Chapter 15: Assessing PrepU
How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation? -"Client states, 'I don't see the point in trying anymore.'" -"Client makes statements indicating a loss of hope." -"Client states that rehabilitation will be unsuccessful." -"Client is demonstrating signs and symptoms of depression."
"Client states, 'I don't see the point in trying anymore.'" Explanation: Subjective data should be recorded using the client's own words, using quotation marks as appropriate. Paraphrasing the client's words may lead to assumptions and misrepresentations.
The nurse is performing an admission assessment. Which are considered objective data? Select all that apply. -38-year-old man -Height: 6 ft (1.82 m) -Weight: 195 lb (89 kg) -"My leg hurts." -"I am afraid something serious is wrong."
38-year-old man Height: 6 ft (1.82 m) Weight: 195 lb (89 kg) Explanation: Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person being assessed. Age, vital signs, height, and weight are objective data. Subjective data are data that the client reports or feels and are usually documented in the record with quotations. The client statements "My leg hurts" and "I am afraid something serious is wrong" are subjective data.
The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side." This statement is an example of: -a cue. -an inference. -a misinterpretation. -duplicate data.
a cue. Explanation: Cues and inferences describe the early analysis of data. "The client does not respond when I speak while standing on the client's right side," is a cue that something may be wrong. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. A nurse can observe a cue directly but not an inference. The information in this case is based on the nurse's direct observation, not interpretation or inference, and thus cannot be a misinterpretation. There is no evidence that the nurse's observation duplicates other data collected.
A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being: -purposeful. -factual. -complete. -able to prioritize.
able to prioritize. Explanation: It is essential to get the most important information first when doing an assessment. This is prioritizing. Being purposeful is when a nurse completes a task that has meaning for the client. Complete means that the information obtained is comprehensive. Factual is concerned with what is actually the case rather than interpretations of or reactions to a situation (for example, a diagnosis as opposed to a hunch).
A 57-year-old client presents to the clinic with a report of abdominal pain. The client underwent a sigmoid colostomy 3 months ago for colon cancer. The client's recovery had been uneventful until 1 week ago. What type of assessment will the nurse perform? -focused assessment -emergency assessment -time-lapsed assessment -funtional assessment
focused assessment Explanation: The nurse will perform a focused assessment. This type of assessment allows the nurse to gather data about a specific problem that has already been identified, such as this client's cancer and subsequent colostomy. The nurse would perform a emergency assessment when a client presents with a physiologic or psychological crisis. This type of assessment allows the nurse to identify life-threatening problems. The nurse would perform a time-lapsed assessment to compare a client's current status to the baseline data obtained earlier. This type of assessment is used most often in residential settings and for those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses. The functional assessment is a comprehensive evaluation of a client's physical strengths and weaknesses in areas such as the performance of activities of daily living, cognitive abilities, and social functioning.
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?" -"What do you envision for your care while you're here at the facility?" -"What practices have you found especially helpful in other settings?" -"What are your expectations from us and from yourself in your care?"
"Is there anything else we should know in order to care for you better?" Explanation: A helpful strategy in the termination phase of an interview is to ask the client: "Is there anything else you would like us to know that will help us plan your care?" This gives the client an opportunity to add data the nurse did not think to include. Expectations and previous practices should be addressed during the working phase of an interview.
A nurse manager identifies a need for further instruction when a new nurse makes which statement? -"Family members are a good source of data when the client is a young child." -"The client is usually the best source for collecting data." -"The client is always the best source for collecting data." -"Caregivers can be a helpful source of data when the client has a limited capacity for information."
"The client is always the best source for collecting data." Explanation: "The client is always the best source for collecting data" is a statement that requires additional instruction by the charge nurse. Although the client is usually the best source for information when collecting data during an assessment, a family member, friend, or caregiver can be especially helpful sources of data when the client is a child or has a limited cognitive capacity.
Which statement by a nurse best indicates an accurate understanding of the different types of assessments? -"The purpose for the assessment offers guidance for which type and how much data to collect." -"How much time the nurse has and how the client is feeling determine which type of assessment to perform." -"The health care provider informs the nurse of which type of assessment to perform for each client." -"It is up to the nurse to decide which assessment to perform."
"The purpose for the assessment offers guidance for which type and how much data to collect." Explanation: The purpose for which the assessment is being performed offers the best guidance for what type and how much data to collect. The type of nursing assessment the nurse should conducted should not depend on (a) the nurse's preference, (b) how much time the nurse has, or (c) what the health care provider wants. It is important to take into account how the client is feeling when preparing to assess, but the client's feelings should not dictate which assessments the nurse performs.
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." -"Crackles indicate that your child may have an allergy." -"We will share this assessment finding with the physical therapist." -"This is a normal finding and nothing of concern."
"We need to validate the information obtained in this assessment." Explanation: The assessment of a toddler should involve the parents, as they are the primary caretakers and most knowledgeable about their toddler's normal behavior and development, as well as the history of any presenting symptoms. The nurse will validate assessment data to verify information and clarify cues and inferences to determine if they are accurate and free of bias. Crackles indicate the presence of fluid in the airways. Client information is shared only with those caregivers who have a need to know the information. Nurses have a duty to teach the parents about their toddler's symptoms.
