WK2 NR 302 EDAPT

For each nursing action during the health assessment of a newly hospitalized client, indicate if it will promote the safety of the client, the nurse, or both by placing a check in the Client or Nurse column. Select all that apply for each nursing action.

CLIENT : Two-factor identification prior to beginning assessment Cleaning health assessment equipment before entering the examination area Closing the door of the examination room Ensuring the call light, telephone, and other necessities are within reach of the client prior to leaving the room NURSE: Cleaning health assessment equipment before entering the examination area Raising the bed to the level of the nurse's waist when the client is confined to bed Ensuring the call light, telephone, and other necessities are within reach of the client prior to leaving the room

allows for a more succinct approach, while noting issues or abnormalities.

Charting by exception

While completing a health history on a new client whose partner is present and providing information, the nurse lays the tablet computer face-up on a counter to examine a wound on the client's leg. When the nurse turns around to pick up the tablet, the client's partner is reading what is on the screen. Which legal or ethical rights did the nurse violate? Select all that apply.​

Health Insurance Privacy and Accountability Act (HIPAA)

Which sections are included in the comprehensive interview? Select all that apply.

History of present illness Reason for visit Social history Allergies

Which questions might the health examiner ask to gather data about the reason a person is seeking care? Select all that apply.​

How can I help you?"​ "When did you first notice the swelling in your legs?"​ "Is the pain constant, or does it come and go?"

Which types of questions are appropriate during a health interview? Select all that apply

Direct, or closed Summarizing Clarifying Reflecting Open-ended

Mariah (pronouns: she/her/hers) is a 17-year-old high school student who was brought to the Emergency Department (ED) by friends who said she passed out at a party. While the health provider and other colleagues began treating Mariah, the nurse spoke with her friends who, after providing contact information for Mariah's parents, left. The nurse was unable to contact Mariah's parents and sees that Mariah is now awake, but drowsy. While the nurse conducts a focused neurological assessment, Mariah shares that she had been drinking alcohol and took a couple of pills a friend gave her to help her headache. She is remorseful and worries that she has let her parents down with her behavior. This is the first time she attended a party with this new group of friends, and she wishes she had never agreed to go. ​ What assessment priority information should the nurse collect now that Mariah is awake? Select all that apply.

Known allergies Medication list Thoughts of hurting herself Medical and surgical history

When documenting the assessment of the eyes, the nurse forgets the appropriate abbreviation for normal reaction of the pupils. Which actions are appropriate at this time? Select all that apply.

Look up the appropriate abbreviation and use it. Write the whole word instead of an abbreviation.

What are examples of communication noise? Select all that apply.

Noisy interview space Cold office Medical terminology

The nurse has an encounter with a client. Which document entry should be used?

Noted respiratory rate of 24 with client sitting up in bed. Asked about additional symptoms, but the client said, "Don't bother me, please leave."

After completing an initial assessment of a client, the nurse has charted that their respirations are eupneic and their pulse is 58 beats per minute.

OBJECTIVE

In which section of the SOAP notes does the nurse document physical assessment findings

Objective

Before starting a health assessment of a new client, the nurse leaves their phone with a colleague and asks that nurse to help other clients should they need something. What communication skills are the nurse demonstrating? Select all that apply.​

Preparing to focus Reducing noise

The client asks to see their medical chart. What is the appropriate response?

Refer them to the records department.

Which data collected from the client is subjective? Select all that apply.

Sensations List of foods eaten in the past 3 days Past medical history Feelings

A client shares with the nurse that they are very anxious about their recent diagnosis of heart failure, having four new medications, and having shortness of breath with activity that is interfering with work. Based on this information, what should the nurse follow up on first?

Shortness of breath

What is subjective data?

Information provided by the client or family

Evaluating Learning The dietician working with Grace uses which teaching methods to keep Grace engaged in learning while evaluating how much she understands? Select all that apply.

Teach-back Return demonstration

The primary purpose of the Health Information Privacy and Accountability Act (HIPAA) is

to protect the security of personal health data collected while providing care.

