Webber 120 chapter 1 NCLEX style question
A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data? What type of work the client does The client's range of motion in her right arm Whether the client is caring for any dependents at home What types of foods the client typically eats
The client's range of motion in her right arm Rationale:Subjective data are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Objective data are what the nurse directly observes when examining the client, such as the range of motion in the client's right arm.
Which assessment finding should the nurse document as objective data? Biographical information Body functions Personal relationships Lifestyle practices
Body functions Subjective data is what the client tells the nurse. Objective data is what the nurse assesses or observes when performing care of a client.
For which of the following clients should a nurse perform a focused assessment? Client with right upper abdominal pain that radiates into the groin area Client with 4-day history of sore throat and fever with enlarged lymph nodes Diabetic with elevated blood sugars for the past 2 weeks Client with elevated blood pressure with no previous history of heart problems
Client with 4-day history of sore throat and fever with enlarged lymph nodes A client with a sore throat and fever with enlarged lymph nodes requires only a focused assessment by the nurse. A focused assessment consists of a thorough assessment of a particular client problem. An elevated blood pressure with no previous history of heart problems requires an initial comprehensive assessment. Right upper abdominal pain that radiates into the groin area is an emergency situation and the nurse should collect only the data necessary to make a quick diagnosis for immediate treatment (emergency assessment). A client with diabetes has a chronic, ongoing health problem that needs reassessment and possibly a change in treatment (ongoing or partial assessment).
A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility? Perform a musculoskeletal examination. Obtain a 24-hour diet recall. Collect subjective and objective data related to overall function. Take anthropometric measurements.
Collect subjective and objective data related to overall function. Rationale:The nurse is responsible for collecting subjective and objective data related to the client's overall function. The physical therapist performs a musculoskeletal examination. A dietitian may take anthropometric measurements in addition to a subjective nutritional assessment, such as a 24-hour diet recall.
A client presents to the health care facility with reports of new onset of chest pain of 3 days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse to perform for this client? Emergency Partial Focused Comprehensive
Comprehensive Rationale:This client presents with a new problem and the nurse should perform a comprehensive assessment. Chest pain is an emergent problem but the client is has stable vital signs and no chest pain so an emergency assessment is not indicated at this time. A partial or focused assessment would not allow collection of enough data to properly complete diagnose the cause of a new problem.
A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment? Empathy Inspection Sympathy Palpation
Empathy Rationale:Empathy is an intuitive awareness of what the client is going through; it helps the nurse to be effective in providing for the client's needs while remaining compassionately detached. Inspection and palpation are skills that help the nurse in collecting objective data of the client's physical characteristics. Sympathy is a feeling that would make the nurse as emotionally distraught as the client; this hampers the ability of the nurse to provide client care.
A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment? Evaluation Diagnosis Implementation Assessment
Evaluation Rationale:The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and the nursing care plan needs to be revised. The assessment stage involves collecting subjective and objective data. The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment. The implementation phase involves carrying out the plan to meet the determined outcome criteria.
A nurse is preparing to interview a client who is a Seventh Day Adventist. The nurse does not agree with this religion's view of modern medicine. Reflection of the nurse on her personal feelings regarding this client and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation? Initiation of a referral that the client doesn't want Formation of judgments that may interfere with the interview Omission of pertinent data needed to make a diagnosis Performance of unnecessary diagnostic tests
Formation of judgments that may interfere with the interview Rationale:After reviewing the client's record, the nurse should remember to keep an open mind and to avoid premature judgments that may alter the ability to collect accurate data. Making a referral that the client may not want, omitting pertinent data, or performing unnecessary tests does not involve personal feelings.
Which actions should a nurse perform before beginning the initial shift assessment of a client? Select all that apply. Gather assessment tools. Check the client's status with the nurse of the previous shift. Review the client's record. Understand the client's knowledge of self-care based on documented age, education, and background. Revise nursing care plans to reflect any change in the client's condition.
Gather assessment tools. Check the client's status with the nurse of the previous shift. Review the client's record. . Rationale:The nurse should review the client's record before meeting the client, as it provides background about chronic diseases and gives clues to how the present illness may impact the client's activities of daily living. Reviewing documented information about the client's medical diagnoses gives an opportunity to compare what the client tells the nurse to what is documented. The nurse should check the client's status with the nurse of the previous shift, as important data may have been shared with the nurse. The nurse should obtain and organize the assessment tools before meeting the client for the assessment. Nursing care plans are to be revised as the outcome criteria are met and the client makes progress toward the expected goals, so this will be done after the nurse performs an assessment and implements treatments. The nurse should not make assumptions about the client's knowledge of self-care based on age, education, and experience; the nurse should validate the client's knowledge with the client.
A nursing instructor is emphasizing the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors that will increase opportunities for nurses with advanced assessment skills should the instructor stress? Select all that apply. Declining health care needs of single parents Growing population of older adults with complex comorbidities Increasing impact of children and the homeless on communities Increasing complexity of acute care Declining numbers of medical students due to rising costs and focus on primary care
Growing population of older adults with complex comorbidities Increasing impact of children and the homeless on communities Increasing complexity of acute care Declining numbers of medical students due to rising costs and focus on primary care
A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following? "I'm sorry, but assessment is ongoing and continuous." "Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end." "Fortunately, assessment only needs to be done at the beginning of your stay." "I'll just need to evaluate you once more, at the end of your stay."