Which are examples of subjective data? Select all that apply. -A nurse observes a client wringing the hands before signing a consent for surgery. -A nurse observes redness and swelling at an intravenous site. -A client describes pain as an 8 on the pain assessment scale. -A client feels nauseated after eating breakfast. -A client's blood pressure is elevated following physical activity. -A client reports being cold and requests an extra blanket.
A client describes pain as an 8 on the pain assessment scale. A client feels nauseated after eating breakfast. A client reports being cold and requests an extra blanket. Explanation: Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. A client's pain, nausea, and chills can only be felt by that person. Data collected about a client, such as the client wringing the hands, redness and swelling at an intravenous site, and a blood pressure measurement, are considered objective data. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client.
A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client? -A full assessment of the urinary system -A focused assessment of the specific problems identified -Obtaining a detailed assessment of the client's sexual history -Conducting a thorough systems review to validate data on the client's record
A focused assessment of the specific problems identified Explanation: The priority assessment at this time is a focused assessment of the client's primary concern. A focused assessment may be performed during the initial assessment if the client's health problem is apparent. A full assessment of the urinary system may be appropriate but is not the priority. A detailed assessment of the client's sexual history is not warranted, and although a thorough systems review is conducted, it is not the priority at this time.
A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client? -A full assessment of the urinary system -Obtaining a detailed assessment of the client's sexual history -A focused assessment of the specific problems identified -Conducting a thorough systems review to validate data on the client's record
A focused assessment of the specific problems identified Explanation: The priority assessment at this time is a focused assessment of the client's primary concern. A focused assessment may be performed during the initial assessment if the client's health problem is apparent. A full assessment of the urinary system may be appropriate but is not the priority. A detailed assessment of the client's sexual history is not warranted, and although a thorough systems review is conducted, it is not the priority at this time.
Which scenario is an example of a time-lapse reassessment? -Seeing a client down on the floor, the nurse assesses the client's airway, breathing, and circulation, calls for help, and begins a quick neurological exam. -A nurse just coming on shift performs a focused physical assessment on each client, based on the client's diagnosis. -A nurse in a long-term skilled nursing facility assesses a new resident's baseline health status. -A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.
A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before. Explanation: The four types of assessment a nurse may perform are initial, focused, time-lapse, and emergency. A time-lapse reassessment is performed to reevaluate any changes in the client's health from a previous assessment. It is used to monitor the status of an already identified problem for a client with whom the nurse is already familiar. In this question the only scenario that depicts these components is that of the client with mobility issues. The assessment of the client who is found down on the floor is an emergency assessment. The assessment of each client based on the client's specific diagnosis is a focused assessment. The baseline assessment of the new resident in the long-term care facility is an initial assessment.
Which statement is true regarding addressing a priority problem? -Addressing priority problems involves skipping interventions. -Priority problems are identified at predetermined intervals throughout the shift. -A priority problem requires a nursing intervention before another problem is addressed. -The priority of problems is established and continued according to the nursing plan of care.
A priority problem requires a nursing intervention before another problem is addressed. Explanation: A priority problem requires a nursing intervention before another problem is addressed, but addressing priority problems does not entail skipping any interventions. The priority of problems can change as a client's condition changes. There are no predetermined times or intervals at which to identify priority problems. This is why critical thinking plays a central role in nursing.
Which statement is true regarding addressing a priority problem? -The priority of problems is established and continued according to the nursing plan of care. -A priority problem requires a nursing intervention before another problem is addressed. -Addressing priority problems involves skipping interventions. -Priority problems are identified at predetermined intervals throughout the shift.
A priority problem requires a nursing intervention before another problem is addressed. Explanation: A priority problem requires a nursing intervention before another problem is addressed, but addressing priority problems does not entail skipping any interventions. The priority of problems can change as a client's condition changes. There are no predetermined times or intervals at which to identify priority problems. This is why critical thinking plays a central role in nursing.
Which is the purpose of a focused assessment? -Provides breadth for future comparisons -Suggests possible problems -Adds depth to existing information -Gives a comprehensive volume of data
Adds depth to existing information Explanation: A focused assessment adds depth to existing information or the initial database gathered by the nurse. A database assessment provides breadth for future comparisons. A focused assessment does not suggest possible problems facing the client but rather rules out or confirms the client's problems. A focused assessment is not voluminous and comprehensive, like a database assessment, but limited and to the point.
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? -Inform the client that the interview must proceed before getting anything that will alter sensorium. -Administer prescribed pain medication prior to conducting the interview. -Document that the client refused the interview. -Use the information that is on the electronic health record and eliminate the need for the interview.
Administer prescribed pain medication prior to conducting the interview. Explanation: The nurse should make every effort to make the client comfortable prior to interviewing, including obtaining an prescription for and administering pain medication; if the pain persists, obtain only vital data and defer the remainder of the interview until the client is more comfortable. The information on the electronic health record is not inclusive of the subjective data from the client. The client is not refusing the interview, and the nurse can always come back later to complete it.
Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training? -Validation is an important part of assessment. -Validation helps to keep data as free from error as possible. -All data collected need to be validated. -Validation is the act of confirming or verifying.
