Chapter 14 and 15

Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?

"Assessment data about the client should be collected continuously."

Which of the following questions or statements would be an appropriate termination of the health history interview?

"Can you think of anything else you would like to tell me?"

A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have 17. been so constipated lately." How should the nurse respond?

"Do you take anything to help your constipation?"

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this 7. problem before. What type of assessment would the nurse do?

Focused assessment

A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and 23. orientation every few minutes. The nurse is performing which type of assessment?

Focused assessment

Of the following information collected during a nursing assessment, which are subjective data?

nausea, abdominal pain

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is 24. being performed?

Focused

A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of 12. the following statements by the nurse would recognize the client's value as an individual?

"Mr. Koeppe, tell me what you do to take care of yourself."

Which of the following questions or statements would be appropriate in eliciting further information when conducting a 15. health history interview?

"Tell me more about what caused your pain."

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car 11. crash. Which of the following is objective data?

"Unable to palpate femoral pulse in left leg."

Which of the following examples of client data needs to be validated? Select all that apply.

A client has trouble reading an informed consent, but states he does not need glasses. An elderly client explains that the black and blue marks on his arms and legs are due to a fall.

After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes 27. which of the following as objective data?

Auscultation of the lungs

The nurse is reviewing information about a client and notes the following documentation Client is confused. The nurse 33. recognizes this information is an example of what?

An inference

The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. 32. During the interview, the client denies problems with breathing. What action should the nurse take next?

Clarify discrepancies of assessment data with the client.

A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the 21. following is a primary source of information?

Client's wife

Which of the following are examples of common factors in a client that may influence assessment priorities? Select all 31. that apply.

Diet and exercise program Developmental stage Need for nursing

A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation?

Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward.

The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using?

Human Needs (Maslow) model

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 has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the 35. client has a fever. How should the nurse best follow up this cue and inference?

Measure the client's oral temperature

The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the 5. client has a fever. How should the nurse best follow up this cue and inference?

Measure the client's oral temperature.

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital 20. signs. Which of the following data collected can be classified as subjective data?

Nausea

A nurse is collecting data from a home care client. In addition to information about the client's health status, what is 13. another observation the nurse should make?

Safety of the immediate environment

The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's 22. health status. Which of the following would the nurse identify as a subjective cue?

Sharp pain in the knee

An unconscious patient is brought to the emergency department. Which of the following assessments should be 25. implemented first?

The client's airway should be assessed.

Which of the following data regarding a client with a diagnosis of colon cancer are subjective? Select all that apply.

The client's chemotherapy causes him nausea and loss of appetite. The patient has been experiencing fatigue in recent weeks.

A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses 9. the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?

Time-lapsed

While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and 34. documents the event in the client's chart. Which of the following actions clearly demonstrates assessing?

The nurse asking if the client is having pain

A nurse who collected and organized data during a client history realizes that there is not enough information to plan 18. interventions. Which of the following would be the best remedy to prevent this from happening in the future?

The nurse should practice interviewing strategies.

The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for 6. surgery. What is the purpose of this initial assessment?

To establish a database to identify problems and strengths

A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory 8. status?

To identify a life-threatening problem

What is the primary purpose of validation as a part of assessment?

To plan appropriate nursing care

When documenting subjective data, the nurse should do which of the following?

Use the client's own words placed in quotation marks

A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of 28. the following are critical thinking activities linked to assessment? Select all that apply.

Using the nursing process to diagnose a blocked airway Interviewing privately a client suspected of being a victim of abuse Checking with the family about the data supplied by a client suffering from dementia

A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position 14. herself?

sitting at a 45-degree angle to the bed