Fundamentals of Nursing Exam 1

The nurse reports for duty in the emergency department and notes the following clients for which the nurse will be assuming care. After receiving the hand-off report, which client should the nurse prioritize for care? 24-year-old female with cough and fever 7-year-old male with hand laceration 12-year-old female with asthma attack 21-year-old male with possible fracture

12-year-old female with asthma attack

A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priorityassessment 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

Which are examples of subjective data? Select all that apply. Anxiety Light-headedness Nausea Edema Laceration

Anxiety Light-headedness Nausea

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.

Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist? Medical history Progress notes Consultation Laboratory reports

Consultation

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

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

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

The nurse identifies which types of data when performing an assessment? Select all that apply. Subjective Intuition Objective Critical thinking Hunches

Subjective Objective

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.

During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is mostlikely organizing assessment data according to: body systems. functional health patterns. human response patterns. human needs.

body systems

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.

cue

The purpose of obtaining a nursing history is to: assist the physician to establish a medical diagnosis. minimize the time required to establish a nursing diagnosis. focus on objective physical data specific to the client. identify actual and potential health problems.

identify actual and potential health problems.

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

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

inspection

A nurse has just taken vital signs on a newly admitted client. Vital signs would be entered on the client record as which type of data? Subjective Objective Intuitive Hunches

objective

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

objective

During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should: clarify the client's health status. review as much information as possible. identify existing and potential health problems. develop the nursing plan of care.

review as much information as possible.

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. rhe client record from the physician's office.

the initial comprehensive client assessment.

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

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.'"

An 80-year-old client presents to the clinic, reporting a headache that has continued for the past 4 days. Which question(s) should the nurse prioritize in the assessment? Select all that apply. "Have you experienced any falls and hit your head?" "Are you having any dizziness?" "Is the headache affecting your vision?" "Are you allergic to any foods or drugs?" "Are you having any pain in other areas of your body?"

"Have you experienced any falls and hit your head?" "Are you having any dizziness?" "Is the headache affecting your vision?"

A nurse is asking questions about a client's sexual history. Which is the best question for the nurse to ask to determine the client's use of safer sexual practices? "How many sexual partners have you had in the past 6 months?" "Do you use condoms?" "How do you protect yourself when having sex?" "Are you in a committed relationship?"

"How do you protect yourself when having sex?"

A nurse manager identifies a need for further instruction when a new nurse makes which statement? "The client is always the best source for collecting data." "The client is usually the best source for collecting data." "Family members are a good source of data when the client is a young child." "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."

Which statement made by the nurse indicates data that would be documented as part of an objective assessment? "The client's sister reports that the client has unrelieved pain." "The client's right leg is cold to the touch, from the knee to the foot." "The client reports nausea following eating." "The client reports having heartburn after breakfast."

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

Which statement by a nurse best indicates an accurate understanding of the different types of assessments? "It is up to the nurse to decide which assessment to perform." "How much time the nurse has and how the client is feeling determine which type of assessment to perform." "The purpose for the assessment offers guidance for which type and how much data to collect." "The physician informs the nurse of which type of assessment to perform for each client."

"The purpose for the assessment offers guidance for which type and how much data to collect."

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."

Which assessment data cue does the nurse recognize as subjective data? -A pain rating of 7 -Wheezing throughout lung fields -Bilateral pedal edema 2+ -Pupils equal and accommodate and react to light

-A pain rating of 7

Which are examples of subjective data? Select all that apply. -Anxiety -Light-headedness -Nausea -Edema -Laceration

-Anxiety -Light-headedness -Nausea

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficent data for planning care. Which action by the nurse would be most appropriate in this situation? -Ask the client to wake up and try to answer the interview questions. -Ask the client's spouse to come in and answer the interview questions. -Wait until the next day to obtain the answers to the interview questions. -Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

-Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

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

A client is admitted for removal of a cancerous tumor of the lung. The client expresses concern to the nurse about how the cancer and the treatment will affect the client's family. The client explains that the client's spouse has never worked outside the home and that the client is concerned that their financial situation will be compromised by this illness. Which would be the best nursing diagnosis for this client? -Risk for Interrupted Family Processes -Impaired Social Interaction -Chronic Low Self-Esteem -Risk for Loneliness -Death Anxiety

-Risk for Interrupted Family Processes

Which is the primary reason for a nurse collecting data continuously on a client? -It gives the nurse more information to document on the client. -It makes the client feel as if the nurse is spending more time with the client. -The client's health status can change quickly. -Most facilities require it for reimbursement.

-The client's health status can change quickly.

The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to: -examine certain body systems. -complete an exam of all body systems. -perform a review of the problem areas. -focus on only the systems that the client is comfortable with.

-complete an exam of all body systems.

The purpose of obtaining a nursing history is to: -assist the physician to establish a medical diagnosis. -minimize the time required to establish a nursing diagnosis. -focus on objective physical data specific to the client. -identify actual and potential health problems.

-identify actual and potential health problems.

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.

Which statement is true regarding addressing a priority problem? Addressing priority problems involves skipping interventions. Prioriy 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.