All data collected need to be validated. Explanation: Validation is the act of confirming or verifying. The purpose of validation is to keep data as free from error as possible. It is an important part of assessment. However, it is neither possible nor necessary to validate all data; nurses should decide which items need verification.
Which are examples of subjective data? Select all that apply. -Anxiety -Light-headedness -Nausea -Edema -Laceration
Anxiety Light-headedness Nausea Explanation: Subjective data are those that only the person experiencing them can perceive and report, such as anxiety, light-headedness, and nausea. Objective data are those that someone other than the person experiencing them can observe, such as edema and laceration.
When is the best time for a nurse to take a client's health history? -After the client is settled and feels ready -As soon as possible after a client presents for care -Within 24 hours of admission -Anytime before the client is discharged
As soon as possible after a client presents for care Explanation: The nursing health history captures and records the uniqueness of the client and should be obtained as soon as possible after a client presents to the health care facility for care. If the nurse waits until the client is ready, this may occur too late and the problem may become more problematic. Twenty-four hours is also too long. Waiting until the client is discharged is inappropriate because important medical as well as psychological information may be missed or not communicated.
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? -Obtain an electrocardiogram daily. -Begin client education regarding a low-fat diet. -Assess cholesterol levels. -Assess blood pressure with a large cuff.
Assess blood pressure with a large cuff. Explanation: When assessing an obese client, a larger blood pressure cuff will likely be needed to prevent false high readings. It is not in the nurse's scope of practice to determine when and if cholesterol levels and an electrocardiogram are ordered. Diet education may or may not be warranted depending on the cause of the obesity.
A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority? -Assess the client's diet. -Assess the client's activity level. -Assess the client's blood pressure. -Assess the client's medication regimen.
Assess the client's blood pressure. Explanation: The priority intervention for the client with an unstable blood pressure is to first measure the blood pressure. Once the nurse is certain that this is within safe parameters, the nurse should assess the client's diet, activity level, and medication regimen.
The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client? -Collaborate with the client to form goals. -Apply supplemental oxygen by face mask as needed. -Document "altered oxygenation" on the nursing care plan. -Auscultate the chest for breath sounds.
Auscultate the chest for breath sounds. Explanation: Levels of responsibilities using the nursing process include assessing, diagnosing, planning, implementing and evaluating. The assessment phase of the nursing process includes gathering data by interviewing, observing, and performing a basic physical examination of people with common health problems with predictable outcomes. In this case, the nurse will gather data from the respiratory assessment by auscultating the lung sounds and observing the client's work of breathing. Identifying and documenting a client problem or diagnosis falls within the diagnosing phase of the nursing assessment. The nurse is in the planning phase of the nursing process when collaborating with the client to develop goals for care. For example, for this client, the nurse may establish the goal of improved oxygenation with decreased work of breathing. Applying oxygen is a nursing intervention and this falls within the implementation phase of the nursing process. This is the aspect of the process where the nurse actively carries out the actions that need to be taken to meet the client's care goals.
The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview? -Focus mainly on verbal comments. -Fill in the words for the client. -Avoid the impulse to interrupt. -Fill in quiet spaces and pauses.
Avoid the impulse to interrupt. Explanation: When doing an interview with a client, the nurse must listen actively for feelings, in addition to the verbal comments made by the client. The nurse should demonstrate patience if the client has a memory block and should avoid the impulse to fill in words or interrupt the client. Pauses in the conversation should be allowed, as silence gives both parties time to gather thoughts.
The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data? -During the collection of data only -In the middle of the data-gathering process -At the end of the data-gathering process -Both during the collection and at the end of the collection
Both during the collection and at the end of the collection Explanation: Not all data need to be validated, but the nurse may validate data during the collection or at the end of the data-gathering process. When it is clear that the data are correct, the nurse may analyze the data and formulate nursing diagnoses.
Which is the most appropriate reason for a nurse to ask a client what the client would like to be called? -It signifies that the nurse wants to be friendly. -It allows the client to control the situation. -It communicates respect for the client. -It ignores the policies of the facility.
It communicates respect for the client. Explanation: When conducting an interview with a client, the nurse should verify the person's name and ask what the person would like to be called. This communicates the nurse's respect for the client and indicates that the nurse recognizes the client as an individual. The nurse is there to conduct the interview, not to be friendly. Asking the question has nothing to do with the agency's policy nor does it allow the client to be in control.
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? -Carefully review the client's record. -Make the questions short. -Organize all questions into categories. -Tell the client the questions will be quick.
Carefully review the client's record. Explanation: Before beginning to collect data on a client, the nurse should review the client's record for data. Then the nurse can identify lower-priority data that are not important for the client's assessment. The nurse should avoid telling the client the questions will be quick or making the questions shorter, as proper assessment may not be quick and may necessitate longer questions. A nurse could organize the questions into categories, but reviewing the client's record would be more effective for avoiding duplication of information and ensuring that the assessment is efficient and comprehensive.
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? -Tell the client the questions will be quick. -Make the questions short. -Organize all questions into categories. -Carefully review the client's record.