I'm sorry, but assessment is ongoing and continuous." Rationale:Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ongoing and continuous throughout all the phases of the nursing process.
A nurse has completed assessment of a client with Alzheimer's disease and documentation of the information obtained from the client and now needs to analyze the data collected. Which nursing actions should be included in this phase of the nursing process? Select all that apply. Development of a nursing care plan Identification of collaborative problems Formulation of nursing diagnosis(es) Identification of the need for referrals Assessment of the outcome of the care plan
Identification of collaborative problems Formulation of nursing diagnosis(es) Identification of the need for referrals Assessment of the outcome of the care plan Rationale:The second phase of the nursing process is to identify collaborative problems and the need for referrals as well as formulate nursing diagnoses, for which the nurse must go through the steps of data analysis. Planning is the third phase of the nursing process, which involves development of a nursing care plan and assessment of the outcome of the care plan, based on the nursing diagnosis obtained in the second phase of the nursing process.
A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the client's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse? Relying on objective and subjective information Making incorrect nursing judgments or diagnoses Validating information that is already correct Interjection of the nurse's thoughts or feelings into the data
Making incorrect nursing judgments or diagnoses Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the nursing process. Interjection of the nurse's thoughts or feelings may lead to bias or the withholding of information but would not necessarily result from a lack of a thorough and accurate assessment of a client. Nursing judgments should rely on both objective and subjective information; thus this is not an error. Validating information that is correct makes more work for the nurse but will not be prevented by a thorough and accurate assessment of a client.
Which of the following is the best example of holistic data collection by a nurse? Assessing the client's range of arm motion, auscultating for heart sounds, testing for pupil dilation, and conducting a vision test Performing an x-ray, ECG, exercise stress test, and complete blood count Measuring blood glucose level, cholesterol level, blood pressure, and resting heart rate Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings
Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings
Which of the following is the best example of assessment in everyday life? Taking the dog for a walk in the park to get exercise Measuring the remaining tread on a car tire to determine whether it is time to replace it Listening to a favorite song to relax in the evening Texting a friend to let her know that you made it home safely
Measuring the remaining tread on a car tire to determine whether it is time to replace it As a professional nurse, you will constantly observe situations and collect information to make nursing judgments. This occurs no matter what the setting: hospital, clinic, home, community, or long-term care. You conduct many informal assessments every day. For example, when you get up in the morning, you check the weather and determine what would be the most appropriate clothing to wear. Measuring the remaining tread on a car tire to determine whether it is time to replace it is an example of assessment, as it involves gathering information (the height of the tire tread) to make a decision (whether to buy new tires). The other answers do not involve gathering information to make a decision.
A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing? Ongoing Emergency Focused Comprehensive
Ongoing Rationale:Ongoing, follow-up or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline. An emergency assessment is a very rapid assessment performed in life-threatening situations such as drowning, choking, or cardiac arrest. It is used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. A focused assessment gathers information specific to the problem and does not cover any other areas. A comprehensive assessment is not necessary at this time because the client already has a documented problem.
A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing? Ongoing or partial Initial comprehensive Emergency Focused or problem-oriented
Ongoing or partial Rationale:An ongoing, follow-up or partial assessment of the client consists of data collection that occurs after the comprehensive database is established. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data. In addition, a brief reassessment of the client's body systems and holistic health patterns is performed to detect any new problems. An initial comprehensive assessment involves collection of subjective data about the client's perception of own health of all body parts or systems, past health history, family history, and lifestyle and health practices. A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern and consists of a thorough assessment of a particular client problem, and does not cover areas not related to the problem. An emergency assessment is a very rapid assessment performed in life-threatening situations.
A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas? Focuses only on the client's psychological, sociocultural, and spiritual well-being Focuses primarily on the client's physiologic development status Physiologic, psychological, sociocultural, developmental, and spiritual data Involves the client's musculoskeletal system and activities of daily living
Physiologic, psychological, sociocultural, developmental, and spiritual data
In which situation should a nurse perform an emergency assessment of a client? rash Shortness of breath Broken arm Ear pain
Shortness of breath Rationale:An emergency assessment is a very rapid assessment performed in life threatening situations such as drowning, choking, or cardiac arrest. It is also used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. Shortness of breath requires an emergency assessment to promptly assess the client's ability to maintain an adequate airway. A broken arm, body rash, and ear pain require a focused assessment to gather information specific to the problem.
A nurse is working with a client who has AIDS. Which of the following is an example of subjective data that might be gathered for this client? The client's pain level Presence of bacterial pneumonia on blood test results The client's current body weight The client's latest CD4 cell count
The client's pain level Rationale:Subjective data are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Objective data are those that the nurse observes directly, and include the following: physical characteristics (e.g., skin color, posture); body functions (e.g., heart rate, respiratory rate); appearance (e.g., dress and hygiene); behavior (e.g., mood, affect); measurements (e.g., blood pressure, temperature, height, weight); and results of laboratory testing (e.g., platelet count, x-ray findings).
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment? To evaluate whether outcomes of treatment are met To collect subjective data related to the client's overall health To determine any changes from the baseline data To perform a rapid assessment for prompt treatment
To determine any changes from the baseline data Rationale:Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment (emergency assessment). Evaluation is done after an intervention to determine whether the outcomes have been achieved.
