Chapter 14: Assessing

Which are examples of objective data? Select all that apply.

Laboratory test results Breath sounds on auscultation A client's temperature

The nurse must be familiar with the client record in order to provide care effectively. Which parts of the client record include only the findings of physicians? Select all that apply.

Medical history Physical exam Progress notes

The nurse is performing an admission assessment on a young client admitted to the unit. Which are considered objective data? Select all that apply.

38-year-old man Height: 6' (1.82 m) Weight: 195 lb (89 kg)

Which scenario is an example of a time-lapse reassessment?

A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.

Which group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is most likely the cause of this action by the client?

Pain

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

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

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?

"How do you protect yourself when having sex?"

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview?

"Is there anything else we should know in order to care for you better?"

A nurse is performing an assessment on a client. Which should the nurse record as subjective data? Select all that apply.

"My leg hurts when I move." "I am so afraid of what my diagnosis is." "I am always anxious."

The nurse auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding?

"We need to validate the information obtained in this assessment."

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview?

Administer prescribed pain medication prior to conducting the interview.

Which client situation most likely warrants a time-lapse nursing assessment?

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

Which are examples of subjective data? Select all that apply.

Anxiety Light-headedness Nausea

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall?

Assess blood pressure with a large cuff.

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?

Assess the client and re-evaluate the vital signs.

Which is the best source of information for the nurse when collecting data for an assessment?

Client

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply.

Client states, "I feel so sad all of the time" "Client states, "I am in pain."

The nurse is preparing to interview several clients during clinic hours. What language difficulty(ies) might a nurse encounter while performing various interviews in a diverse population of clients? Select all that apply.

Clients not fluent in same language as the nurse. Clients have a limited education. Clients fear saying the wrong thing.

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment

Which are examples of objective data? Select all that apply.

Laboratory test results Breath sounds on auscultation A client's temperature

Which is recommended when conducting a client-nurse interview?

Focus full attention on the client.

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

Focused

What must the nurse do to identify actual or potential health problems?

Gather data from sources

Which piece of client information is subjective?

Generalized myalgia or muscle pain

A nurse is performing an assessment on a client in which the nurse categorizes the data according to various categories of functions. Which assessment model is the nurse using?

Gordon's functional health patterns

After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data?

Hierarchy of Human Needs

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

Inspection

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

Objective

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood cell count. The nurse is gathering which type of data when looking up the lab value?

Objective

Which nursing skill uses all five senses?

Observation

A nurse working on a medicine unit is mentoring a new graduate. The new nurse asks why it is necessary to perform an assessment on the same client twice during a 12-hour shift. What would be the nurse's best response to the new graduate?

Ongoing data collection is critical to the deletion or modification of old problems and finding new ones.

Nurses understand the problem that clients have when they are repeatedly asked the same questions. To best avoid this problem, which intervention should nurses perform when beginning to collect assessment data?

Organize all questions into categories.

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply.

Respect for client Competence Professionalism Caring

What should the nurse do prior to performing an initial assessment on a newly admitted client?

Review the records available on the client.

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client?

Risk for Impaired Parenting

The nurse is caring for a client who has just had a lower leg amputation following a motor vehicle accident. During the planning phase of the nursing process, the nurse will prioritize which problems on the first postoperative day? Select all that apply.

Risk for infection Risk for impaired coagulation

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

Secondary

During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

Sitting at eye level with the client

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments?

The nurse

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?

The nurse should consult with another nurse for that colleague's description of the assessment or observations.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver?

The nurse uses open-ended questions when working with a crying client.

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?

The nursing and medical literature

A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing?

Time-lapse

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?

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

When performing an assessment, the nurse should focus most on the developmental stage for which client?

Toddler

The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "No." What is the best thing for the nurse to do next?

Validate the data.

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?

Verbally report the finding immediately to the client's physician.

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?

Watching client walk into room

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being:

able to prioritize.

The purpose of obtaining a nursing history is to:

identify actual and potential health problems.

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

inform the client of the maintenance of confidentiality.

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

subjective

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is:

the initial comprehensive client assessment.

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse:

uses broad, open statements to communicate with the client.