Carefully review the client's record. Explanation: Before beginning to collect data on a client, the nurse should review the client's record for data. Then the nurse can identify lower-priority data that are not important for the client's assessment. The nurse should avoid telling the client the questions will be quick or making the questions shorter, as proper assessment may not be quick and may necessitate longer questions. A nurse could organize the questions into categories, but reviewing the client's record would be more effective for avoiding duplication of information and ensuring that the assessment is efficient and comprehensive.
Which is the best source of information for the nurse when collecting data for an assessment? -Primary health care provider -Client -Charge nurse -Medical record
Client Explanation: The client is the primary, and usually best, source of information when doing an assessment. The medical record may also provide information, but only if the client has been at the health care facility before; even then, the client is likely to have more current information than the medical record. Although the charge nurse is responsible for the care of all clients on the unit, the charge nurse is not likely to know the details of any one client's information. The primary health care provider would provide medical care based on the medical assessment and would not have more information than the client about the client's current health status.
Which group of terms best defines assessing in the nursing process? -Problem-focused, time-lapsed, emergency-based -Designing a plan of care, implementing nursing interventions -Collection, validation, communication of client data -Nurse-focused, establishing nursing goals
Collection, validation, communication of client data Explanation: Assessing is the systematic and continuous collection, validation, and communication of client data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem-focused, time-lapsed, and emergency-based describe types of assessments. Assessments are nurse-focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are.
A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrointestinal symptoms or should be reported to the health care provider. Which action should the nurse perform next? -Consult with another nurse. -Call the family. -Wait and see whether the pain subsides. -Chart the information.
Consult with another nurse. Explanation: A nurse who is unsure of the significance of a particular finding should consult with another nurse. In some instances, years of experience are needed to distinguish significant from insignificant findings. Calling the family is not appropriate at this point as there is no information to report to them. Charting the information is important after the consultation with another nurse. Waiting to see whether the pain subsides is not appropriate; a timely assessment is needed for this client.
Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist? -Consultation -Medical history -Laboratory reports -Progress notes
Consultation Explanation: The client's health care provider may invite a specialist to assess and treat the client. The focus of this part of the record is additional findings related to the client's medical diagnosis and treatment; it is found in the section called "Consultation." Laboratory reports are related to the laboratory values of the client. Progress notes are the part of a medical record where health care professionals describe details to document a client's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. The medical history or case history of a client is information gained by a health care provider by asking specific questions, either of the client or of other people who know the person and can give suitable information.
A client who is bleeding profusely from a stab wound is brought to the emergency department. Which type of assessment is most appropriate for this client? -Focused -Time-lapse -Initial -Emergency
Emergency Explanation: An emergency assessment is used to identify life-threatening problems and done when a physiologic or psychological crisis presents. It is different from a focused assessment, which is used to gather information about a particular problem. A time-lapse reassessment takes place after the initial assessment to evaluate any changes in the client's health.
A 24-year-old client presents to the emergency department with signs and symptoms of a sickle cell crisis. The nurse quickly obtains the necessary laboratory tests to assist with the assessment, as well as conducts an assessment of the client to determine the proper nursing care the client will require. Which type of assessment did the nurse perform in this situation? -Focused -Comprehensive -Emergency -Initial
Emergency Explanation: The nurse should complete an emergency assessment which will focus on the sickle cell crisis so that immediate care can be started to best treat the client. A focused assessment is conducted when more data are needed about a specific situation or health concern. The initial, comprehensive assessment is conducted to establish the client's medical and health condition. It will identify potential concerns as well as identify what the client is doing to ensure a healthy life.
A nurse is completing the assessment of an 85-year-old client who is being admitted to a memory care home for progressing dementia. The client is unable to answer some of the questions or provide some of essential information that the nurse needs to create the best nursing care plan for this client. Which source will be the best for the nurse to consult to gain this missing information? -Social media -Past medical records -Family member -Neighbors
Family member Explanation: The nurse should consult with family members or significant others to gain this information. The best contact will be the individual who has been caring for the client most recently. Past medical records, social media, and neighbors will be limited in information about the client and most likely will be unable to provide the most accurate information.
A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client? -Focused -Head-to-toe -Time-lapse -Emergency
Focused Explanation: In a focused assessment, the nurse gathers information about a specific problem that has already been identified. A head-to-toe assessment is an initial, complete assessment, typically to assess for any problems that have not been identified yet. An emergency assessment is used to identify a life-threatening problem. A time-lapse reassessment is scheduled to compare current status with the baseline obtained earlier.
A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client? -Head-to-toe -Focused -Emergency -Time-lapse
Focused Explanation: In a focused assessment, the nurse gathers information about a specific problem that has already been identified. A head-to-toe assessment is an initial, complete assessment, typically to assess for any problems that have not been identified yet. An emergency assessment is used to identify a life-threatening problem. A time-lapse reassessment is scheduled to compare current status with the baseline obtained earlier.
A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? -Focused -Initial -Emergency -Time-lapse
Focused Explanation: The nurse is performing a focused assessment, which involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the client's health. An emergency assessment is performed to identify life-threatening problems. A time-lapse assessment compares a client's current status to baseline data obtained earlier.