Evaluation of Previous Teaching Grace returns to the university clinic two weeks after her initial visit for a follow-up assessment. Which statements, if made by Grace, indicate to the health examiner that she is adhering to her diabetes management plan? Select all that apply.

"I must have been stressed to let my diabetes get out of control like that. I've asked my roommate to let me know if she thinks it is happening again." "My blood sugar has been lower since I started incorporating more fresh produce in my diet."

Mariah (pronouns: she/her/hers) is a 17-year-old high school student who was brought to the Emergency Department (ED) by friends who said she passed out at a party. While the health provider and other colleagues began treating Mariah, the nurse spoke with her friends who, after providing contact information for Mariah's parents, left. Mariah's parents arrive 30 minutes after speaking with the nurse. They are anxious, though relieved to see Mariah is awake and appears unharmed. After speaking with the healthcare provider, Mariah's mother approaches the nurse to ask what information Mariah provided before they arrived. Which response by the nurse demonstrates she understands Mariah's rights to privacy as a minor?​

"If you can wait a moment, I will make sure Mariah and her father don't need anything so we can go into the consultation room and speak in private."

Which questions are asked by the health examiner to obtain subjective data? Select all that apply.

"On a scale of 1-10, how badly does your knee hurt?" "Can you tell me about the last time your blood sugar got this high?" "Does it hurt when I press here?"

What the health examiner learns using the assessment techniques of inspection, palpation, percussion, and auscultation. What the person shares about themselves.

1. OBJECTIVE DATA 2. SUBJECTIVE DATA

Prior to leaving the hospital room at the end of an assessment, what actions are completed by the examiner? Select all that apply.

Assess the client's level of comfort. Return the bed to the low position. Ensure the wheels on the bed are locked. Place the call light within reach of the client.

When teaching an older adult about risks for a stroke, the health provider uses which teaching technique?

Begin each teaching session with the most important information about strokes

In situations like Mei's, when care is needed by an individual who is unable to express their preferences or desires, which ethical principles influence the decision to provide care based on the client's presenting state of health? Select all that apply.

Beneficence Nonmaleficence

While documenting health assessment data on the point of care (POC) electronic health record (EHR), the nurse becomes aware that a colleague who is not caring for the client is standing behind them reading what is on the screen. What steps will the nurse take to protect the client's privacy?​ Place the actions the nurse will take in the order in which they should be completed, starting with the highest priority action first.​

Block the colleague's view of the EHR. Apologize to the client for the interruption. Ask the colleague if they need assistance. If the colleague needs your assistance, step out of the room to discuss. Determine the priority of the colleague's request. Return to the health assessment if the colleague's request is not a first-level priority.

While documenting a physical assessment, the nurse realizes they did not check the client's eyes. What should the nurse do?

Complete the proper assessment and then document.

Mariah (pronouns: she/her/hers) is a 17-year-old high school student who was brought to the Emergency Department (ED) by friends who said she passed out at a party. While the health provider and other colleagues began treating Mariah, the nurse spoke with her friends who, after providing contact information fo

Contact Mariah's parents.​

In what ways can low health literacy impact the health of an individual? Select all that apply.

Decreased adherence to prescribed medications More trips to the emergency departmENT Increased cost of care

A client shares with the nurse that they are very anxious about their recent diagnosis of heart failure, having four new medications, and having shortness of breath with activity that is interfering with work. Based on this information, the health examiner identifies which nursing diagnosis is related to educational needs?

Deficient knowledge (medication) related to inexperience with newly ordered therapy

Which principles of communication are appropriate for the examiner to use when providing client education? Select all that apply.

Focus on the key information Use simpler words for medical terms when able Use the active voice

The goal of the interview is:

Gather pertinent information about the client's current health situation and any potential contributing factors.

Match the medical phrase to the statement that will be more readily understood by those who are not medical professionals.

Have you been dizzy?-Have you experienced syncopal episodes? Heart attack--Myocardial infarction The results of your blood work are normal.--Your CBC and CMP are within limits.

Which is an example of objective data?

Hearing a popping sound when the left knee is extended

An adolescent recently diagnosed with asthma is seen in an urgent care center in an acute asthmatic state. The examiner determines that previous health education has not been retained and is putting the teen's health at risk. Which information is most important for the examiner to teach during this episode of care?

