PrepU Client Assessment- Chpt 1 Analyzing Data to Make Accurate Clinical Judgements

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?

Ask the client about the most recent experiences of pain. Rationale: Data are best validated by the client. Other sources are valid and useful, but the client is the ultimate source, especially in the case of subjective data.

An assessment that concentrates on patterns of role performance that all humans share is called what?

Functional

A client has been admitted with new onset hypertension with a past medical history of asthma, type 2 diabetes, and hypercholesterolemia. After developing a nursing care plan, the nurse reports findings to the health care provider. After receiving medication orders from the health care provider, the nurse administers several medications for hypertension. What is the next best action of the nurse?

Evaluate patient outcome. Rationale: The nurse should evaluate the effectiveness of the antihypertensive medications. The plan of care will not be updated until the interventions are evaluated. Nursing diagnosis and comprehensive assessments have already been completed.

Revising the plan as needed occurs in what part of the nursing process?

Evaluation Rationale: Evaluation assesses whether the outcome criteria have been met and revising the plan as necessary. Diagnosis occurs when the data has been analyzed and a professional judgement occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan.

Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next?

Evaluation Rationale: Because the nurse administered the insulin, the effectiveness of the insulin needs to be evaluated. The nurse already assessed the client, diagnosed the client with hyperglycemia, and implemented a plan to treat the hyperglycemia.

As a nurse becomes more proficient and comfortable in his or her role, what increases?

Knowledge base and expertise Rationale:As the nurse becomes more proficient and comfortable in his or her role, the accountability does not decrease, but the knowledge base and expertise increase to foster confidence.

The purpose of a health assessment includes what? (Select all that apply.)

A. Identifying the client's major disease process B. Collecting information about the health status of the client (Yes) C. Clarifying the client's ability to pay for health care D. Evaluating client outcomes (yes) E. Synthesizing collected data (yes) Rationale: Health assessment is "gathering information about the health status of the client, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings and evaluating client care outcomes" (AACN, 2008). While the nurse may elicit financial information and information about disease processes during a health assessment, the purposes of the activity are not to identify the client's major disease process or ability to pay.

Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first?

Conduct a focused assessment. Rationale: Because a comprehensive assessment had already been conducted, the nurse would perform a focused assessment based on the observed neurological changes. The nurse would need to obtain more information before alerting the critical assessment team or contacting the health care provider; some actions would include completing the physical neurological exam, checking blood glucose, checking for changes in medications that may have contributed to the change in mental status, and reviewing the a.m. labs for abnormal sodium level.

A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?

Critical Thinking Rationale: Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems. Diagnostic reasoning is important in developing diagnostic statements, not in caring for multiple clients with complex care needs. Physical assessment is important in the building the foundation of the nursing care plan. The nursing care plan directs the care that will be provided for the individual client, but does not address the needs of caring for multiple clients.

When doing an overall assessment of a client, the nurse is able to use findings for which primary purpose?

Identify in what areas the client needs the most care. Rationale: During the overall assessment of the client, the nurse is able to use the findings and decide in which areas the client is in need of the most care. The nurse should not identify conditions that the health care provider may have missed or identify the client's medical diagnosis, as making medical diagnoses are not within the nursing scope of practice. The nurse may provide education to the client's family throughout the client's care; however, the nurse should not delegate education of the family to the client, because this is the nurse's responsibility.

The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next?

Validate that the client understands how to use the inhalers. Rationale: The nurse should not assume that the client knows how to administer their medications. The nurse should always validate information, for example, that the client knows how to properly administer the inhalers. If the nurse does not validate that the client knows how to properly administer medication, the treatment may be ineffective.