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 -Functional Health Patterns -Human Response Patterns -Body Systems Model
Hierarchy of Human Needs Explanation: Maslow uses a hierarchy of five sets of human needs to organize data with basic physiological needs, such as the need for oxygen, being the most urgent. Gordon's (1994) framework identifies 11 functional health patterns and organizes client data into these patterns. The human response patterns organize data according to human responses to interventions. A medical model used to organize data collection, with which all nurses are familiar, is the body systems model. This method organizes data collection according to organ and tissue function in various body systems.
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 stands at the foot of the bed. -If both the nurse and client are seated, their chairs are at right angles to each other, 30 cm apart. -If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. -If the client is in bed, the nurse stands at the side of the bed.
If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. Explanation: If the client is in bed, the nurse sitting in a chair placed at a 45-degree angle to the bed ensures the nurse is sitting at eye-level with the client, which promotes communication. If the nurse is standing at the foot or at the side of the client's bed, an authoritative position is established, which does not promote good communication. If both the nurse and the client are seated, being 30 cm apart intrudes upon personal space; ideally the nurse and client should be about 1 m apart.
Which are examples of objective data? Select all that apply. -A client's report of pain -Laboratory test results -Breath sounds on auscultation -A client's report of being unable to breathe -A client's temperature
Laboratory test results Breath sounds on auscultation A client's temperature Explanation: Objective data are those that the nurse can gathered from observation (e.g., posture, skin color, behavior), health records (e.g., laboratory test results, reports from other health care team members), and physical assessment (e.g., breath sounds, strength of extremities, blood pressure, temperature). Subjective data are those that only the person experiencing them can perceive and report, such as pain and a feeling of being unable to breathe.
The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next? -Recheck the client's pulse at the next scheduled assessment time and document the findings on the chart. -Recheck the client's pulse in 2 hours. -Notify the health care provider after the next scheduled assessment time if the pulse is unchanged. -Notify the health care provider of the change and document the finding. -Document the findings on the chart and recheck in 1 hour.
Notify the health care provider of the change and document the finding. Explanation: When a pulse deficit is present, the radial pulse rate is always lower than the apical pulse rate. The nurse should document and report to the health care provider any new finding of a pulse deficit immediately so that evaluation and follow-up can occur. The nurse should not wait until after rechecking the pulse to document the finding or report it to the health care provider.
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? -Subjective -Objective -Physical -Unreliable
Objective Explanation: Objective data are data that are observable and measurable and can be seen, heard, felt, or measured by someone other than the client. Subjective data are information perceived only by the affected person. Physical and unreliable are not types of data.
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? -Subjective -Objective -Primary -Secondary
Objective Explanation: Reports of laboratory studies and other diagnostic tests are considered objective data, which can either confirm or refute other data collected during the nursing exam and history. Subjective data are about a client's feeling or what the client states. Primary data are collected by an investigator conducting research. Common sources of secondary data for social science include censuses, information collected by government departments, organizational records, and data that were originally collected for other research purposes.
Which nursing skill uses all five senses? -Documentation -Observation -Listening -Caring
Observation Explanation: Observation is the conscious and deliberate use of the five senses (sight, smell, hearing, taste, and touch) to gather data. Documentation uses sight (seeing the client's chart) and touch (typing on a keyboard or writing with a pen). Listening involves just hearing what the client is saying. Caring need not involve any of the senses but is displaying kindness and concern for others.
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? -We have always done it this way for as long as I have worked here. -It is policy and we have to follow the facility's rules. -It will give you lots of chances to practice your assessment skills. -Ongoing data collection is critical to the deletion or modification of old problems and finding new ones.
Ongoing data collection is critical to the deletion or modification of old problems and finding new ones. Explanation: It is impossible to give quality care without knowledge of changes in the client's status. Ongoing data collection is critical to the deletion or modification of old problems and identification of new problems. Even though it will give the new graduate experience, this is not why the assessment is done twice during a 12-hour shift. A policy is developed to maintain agency consistency. Nurses have professional accountability and should not blindly follow agency policy.
The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client? -Hunger -Low anxiety -Pain -Sleepiness
Pain Explanation: Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief. Sleepiness would be observed if the client did not respond in a timely manner. A client with low anxiety is relaxed and would answer the question with intention and thoughtfulness. A hungry client would be short-tempered and angry.
When assessing the firmness of a client's abdomen, the nurse should use which assessment technique? -Inspection -Palpation -Percussion -Auscultation
Palpation Explanation: Physical assessment skills of the nurse include auscultation, percussion, inspection, and palpation. Palpation is the use of touch to assess a client. It would be appropriate for assessing the firmness of the client's abdomen. None of the other assessment skills would allow the nurse to assess the firmness of the client's abdomen. Inspection is the use of visual observation to assess a client. Percussion is the use of striking with the fingers against the client's body to assess a client. Auscultation is the use of a stethoscope to assess body sounds within the client, such as heart and lung sounds.
Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply. -Number of years in profession -Professionalism -Respect for client -Caring -Competence
Professionalism Respect for client Caring Competence Explanation: The nurse's interpersonal competence is critical beginning with the very first assessment. The client's initial impression is crucial. The nurse's competence, professionalism, and interpersonal qualities of caring and respect invite confidence and assure the client that help is available. The length of time as a nurse does not influence competence and professionalism.
