem is addressed. While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate? - Consult with another nurse for that colleague's description of the assessment or observations.

While admitting a teenage client who has a diagnosis of anorexia, the client informs the nurse of a 5

pound weight loss within the last 6 months. What should the nurse do with this data? - Validate the weight loss with the client.

Nurses collect objective and subjective data during the client interview. Which client data is subjective data? Select all that apply.

You Selected: A client describes his pain as an 8 on the pain assessment scale. A client feels nauseated after eating his breakfast. A client reports being cold and requests an extra blanket.

The nurse is conducting a client interview and notices that the client answers every questions with a "yes" or "no" response. What is most likely the cause of this action by the client?

pain

A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of a focus assessment?

adds depth to existing information

The nurse has identified a priority problem on her unit. Which statement is true regarding addressing a priority problem?

A priority problem

"The nurse is conducting an interview with a newly admitted client. Which listening behavior guideline should the nurse implement in order to have a successful interview?

Avoid the impulse to interrupt

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?

Emergency assessment

A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client?

Focused

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?

Time-lapsed assessment

A nurse is interviewing a hospitalized client. Which nurse

client positioning facilitates an easy exchange of information? - If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed

The nurse is caring for a 14

year-old adolescent who has just delivered her first baby girl. The adolescent states that she lives with an aunt and has no other family around her. The delivery was uncomplicated and the newborn is healthy. Which of the following would be the primary nursing diagnosis for this patient? - Risk for Impaired Parenting

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?

objective

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply.

Client states, "I am in pain." Client states, "I feel so sad all of the time."