Chapter 16: Nursing Assessment

A nurse is completing an assessment using the PQRST to obtain data about the patient's chest pain. Match the questions to the components of the PQRST that the nurse will be using: A. Where is the pain located? B. What causes the pain? C. Does it come and go? D. What does the pain feel like? E. What is the rating on a scale of 0 to 10? 1. Provokes 2. Quality 3. Radiate 4. Severity 5. Time

A - 3 B - 1 C - 5 D - 2 E - 4

Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? A. "Data interpretation occurs before data validation." B. "Validation involves looking for patterns in professional standards." C. "Validation involves comparing data with other sources for accuracy." D. "Data interpretation involves discovering patterns in professional standards."

C. "Validation involves comparing data with other sources for accuracy." Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. The nurse should validate data before interpreting the data and making inferences. The nurse is interpreting and validating patient data, not professional standards.

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? A. Completes a comprehensive database B. Identifies pertinent nursing diagnoses C. Intervenes based on priorities of patient care D. Determines whether outcomes have been achieved

A. Completes a comprehensive database The assessment phase of the nursing process involves data collection to complete a thorough patient database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis phase or second phase. The nurse carries out interventions during the implementation phase (fourth phase), and determining whether outcomes have been achieved takes place during the evaluation phase (fifth phase) of the nursing process.

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do? A. Consider cultural differences during this assessment. B. Ask the patient to make eye contact to determine her affect. C. Continue with the interview and document that the patient is depressed. D. Notify the health care provider to recommend a psychological evaluation.

A. Consider cultural differences during this assessment. To conduct an accurate and complete assessment, consider a patient's cultural background. This nurse needs to practice culturally competent care and appreciate the cultural differences. Assuming that the patient is depressed or in need of a psychological evaluation or to force eye contact is inappropriate.

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? A. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. B. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the f wants something done. C. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. D. The nurse elevates a leg cast when the patient reports decreased mobility.

A. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. The only scenario that validates a patient's report with a nurse's observation is changing the wound dressing. The nurse validates what the patient says by observing the dressing. The rest of the examples have the nurse acting only from a patient and/or family reports, not the nurse's assessment.

The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview? A. The patient's room with the door closed B. The waiting area with the television turned off C. The patient's room before administration of pain medication D. The waiting room while the occupational therapist is working on leg exercises

A. The patient's room with the door closed Distractions should be eliminated as much as possible when interviewing a patient with a hearing deficit. The best place to conduct this interview is in the patient's room with the door closed. The waiting area does not provide privacy. Pain can sometimes inhibit someone's ability to concentrate, so before pain medication is administered is not advisable. It is best for the patient to be as comfortable as possible when conducting an interview. Assessing a patient while another member of the health care team is working would be distracting and is not the best time for an interview to take place.

A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.) A. Patient's temperature B. Patient's wound appearance C. Patient describing excitement about discharge D. Patient pacing the floor while awaiting test results E. Patient's expression of fear regarding upcoming surgery

ANS: C, E Subjective data include patient's feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data. Objective data are observations or measurements of a patient's health status. In this question, the appearance of the wound and the patient's temperature are objective data. Pacing is an observable patient behavior and is also considered objective data.

The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask? A. "Is there anything that you are stressed about right now that I should know?" B. "What reasons do you think are contributing to your fatigue?" C. "What are your normal work hours?" D. "Are you sleeping 8 hours a night?"

B. "What reasons do you think are contributing to your fatigue?" The question asking the patient what factors might be contributing to the fatigue will elicit the best open-ended response. Asking whether the patient is stressed and asking if the patient is sleeping 8 hours a night are closed-ended questions eliciting simple yes or no responses. Asking about normal work hours will elicit a matter-of-fact response and does not prompt the patient to elaborate on the daytime fatigue or ask about the contributing reasons.

A nurse has already set the agenda during a patient-centered interview. What will the nurse do next? A. Begin with introductions. B. Ask about the chief concerns or problems. C. Explain that the interview will be over in a few minutes. D. Tell the patient "I will be back to administer medications in 1 hour."

B. Ask about the chief concerns or problems. After setting the agenda, the nurse should conduct the actual interview and proceed with data collection, such as asking about the patient's current chief concerns or problems. Introductions occur before setting the agenda. Begin an interview by introducing yourself and your position and explaining the purpose of the interview. Your aim is to set an agenda for how you will gather information about a patient's current chief concerns or problems. The termination phase includes telling the patient when the interview is nearing an end. Telling the patient that medications will be given later when the nurse returns would typically take place during the termination phase of the interview.

While completing an admission database, the nurse is interviewing a patient who states "I am allergic to latex." Which action will the nurse take first? A. Immediately place the patient in isolation. B. Ask the patient to describe the type of reaction. C. Proceed to the termination phase of the interview. D. Document the latex allergy on the medication administration record.