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 -Number of years in profession -Caring
Respect for client Competence Professionalism Caring Explanation: The nurse's interpersonal competence is critical beginning with the very first assessment. The client's initial impression is crucial. The nurse's competence, professionalism, and interpersonal qualities of caring and respect invite confidence and assure the client that help is available. The length of time as a nurse does not influence competence and professionalism.
During the interview component of the health assessment, how does the nurse convey to the client that the information is important? -Nodding frequently during the interview -Sitting at eye level with the client -Standing next to the client while interviewing -Limiting questions to those with yes or no answers
Sitting at eye level with the client Explanation: When the client responds to a question, the nurse conveys interest by maintaining eye contact, occasionally nodding, or verbally responding to the client's remarks. This is best accomplished by selecting a seat at eye level to allow direct engagement with the client during the interview. Standing during the interview can limit the interaction between nurse and client. Questions should be open-ended to elicit the most information and engage the client. Yes or no (close-ended) questions do not encourage the client to provide the level of detail the nurse is attempting to collect.
A family presents to the emergency room with a 4-year-old child who is crying and reporting that the skin on the legs are itching and hurting. The parent explains that they were out walking in the woods when the child went running off the path and into some tall weeds. Which finding(s)s should the nurse prioritize in this assessment? Select all that apply. -4-year-old at 85 percentile of growth and development Stating "My legs feel like they are burning" -Redness and blisters forming on both legs -Respirations 18 breath/min and regular -Crying and trying to scratch legs due to itching
Stating "My legs feel like they are burning" Redness and blisters forming on both legs Crying and trying to scratch legs due to itching Explanation: This client needs an emergency assessment to ensure the child did not encounter any poisonous vegetation such as poison ivy. Reports of burning, redness, blisters, and itching all indicate a possible reaction to poisonous foliage and require immediate attention and care. The other findings will be assessed after the emergent situation is stabilized.
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 focus assessment done when admitted to the ER. -the initial comprehensive client assessment. -the health record from a previous admission. -the client record from the health care provider's office.
the initial comprehensive client assessment. Explanation: The initial comprehensive client assessment results in the baseline data that enables the nurse to make judgments, plan care, and refer clients to other health care workers if necessary.
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? -Explanatory -Subjective -Objective -Severe
Subjective Explanation: Cues may be signs (objective) or symptoms (subjective). Objective cues, called signs, are observable, perceptible, and measurable by someone other than the person experiencing them. Subjective cues, called symptoms, are only observable, perceptible, and measurable by the person experiencing them. The pain described by the client in this question is a subjective cue, as only the client is able to perceive it. Explanatory suggests that the client would offer an explanation or comparison to describe the pain in the right leg. Severe is an adjective that might be the equivalent of 8/10 on the pain scale as reported by the client.
The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment? -Supplement the client's information by speaking with family or friends. -Obtain the client's records from admissions to other institutions. -Limit the assessment to objective data. -Perform the assessment in several short episodes rather than at one sitting.
Supplement the client's information by speaking with family or friends. Explanation: Family and friends can be an invaluable source of assessment data, especially in the care of clients who have cognitive deficits. It would be inappropriate to limit an assessment to solely objective data. Using previous medical records and breaking up the assessment are appropriate measures, but they do not supersede the importance of using family and friends as data sources.
The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source? -The nurse tells the client to attempt to void. -The client tells the nurse that there is a burning sensation when voiding. -The health care provider prescribes medication to help the client void. -The client's spouse reports the client experienced incontinence a few days ago.
The client tells the nurse that there is a burning sensation when voiding. Explanation: Subjective data consist of information that only the client can describe, such as feelings, sensations, or experiences. An example of subjective data is a client's report of pain or fatigue. Objective data are those that can be measured and observed by others, a fever or a broken bone. The primary source is the client. Secondary sources include family members, reports, test results, and other health care providers.
Which items reflect the assessment phase of the nursing process? Select all that apply. -The nurse assists the client with coughing and deep breathing every hour. -The nurse asks the client, "How would you rate your pain?" -The client states, "I rarely sleep more than 6 hours." -The client's abdomen is firm and distended with hypoactive bowel sounds. -The nurse and the client determine a tolerable pain level.
The nurse asks the client, "How would you rate your pain?" The client's abdomen is firm and distended with hypoactive bowel sounds. The client states, "I rarely sleep more than 6 hours." Explanation: Assessment data would include the client statement regarding sleep, the nurse's question about a pain rating, and physical assessment data of the abdomen. Seeking input from the data in setting goals would occur during the outcome identification and planning phase. Assisting the client with coughing and deep breathing would occur during the implementation phase.
A nurse is interviewing a new client admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview? -The nurse assesses the client's comfort and ability to participate in the interview. -The nurse asks the client if there is anything else that needs to be divulged -The nurse gathers all the information needed to form the subjective database. -The nurse recapitulates the interview, highlighting important points.
The nurse assesses the client's comfort and ability to participate in the interview. Explanation: During the introductory phase of the interview, the nurse determines if the client is going to be able to participate in the interview. The highlighting of important points occurs in the termination phase of the interview. Ensuring the environment is comfortable and private occurs during the preparatory phase, and the gathering of information occurs during the working phase. Asking the client if any other information needs to be divulged occurs in the termination phase.