How to use an inhaler during an asthma attack

All methods of documenting the health assessment present risks and benefits. What is one risk that charting by exception and narrative documentation have in common?

Important information may not be charted

The health examiner volunteering at a clinic determines that an individual with low health literacy has a new medical diagnosis of chronic obstructive pulmonary disease (COPD) and requires additional teaching about prescribed medications. Which technique is most appropriate for the examiner to use when providing education?

Include the most important information at the beginning of the session

Which factors are barriers to an effective health interview? Select all that apply.

Jargon or unfamiliar terms Bias or prejudices Cultural differences Lack of attention or distractions Different expectations Language differences

The nurse enters the room of a newly admitted client to complete the health assessment. While introducing themselves, the nurse begins to clean and arrange the equipment needed during the assessment and discovers that the wheels on the client's bed are not locked. Drag and place the steps the nurse takes in the correct order, beginning with the first action after finding the wheels unlocked.

Lock the wheels. Ask the client if they are comfortable. Explain the purpose of the health assessment. Complete the health assessment. Ask the client if they need anything. Document the health assessment. Follow up with the colleague who brought the client into the room to remind them to check the bed locks every time they are in a client's room

Select the words or phrases used to document objective data from a recent follow-up health assessment. Client denies trouble breathing, states cough is persistent, and sputum production is decreasing. Lung sounds are clear to auscultation exceptcrackles in left lower lobewhich are decreased since last assessment. Incentive spirometer and coughing with deep breathing completed with client voicing irritation with the intervention; crackles decreased after pulmonary hygiene. Oxygen saturation 96% on room air. BP 148/92, T 100.6 °F tympanic, HR 114 bpm, RR 24 per minute.

Lung sounds are clear to auscultation crackles in left lower lobe decreased since last assessment. Incentive spirometer and coughing with deep breathing completed, Oxygen saturation 96%.,BP 148/92, T 100.6 °F HR 114 bpm, RR 24 per minute.

Indicate which body system may be affected by the listed cues. Select all that apply for each cue.

Neurologic System: Pain 8/10 Blood sugar elevated Burning with urination Confusion Musculoskeletal System: PAIN 8/10 CONFUSION Endocrine System Pain 8/10 Blood sugar elevated CONFUSION

_ information is being recorded when the examiner documents a person's temperature is 102.1 °F and heart rate is 126 beats per minute. Including that the person said they have felt sick for the last two days is an example of documenting _ data.

OBJECTIVE, SUBJECTIVE

Match the correct definitions of privacy and confidentiality.

PRIVACY: Being in a place apart or away from unwanted observation by others CONF: Keeping personal information secured from being seen or heard, or ensuring privacy is maintained

Which are aspects of active listening? Select that all apply

Paying attention to body language Asking clarifying questions Using facial expressions to indicate understanding

What skill is used in active listening?

Paying attention to the client's body language

Which factors increase the need for client education to be incorporated into every encounter with healthcare professionals? Select all that apply.

People want to be more informed Individuals are living longer with chronic illness Shorter hospital stays Understanding steps to be healthy promotes healthy behaviors in many individuals

When planning client education for someone whose preferred language differs from their own, the nurse incorporates which principles of effective teaching to promote client understanding? Drag and drop all that apply.

Principles of Effective Teaching Focus on the key information. Use simpler words for medical terms when able. Use a certified medical interpreter.

the amount of protected health information that is needed for a healthcare worker to do their job safely.​

Responsible: Nurses Doctors Billing department colleagues​ Pharmacy colleagues NOT RESPONSIBLE : A client's partner

Consider the following scenario, and then determine which data are objective and which are subjective. Mrs. Johnson (pronouns: she/her/hers) has been hospitalized for gallbladder surgery. During the morning assessment, the nurse obtains the following information: Vitals: T 101.4 °F, P 97, R 18, BP 132/90. Mrs. Johnson feels warm to the touch but is shivering slightly and complaining of being cold. When the nurse asks her how she slept last night, she replies, "Not well at all. I feel like I only slept an hour all night." Mrs. Johnson appears to not want to move in bed and is guarding her abdomen. When the nurse her about her pain on a scale of 0-10, with 10 being the worst pain imaginable and 0 being no pain at all, she replies with a pain score of 8.