B. Ask the patient to describe the type of reaction. The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered.

A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? A. Complete the questions in chronological order. B. Focus on the patient's presenting situation. C. Make accurate interpretations of the data. D. Conduct an observational overview.

B. Focus on the patient's presenting situation. A problem-oriented approach focuses on the patient's current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection.

A nurse is conducting a nursing health history. Which component will the nurse address? A. Nurse's concerns B. Patient expectations C. Current treatment orders D. Nurse's goals for the patient

B. Patient expectations Some components of a nursing health history include chief concern, patient expectations, spiritual health, and review of systems. Current treatment orders are located under the Orders section in the patient's chart and are not a part of the nursing health history. Patient concerns, not nurse's concerns, are included in the database. Goals that are mutually established, not nurse's goals, are part of the nursing care plan.

A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse? A. The nurse makes eye contact with the patient. B. The nurse speaks only to the patient's daughter. C. The nurse leans forward while talking with the patient. D. The nurse nods periodically while the patient is speaking.

B. The nurse speaks only to the patient's daughter. Gathering data from family members is acceptable, but when a patient is able to interact, nurses need to include information from the older adult to complete the assessment. Therefore, the charge nurse must correct this misconception. When assessing an older adult, nurses need to listen carefully and allow the patient to speak. Positive nonverbal communication, such as making eye contact, nodding, and leaning forward, shows interest in the patient. Thus, the charge nurse does not need to intervene or follow up.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? A. Administer scheduled medications assuming that the NAP would have reported abnormal vital signs. B. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon request. C. Ask the NAP to record the patient's vital signs before administering medications. D. Omit the vital signs because the patient is presently in no distress.

C. Ask the NAP to record the patient's vital signs before administering medications. The nurse should ask the nursing assistive personnel to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action.

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations? A. Proceed to the next patient's room to make rounds. B. Determine the patient does not want any pain medicine. C. Ask the patient about the facial grimacing with movement. D. Administer the pain medication ordered for moderate to severe pain.

C. Ask the patient about the facial grimacing with movement. First, the nurse needs to clarify/verify what was observed with what the patient states. Proceeding to the next room is ignoring this visual cue. The nurse cannot assume the patient does not want pain medicine just because he reports a 2 out of 10 on the pain scale. The nurse should not administer medication for moderate to severe pain if it is not necessary.

A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information? A. Carefully review lab results. B. Conduct the physical assessment. C. Perform a thorough nursing health history. D. Prolong the termination phase of the interview.

C. Perform a thorough nursing health history. The nursing health history also includes a description of a patient's habits and lifestyle patterns. Lab results and physical assessment will not reveal as much about the patient's habits and lifestyle patterns as the nursing health history. Collecting data is part of the working phase of the interview.

Which method of data collection will the nurse use to establish a patient's database? A. Reviewing the current literature to determine evidence-based nursing actions B. Checking orders for diagnostic and laboratory tests C. Performing a physical examination D. Ordering medications

C. Performing a physical examination You will learn to conduct different types of assessments: the patient-centered interview during a nursing health history, a physical examination, and the periodic assessments you make during rounding or administering care. A nursing database includes a physical examination. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. The nurse uses results from the diagnostic and laboratory tests to establish a patient database, not checking orders for tests.

The nurse is gathering data on a patient. Which data will the nurse report as objective data? A. States "doesn't feel good" B. Reports a headache C. Respirations 16 D. Nauseated

C. Respirations 16 Objective data are observations or measurements of a patient's health status, like respirations. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data. States "doesn't feel good," reports a headache, and nausea are all subjective data. Subjective data include the patient's feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition.

A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data? A. The patient can now perform the dressing changes without help. B. The patient can begin retaking all of the previous medications. C. The patient is apprehensive about discharge. D. The patient's surgery was not successful.

C. The patient is apprehensive about discharge. Subjective data include expressions of fear of going home and being alone. These data indicate (use inference) that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed.

While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take? A. Tell the patient to just focus on the leg and cast right now. B. Document the sleep patterns and information in the patient's chart. C. Explain that a more thorough assessment will be needed next shift. D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.

D. Ask the patient about usual sleep patterns and the onset of having difficulty resting. The nurse must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the patient about usual sleep patterns and the onset of having difficulty resting. The nurse should assess before documenting and should not ignore the patient's report of a problem or postpone it till the next shift.

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using? A. Gordon's Functional Health Patterns B. Activity-exercise pattern assessment C. General to specific assessment D. Problem-oriented assessment

D. Problem-oriented assessment The nurse is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the nurse focuses immediately on the problem at hand (dressing and drainage from surgery) and performs a problem-oriented assessment. Utilizing Gordon's Functional Health Patterns is an example of a structured database-type assessment technique that includes 11 patterns to assess. The nurse in this question is performing a specific problem-oriented assessment approach, not a general approach. The nurse is not performing an activity-exercise pattern assessment in this question.