A nurse is interviewing a new client admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview? -The nurse assesses the client's comfort and ability to participate in the interview. -The nurse recapitulates the interview, highlighting important points. -The nurse asks the client if there is anything else that needs to be divulged -The nurse gathers all the information needed to form the subjective database.
The nurse assesses the client's comfort and ability to participate in the interview. Explanation: During the introductory phase of the interview, the nurse determines if the client is going to be able to participate in the interview. The highlighting of important points occurs in the termination phase of the interview. Ensuring the environment is comfortable and private occurs during the preparatory phase, and the gathering of information occurs during the working phase. Asking the client if any other information needs to be divulged occurs in the termination phase.
Following a client interview, the nurse is organizing data obtained according to Gordon's functional health patterns model. Which statements reflect the focus of this model? Select all that apply. -The nurse clusters or organizes data according to a hierarchy of basic human needs. -The nurse collects data regarding the client's health perception and health management. -The nurse explores the client's perception of the client's major roles and responsibilities in life. -The nurse assesses and collects data on the major body systems. -The nurse collects and organizes data related to human response patterns. -The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality.
The nurse collects data regarding the client's health perception and health management. The nurse explores the client's perception of the client's major roles and responsibilities in life. The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality. Explanation: Gordon's framework identifies 11 functional health patterns and organizes client data within these patterns, including one's own perception of health and health promotion activities. Self-perception/self-concept attitudes is one of the functional health patterns identified with this model. The perception of the major roles and responsibilities in the client's life falls into this category. Gordon also identifies assessment of areas such as elimination, activity, sleep, and sexuality as part of the model. Clustering data according to a hierarchy of basic needs describes Maslow's model. The body systems model organizes the assessment into categories of the major body systems, such as cardiovascular and respiratory systems, and follows most medical models. Data related to human response patterns describe the human response patterns (unitary person) model.
A nurse is beginning the preparatory phase of the nursing interview for a client who fractured the left leg in a fall. Which nursing actions occur in this phase of the nursing interview? Select all that apply. -The nurse ensures that the interview environment is private and comfortable. -The nurse initiates the interview by stating the nurse's name and status. -The nurse recapitulates the interview, highlighting key points. -The nurse arranges the seating in the interview room to facilitate an easy exchange of information. -The nurse prepares to meet the client by reading current and past records and reports.
The nurse ensures that the interview environment is private and comfortable. The nurse arranges the seating in the interview room to facilitate an easy exchange of information. The nurse prepares to meet the client by reading current and past records and reports. Explanation: Providing a private and comfortable environment, arranging seating, and reading current and past records about a client all take place during the preparatory phase of the nursing interview. The nurse states the nurse's name during the introductory phase. The nurse recapitulates the interview during the concluding phase.
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 client -The client's health care provider -The client's chart -The nursing and medical literature
The nursing and medical literature Explanation: In addition to information about medical diagnoses, treatment, and prognosis, a literature review of nursing and medical references offers nurses important information about nursing diagnoses, developmental norms, and psychosocial and spiritual practices that are helpful when assessing and caring for clients. Consulting with the client, health care provider, or client's chart would not give as comprehensive of a review.
A nurse practitioner in private practice with a health care provider 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? -Complete -Focused -Time-lapse -Emergency
Time-lapse Explanation: The four types of nursing assessment include complete, focused, time-lapse, and emergency. In time-lapse assessments, the nurse reassesses a client and condition that is already known to re-evaluate the client's status. In this case the nurse is revisiting the client's feelings and plans to change her life situation by leaving her abusive husband. In emergency assessments, the nurse assesses the client for life-threatening problems which are acutely present.. In focused assessments, the nurse focuses on assessing a specific problem that is already known to exist to further refine planning interventions. In complete (general or initial) assessments, the nurse does a thorough assessment of all aspects of a client's health status on the client's admission to a health care facility.
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? -Emergency assessment -Patient centered assessment method (PCAM) -Time-lapsed assessment -Initial assessment
Time-lapsed assessment Explanation:
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? -Developmental stage assessment -Time-lapsed assessment -Emergency assessment -Focused assessment
Time-lapsed assessment Explanation: A time-lapsed assessment is scheduled to compare a client's current status to the baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time are scheduled for this type of check. An emergency assessment is conducted if the client is having an emergency such as chest pain or hemorrhaging from the hand. Focused assessment is performed on clients focusing on the system or systems involved in the client's problem. Developmental stage assessment is the process of mapping a child's performance compared with children of similar age.
When performing an assessment, the nurse should focus most on the developmental stage for which client? -Toddler -Young adult -Middle-age adult -Adolescent
Toddler Explanation: Nursing assessments vary according to the client's developmental needs. When assessing an infant, toddler, or child, the nurse should give special attention to physiologic and psychosocial aspects of growth and development to identify client problems. It is not as important to focus on developmental stage when assessing clients in the other age groups, because their developmental needs do not vary as much and do not affect the assessment as much.
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? -Chart the data. -Validate the data. -Ignore the client's answer. -Ignore the client's nonverbal behavior.