SUBJECTIVE : Mrs. Johnson replies, "Not well at all. I feel like I only slept an hour all night." Mrs. Johnson is complaining of being cold. OBJECTIVE: T = 101.4 °F Mrs. Johnson feels warm to the touch. Mrs. Johnson is shivering slightly. Mrs. Johnson is guarding her abdomen.

Drag the information into the correct SOAP section.

SUBJECTIVE: Client symptoms Chief complaint OBJ: Vital signs Lab report ASSESMENT: Phlebitis of the IV site Orthostatic syncopal episode PLAN: Suggest labs to assess hydration status Discontinue current IV and gain order for new IV placement

What step, taken by the nurse, will best promote the accuracy of information gathered during the health assessment of a client who does not speak English?Drag the correct step here:

Securing an interpreter.

goes in the S section of the SOAP notes

Subjective information from the client, family, or medical record

SOAP stands for:

Subjective, Objective, Assessment, Plan

Which statements best describe the goals of timely and accurate documentation of healt

To provide information to the healthcare team To provide a comprehensive database of a person's current state of health and wellness To establish goals for care collaboratively with the individual seeking care

Which cues observed during a health assessment alert the examiner that education is needed? Select all that apply.

When asked how long they have had high blood pressure, the individual says they don't have that The individual requests information about their illness The person is unable to recall the reason they are taking two of their prescribed medications

Which cues observed during a health assessment alert the examiner that education is needed? Select all that apply.

When asked how long they have had high blood pressure, the individual says they don't have that. The individual requests information about their illness. The person is unable to recall the reason they are taking two of their prescribed medications.

Grace (pronouns: she/her/hers) is a 21-year-old college student being seen in the university health clinic for an episode of mild hyperglycemia. During the health assessment, the examiner learns that Grace has had diabetes mellitus type 1 since she was 6 years old and that she manages her blood sugar with diet and an insulin pump. The examiner asks Grace to share what she has eaten over the last three days. After much thought, Grace shares that she has been studying for finals and can only recall drinking coffee with cream and food from the vending machine in the dormitory. Answer the following questions related to Grace's case.

While Grace is receiving care for her hyperglycemia, the health examiner determines that she would benefit from additional information about which aspect of managing her diabetes? Eating healthy during times of stress

Identify the words or phrases that the examiner uses to determine Grace's level of health literacy.

college student Grace has had diabetes mellitus type 1 since she was 6 years old manages her blood sugar with diet and an insulin pump

Documentaion

complete concurrently with accuracy client

Select the words/phrases that are cues that the teen lacks knowledge about the inhaler. Select all that apply.

never did understand what the inhaler was for I gave it to him

The client presents with sudden onset of blurred vision, diplopia (double vision), bilateral arm weakness with L > R, and left eye ptosis (droop). Lumbar puncture revealed increased protein in the cerebrospinal fluid (CSF). Social History: Denies alcohol and tobacco use; retired teacher; lives with spouse and two cats. Allergies: Acnotex and Bactrim DS

sudden onset of blurred vision, diplopia (double vision), bilateral arm weakness with L > R,Denies alcohol and tobacco use lives with spouse and two cats, Acnotex and Bactrim DS

The Minimum Necessary Rule covers

the amount of protected health information that is needed for a healthcare worker to do their job safely.​

Select the subjective words or phrases present in the plan of care documentation. Upon assessment of vital signs, the client's blood pressure was 190/92. They were questioned about their medication adherence, and slowly during the course of the client interview, it was shared that they had not refilled or taken their hypertension medications in over one year. This client did not appear to understand the severity of their health issues at this time. They are a poor historian and seemed to have a lack of understanding of how quickly this event could have taken a much worse route. Client education and support for the current situation as well as a lengthy discussion about the consequences of non-adherence to medications was completed.

they had not refilled or taken their hypertension medications in over one year

When Mei's daughter arrives, Mei is in a stable condition and breathing on her own with the breathing tube in place. Mei's daughter is upset to see her mother has been intubated since Mei specifically said she did not want that. What is the best way for the nurse to begin the health history assessment?

