EAQS Chapter 16 Nurse Assessment

During a visit to the clinic, a patient tells the nurse that he has been sick to his stomach for 3 days, and he vomited twice yesterday. Which response by the nurse is an example of probing?

"Is anything else bothering you?"

Which question by the nurse while taking an interview can strengthen his or her connection with a postoperative patient?

"Tell me, how are you managing your pain at home?"

A night shift nurse has taken over for the nurse from the previous shift. There are four new patients, and the nurse needs to interview them to complete the nursing histories. When would the nurse plan to interview these patients?

After reviewing the information given in the change-of-shift report

The nurse asks a patient several questions: "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview?

Collecting the assessment

Which type of question is used when starting the assessment of a patient?

Open-ended

The nurse is collecting the history of a patient who complains of shortness of breath. The nurse later asks the patient, "What else is bothering you?" This is an example of which interview technique?

Probing

The nurse is assessing a patient with diabetes using Gordon's model of functional health patterns. Which pattern is not a functional pattern in Gordon's model?

Dependence-independence pattern

A patient is admitted to the hospital for severe dehydration. The nurse asks the patient about bowel movements, urine output, and sweating. On the basis of Gordon's functional health patterns, which pattern is the nurse assessing?

Elimination pattern

The nurse uses various assessments to collect data about a patient. Which statement is true about the types of assessments? Select all that apply. One, some, or all responses may be correct.

Emergency assessment is performed when the patient's situation is life threatening. Ongoing assessment is performed and continued throughout the patient's health care experience. Focused assessment is done after a patient's general problems have been identified, when a patient has a complaint, or describes a new problem.

The nurse is caring for a 50-year-old patient. The patient had the gall bladder removed, and it is day 2 postsurgery. The nurse finds that the patient is uncomfortable and in pain. The nurse also notices some oozing from the site of the surgery. Which nursing actions are needed for the patient?

Gather information about his problem, identify the exact problem, plan appropriate nursing action, perform the required nursing actions, and then evaluate the outcome.

The nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. The nurse uses a finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells the nurse the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of which type of assessment?

Problem focused

A patient with arthritis informs the nurse that the knee pain is worse during rest and while climbing stairs. The pain improves when the patient is walking. The patient takes ibuprofen and acetaminophen for pain relief. What is the precipitating factor in this case? Select all that apply. One, some, or all responses may be correct.

Rest Climbing up the stairs

The nurse is completing a shift and is handing over patient care to the next nurse on duty. Which action would the nurse take during the bedside hand-off?

Share information about the patient's condition.

A student nurse is gathering information from an elderly patient. Which of the student nurse's actions indicates the need for further teaching?

Sitting straight in the chair while talking with the patient

The nurse is conducting an interview of a patient who complains of chest pain. The nurse says, "I have just two more questions for you." In which stage of the interview is the nurse?

Terminating the interview

The nurse is conducting a physical assessment on a patient admitted to the hospital with hypertension. Which attribute of the nurse will help him or her make a proper assessment about this patient? Select all that apply. One, some, or all responses may be correct.

The nurse's relevant knowledge The nurse's critical thinking attitude The nurse's prior clinical experience

A patient is scheduled for a prostatectomy. The patient is worried that he may not be able to have sex after surgery. Which response by the nurse is appropriate?

Your surgeon will talk to you about the surgery. Don't be afraid to ask this question."

A mother finds her 26-year-old daughter unconscious at home. She is taken to the hospital by ambulance while the mother and her 1-year-old granddaughter follow. Who would be the primary source of information in this case?

mother

A patient reports severe abdominal pain in the right iliac region. The nurse is completing the nursing history. Which information would the nurse elicit to help arrive at the probable cause of abdominal pain?

Some questions about the digestive system

According to Gordon's model, which health pattern describes the patient's spiritual attitude?

Value-belief pattern

The nurse is caring for a 50-year-old patient. The patient had his gall bladder removed, and it is the second postoperative day. The nurse finds that the patient is uncomfortable and in pain. The nurse also notices some oozing from the site of surgery and decides to gather information from the patient about the pain. Which question related to the complaint could the nurse ask? Select all that apply. One, some, or all responses may be correct.

"Can you show me where exactly the pain is?" "Have you turned or moved since last night?" "On a scale of 0 to 10, how severe would you rate this pain?"

The nurse is interviewing a patient who is admitted to the hospital with complaints of abdominal pain. Which question would the nurse ask to gather data about the patient's present illness and health concerns? Select all that apply. One, some, or all responses may be correct.

"Can you tell me about your illness?" "When did the pain start and how long has it lasted?" "Can you show me where the pain is located?" "Is the pain accompanied by any other problems or complaints?"

The nurse is interviewing a patient who comes into the emergency department with a headache of 5 days' duration. Which question from the nurse is an example of a closed-ended question? Select all that apply. One, some, or all responses may be correct.

1. "Do you have pain now?" 2. "Is your headache severe?" 3."Are you frightened that the diagnosis will be cancer?

The nurse assesses a patient who comes to the pulmonary clinic: "I see that it has been more than 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also, I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following this plan?" The nurse's assessment covers which of Gordon's functional health patterns?

Health perception and management

When performing the initial interview for a patient admitted to the hospital, which characteristic of the patient should the nurse document as objective data? Select all that apply. One, some, or all responses may be correct.

Body temperature of 104° F (40° C) A raised, red swelling on the back Drainage from wounds on the right hand and the right foot

Which action by the nurse indicates the setting-the-stage phase of the patient-centered interview? Select all that apply. One, some, or all responses may be correct.

Greeting the patient with his or her full name Ensuring a private area by shutting doors or closing the curtains Explaining to the patient the reason for conducting the interview

A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses the inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse assess?

Health perception and health management pattern

For which purpose would a nurse perform a comprehensive nursing assessment? Select all that apply. One, some, or all responses may be correct.

Interpret and validate the data collected. Establish a database about the patient's needs and health problems. Collect data with which to plan and evaluate care

The nurse is caring for a 50-year-old patient who has had a gall bladder removal and is postoperative day 2. The patient appears to be in pain. Which patient assessment finding collected by the nurse is categorized as objective data? Select all that apply. One, some, or all responses may be correct.

Minimal oozing at the incision site Fever of 104° F (40° C)

A 65-year-old male patient is admitted to the hospital with severe abdominal pain. The nurse has to obtain his health history. What is a different way in which the nurse can encourage the patient to provide more information? Select all that apply. One, some, or all responses may be correct.

Nod head showing agreement. Lean forward when the patient is talking. Maintain good eye contact with the patient.

The nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest?

The nurse has allowed stereotyping to influence her assessment

The nurse finds that a patient who is scheduled for an appendectomy is crying and infers that the patient is crying because of anxiety over the surgery or the hospital admission. Which action is appropriate for the nurse to take?

The nurse validates the inference by asking the patient about the crying behavior.

A 65-year-old male patient is admitted to the hospital with severe abdominal pain. The nurse has to obtain his health history. From which potential sources might the nurse obtain patient information? Select all that apply.

The patient himself The patient's family members The patient's previous medical records and data

The nurse is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths per minute. He lost his wife just a month ago. The nurse's knowledge about this patient would result in which type of assessment approach at this time? Select all that apply.

Using multiple visits to gather a complete database A problem-focused approach