Validate the data. Explanation: Data need to be validated when there are discrepancies (e.g., the client says there is no pain but the nonverbal behavior indicates that the client is experiencing pain). The nurse should not ignore the client's answer or the client's nonverbal behavior. The nurse should chart the assessment, but the priority is to validate the differences in the verbal communication and nonverbal behavior.
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 -Palpating the skin for pain and temperature -Reviewing past records for ultrasound -Measuring the pedal pulse
Watching client walk into room Explanation: Observation is the first step of a physical examination. This is when the nurse watches the client to observe any subtle indications of a problem, watches body language to see how it corresponds to the verbal communication, and determines possible areas which will need a focused assessment as the initial assessment develops. Review of past records should occur before the physical assessment is conducted. Assessing the area for pain, temperature and pulse are methods used during palpation.
The nurse is caring for a 14-year-old client who has just gave birth. The client reports living with an aunt and having no other family around. The birth was uncomplicated, and the newborn is healthy. Which is the primary nursing concern the nurse will identify for this client's care planning? -loneliness risk -acute pain -altered parenting risk -ineffective breastfeeding -ineffective feeding pattern in the newborn
altered parenting risk Explanation: A 14-year-old parent with little family support is at risk for difficulties with the expanded role of parent. The client has not stated feeling loneliness or pain. The newborn's feedings are not discussed in the scenario.
While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, "The client's hearing may be impaired on the right side." This statement is an example of: -a cue. -erroneous data. -duplicate data. -an inference.
an inference. Explanation: The judgment a nurse makes about a cue is known as an inference. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. The nurse can observe a cue directly, but not an inference. The key is the verb used —"hearing may be impaired." The statement is not erroneous or duplicate data.
A 57-year-old client presents to the clinic with a report of abdominal pain. The client underwent a sigmoid colostomy 3 months ago for colon cancer. The client's recovery had been uneventful until 1 week ago. What type of assessment will the nurse perform? -time-lapsed assessment -emergency assessment -focused assessment -funtional assessment
focused assessment Explanation: The nurse will perform a focused assessment. This type of assessment allows the nurse to gather data about a specific problem that has already been identified, such as this client's cancer and subsequent colostomy. The nurse would perform a emergency assessment when a client presents with a physiologic or psychological crisis. This type of assessment allows the nurse to identify life-threatening problems. The nurse would perform a time-lapsed assessment to compare a client's current status to the baseline data obtained earlier. This type of assessment is used most often in residential settings and for those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses. The functional assessment is a comprehensive evaluation of a client's physical strengths and weaknesses in areas such as the performance of activities of daily living, cognitive abilities, and social functioning.
The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing? -comprehensive assessment -database assessment -focused assessment -functional assessment
functional assessment Explanation: The nurse is performing a functional assessment that focuses on areas that relate to the physical performance of activities, such as how the client is able to meet activities of daily living, demonstration of cognitive abilities, and social functioning. A comprehensive assessment encompasses all of the assessment data for the client. The focused assessment relies on one area of functioning such as the respiratory system if a client is having an asthma attack. The database assessment is performed during the initial history and physical portion of the client's illness and represents a comprehensive and all inclusive initial collection of data.
During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should: -review literature pertinent to the client's attributes. -assess personal feelings regarding similar clinical situations. -inform the client of the maintenance of confidentiality. -implement supportive nursing interventions.
inform the client of the maintenance of confidentiality. Explanation: During the introductory phase, the nurse should inform the client how the information will be used and that confidentiality will be maintained. The alternate responses are not associated with the interview process and experience for the client.
The nurse is assessing the client's abdominal wound and notes yellow-green purulent wound drainage. The nurse recognizes that the drainage is an example of: -a judgment. -an inference. -objective data. -subjective data.
objective data. Explanation: Yellow-green purulent wound drainage is an example of objective data. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Subjective data are information perceived only by the affected person. Only the person experiencing pain can assign a rating to it. Making a judgment derived from data cues is an inference. An inference must be validated with subjective and/or objective data cues.
What is the purpose of obtaining a nursing history? -to assist the health care provider to establish a medical diagnosis -to minimize the time required to establish a nursing concern for care planning -to focus on objective physical data specific to the client -to identify actual and potential health problems
to identify actual and potential health problems Explanation: The purpose of the nursing health history is to identify the client's strengths and weaknesses; health risks, such as hereditary and environmental factors; and potential and existing health problems. This interview does not typically include physical assessment of a client. As part of the nursing assessment and overall nursing process, its purpose is not to influence time within the process. The health care provider's medical work-up provides the data to develop the medical diagnoses.
A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: -agrees with each of the client's statements. -attempts to write down everything the client says. -uses broad, open statements to communicate with the client. -reassures the client of good outcomes.
uses broad, open statements to communicate with the client. Explanation: The nurse should use broad, open statements to facilitate communication during an interview. Using close-ended questions, which prompt yes or no answers, should be avoided, as it does not provide the level of the detail the nurse is seeking. The nurse should pay full attention to the client; paying too much attention to note-taking or making computer entries will interfere with good communication. The nurse should avoid providing false reassurance and agreeing with every statement the client makes.