"I am sorry this happened. Since we did not know your mother has an advance directive, we did what we believed to be best. Can you share more about your mom's health?"

The nurse enters a client's room and finds them looking at the packet of papers that are given to all clients at the time of admission. As the client sets the folder aside, they ask, "Why do they give me this stuff every time I come to the hospital? Do they not realize I've seen it all before?" What is the best response by the nurse?

"I know you are familiar with the information, but not everyone is. By providing the packets to each client, we are sure everyone has access to information about the hospital and their rights as a client."

While completing a health assessment, the client begins slurring their speech. The nurse notes that the client, who was confused a moment ago, now has right-sided facial drooping. What is the most appropriate action for the nurse to take next?

Call out for help.

Select the words or phrases in the client statement that are subjective data.

fell down the stairs last evening, twisted my ankle put ice on it kept it elevated I can't put any weight on it took some ibuprofen still pretty bad

What is the appropriate distance between the client and examiner during the health assessment interview?

4 FT

The nurse uses a variety of skills to obtain a health history. For each statement, match the skill demonstrated by the nurse speaking.​

"Thank you for listing your medications. When was the last time you took your high blood pressure pill?"​ Clarification "It must have been difficult to leave your abusive relationship."​ EMPATHY "Thank you for listing your medications. Can you tell me how often you use your rescue inhaler for asthma?"​ QUESTIONING

Drag each statement into the correct area.

CORRECT PRACTICES: Use only approved abbreviations. Chart throughout the day. Write legibly. INCORECT PRACTICES: Use only approved abbreviations. Chart throughout the day. Write legibly.

Review one client's chart entries below. Which entry does not follow documentation best practices?

CORRECT: 10/22/20XX17:15New prescription for oral pain medication received without further orders; pain medicine administered (see MAR). ---------- J. Samuels, RN 10/22/20XX17:55In bed with upper side rails in place; assessment unchanged; rates pain 3/10 and denies any needs at this time. ---------- H. Simpson, RN 10/22/20XX18:45Client reports pain is gone; posterior LLE assessment unchanged; client freely moves LLE at ankle and knee joints; walking in room without discomfort. ---------- H. Simpson, RN Showing student answer. Correct! INCORRECT: 10/22/20XX18:00At 16:50, client in chair rubbing back of left lower extremity (LLE); rates pain 8/10 and requested oral pain medication; posterior LLE cool to touch, no swelling or redness noted; when asked, client says they backed into an open drawer approximately 20 minutes ago. ---------- J. Samuels, RN

What information should be documented in the health record? Select all that apply.

Care plan Health assessment Evaluation of therapy or care Medication administration Physical assessment

The nurse is reviewing data collected during the assessment of an adolescent who was involved in a skateboarding accident. Which cues relate to the accident?​ Select all that apply

Client reports pain is 8/10 Scraped knees, bilaterally Swollen left ankle Ice pack on left shoulder

Which excerpt from the healthcare provider's admission assessment does the nurse interpret as objective data? Select all that apply.

Client's clothes are wrinkled and dirty. Mother frequently interrupts the client to contradict what they are saying. Source of information: 17-year-old client and their mother.

Which factors make including health teaching in the health assessment appealing? Select all that apply.

It may be the only opportunity to correct misperceptions The setting is private The focus is on the person's health status and needs

Drag the statement that is true about documentation here:

Leaving charting until the end of the day can lead to inaccurate documentation.

A client tells the nurse that they are very nervous, nauseated, and "feel hot." What type of data is this?

SUBJECTIVE

Indicate if each actions made by the examiner during the physical assessment is completed to gather subjective and/or objective data. Each action may fall into more than one category.

SUBJECTIVE: Listening OBJECTIVE : Listening Touching Looking Smelling

A client tells the nurse that they are very nervous, nauseated, and "feel hot." What type of data is this?

Swelling and bruising of the left ankle