Nursing Process (PREPU Questions) CHP 14 - ASSESSMENT

Which is the primary reason for a nurse collecting data continuously on a client? Most facilities require it for reimbursement. It gives the nurse more information to document on the client. It makes the client feel as if the nurse is spending more time with the client. The client's health status can change quickly.

The client's health status can change quickly.

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? "Do you use condoms?" "Are you in a committed relationship?" "How many sexual partners have you had in the past 6 months?" "How do you protect yourself when having sex?"

"How do you protect yourself when having sex?"

Which statement made by the nurse indicates data that would be documented as part of an objective assessment? "The client reports having heartburn after breakfast." "The client reports nausea following eating." "The client's sister reports that the client has unrelieved pain." "The client's right leg is cold to the touch, from the knee to the foot."

"The client's right leg is cold to the touch, from the knee to the foot."

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? Notify the health care provider of the blood pressure result. Assess the client and re-evaluate the vital signs. Review the client's medication list and notify the nursing supervisor. Direct the UAP to take the blood pressure in the other arm with a large cuff.

Assess the client and re-evaluate the vital signs.

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview? Fill in quiet spaces and pauses. Avoid the impulse to interrupt. Focus mainly on verbal comments. Fill in the words for the client.

Avoid the impulse to interrupt.

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? At the end of the data-gathering process During the collection of data only In the middle of the data-gathering process Both during the collection and at the end of the collection

Both during the collection and at the end of the collection

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? Document on the client's chart that the assessment data may be biased. Verify the information with one or two family members without informing the client. Consult with another nurse for that colleague's description of the assessment or observations. Inform the client of these potential biases and obtain the client's opinion.

Consult with another nurse for that colleague's description of the assessment or observations.

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? Hyperthermia Disturbed sleep pattern Chronic pain Powerlessness Social isolation

Disturbed sleep pattern

What should the nurse do prior to performing an initial assessment on a newly admitted client? Report to the charge nurse what needs to be done for the client. Introduce the members of the health care team to the client. Review the records available on the client. Tell the client that the nurse will do an assessment only if it's convenient.

Review the records available on the client.

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further traning? The nurse introduces onself to the client by pointing to the nurse's name badge. The nurse sits on eye level with the client. The nurse verifies the client's name. The nurse asks the client what name the client would like to be called.

The nurse introduces onself to the client by pointing to the nurse's name badge.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver? The nurse documents the client was crying at the end of the shift. The nurse uses open-ended questions when working with a crying client. The nurse calls the hospital chaplain to talk with the client. The nurse leaves the room when a client is crying to provide privacy.

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? Emergency assessment Focused assessment Developmental stage assessment Time-lapsed 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 Emergency assessment Initial assessment Patient centered assessment method (PCAM)

Time-lapsed assessment

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? Measuring the pedal pulse Palpating the skin for pain and temperature Watching client walk into room Reviewing past records for ultrasound

Watching client walk into room

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

an inference.

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should: implement supportive nursing interventions. review literature pertinent to the client's attributes. assess personal feelings regarding similar clinical situations. inform the client of the maintenance of confidentiality.

inform the client of the maintenance of confidentiality.

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: attempts to write down everything the client says. reassures the client of good outcomes. uses broad, open statements to communicate with the client. agrees with each of the client's statements.

uses broad, open statements to communicate with the client.