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

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.

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.

Which client situation most likely warrants a time-lapse nursing assessment? An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. The nurse has responded to the call light of a hospital client who is reporting shortness of breath and chest pain. A client is being admitted to a general medicine unit after spending several days in the intensive care unit. A nurse is auscultating the lungs and measuring the oxygen saturation of a client who has pulmonary edema.

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

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

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficent data for planning care. Which action by the nurse would be mostappropriate in this situation? Ask the client to wake up and try to answer the interview questions. Ask the client's spouse to come in and answer the interview questions. Wait until the next day to obtain the answers to the interview questions. Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

Which action would the nurse perform in the assessment phase of the nursing process? Developing a plan to manage the client's health problems Coming up with a nursing diagnosis based on a potential health risk Asking the client whether the client has cultural preferences Determining whether the client's goals for wellness have been met

Asking the client whether the client has cultural preferences

What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall? Assess cholesterol levels. Obtain an electrocardiogram daily. Assess blood pressure with a large cuff. Begin client education regarding a low-fat diet.

Assess blood pressure with a large cuff.

The nurse delegates vital signs to be taken and recorded by the unlicensed assistive personnel (UAP). The UAP reports a blood pressure of 230/120 mm Hg on a client. Which is the nurse's priority action? Direct the UAP to take the blood pressure in the other arm with a large cuff. Notify the health care provider of the blood pressure result. Review the client's medication list and notify the nursing supervisor. Assess the client and re-evaluate the vital signs.

Assess the client and re-evaluate the vital signs.

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 At the end of the data-gathering process In the middle 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

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply. Client states, "I feel so sad all of the time." Clothes unkempt and hair greasy Blood pressure 140/82 mm Hg Client states, "I am in pain." Ecchymosis on upper left arm

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

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.'

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

While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate? Consult with another nurse for that colleague's description of the assessment or observations. Inform the client of these potential biases and obtain the client's opinion. Document on the client's chart that the assessment data may be biased. Verify the information with one or two family members without informing the client.

Consult with another nurse for that colleague's description of the assessment or observations.

The nurse is caring for an older adult client admitted to the hospital for a respiratory condition. What type of data should the nurse review prior to caring for this client? Select all that apply. Consultations Lab reports Medical history Progress notes Financial history X-ray reports

Consultations Lab reports Medical history Progress notes Xray reports

The nurse is conducting a health history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next? Continue the health history with questions focusing on respiratory function. Consult with other members of the health care team about the conflicting client information. Prioritize documentation of objective data collected in the examination while avoiding any mention of the discrepancy. Ask significant family members about the client's usual breathing pattern at home.

Continue the health history with questions focusing on respiratory function.

A client has been discharged from an acute care facility with a referral for a home health nurse to make an assessment. What is the priority action by the home health nurse on the initial home visit? Care for the client's physical pain. Establish the client's database. Evaluate the care previously provided. Receive a report from the nursing staff.

Establish the client's database.

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client? Explain the nurse will need to touch the client during the assessment Ask if the client would like the door opened or closed when finished Point out potential nursing care plan goals while assessing Concentrate on a focused assessment of the abdomen and leave the rest of the assessment for a later time

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

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? Family member Past medical records Social media Neighbors

Family member

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

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? Initial Focused Emergency Time-lapse

Focused

What must the nurse do to identify actual or potential health problems? Evaluate care implemented Meet with significant others Call the physician Gather data from sources

Gather data from sources

Which piece of client information is subjective? A temperature of 102°F (38.9°C) Leukoplakia on the client's oral mucosa Generalized myalgia or muscle pain Alert and oriented to person and place but not time or situation Ptosis, a drooping of the eyelid, on the right side

Generalized myalgia or muscle pain

The nurse records the name, age, and genetic background of the client. The data are components of which tool? Objective data gathering Evaluation of data Health history Physical assessment

Health history

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

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.

The nurse is caring for a client who has just had a lower leg amputation following a motor vehicle accident. During the planning phase of the nursing process, the nurse will prioritize which problem(s) on the first postoperative day? Select all that apply. Infection risk Altered body image perception Feelings of loss of power Caregiver fatigue Impaired coagulation potential

Infection risk Impaired coagulation potential

For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment? Focused Psychosocial Physical Initial

Initial

Which statement describes the physical exam technique of auscultation? It is the technique of listening to body sounds with a stethoscope placed on the body surface to amplify sounds. It is a visual examination of the client that is done in a methodical and deliberate manner. It is the specialized use of touch for data collection. It is a technique in which one or both hands are used to strike the body surface in a precise manner to produce a sound.

It is the technique of listening to body sounds with a stethoscope placed on the body surface to amplify sounds.

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

A 33-year-old client is brought to the urgent care center, doubled over in pain and crying. Upon assessment, the client admits to nausea and vomiting ×3 during the morning. Which action should the nurse prioritize after noting right lower quandrant (RLQ) rebound tenderness, blood pressure of 130/92 mm Hg, and pulse 100 beats/min and weak? Notify the health care provider immediately Start an IV of normal saline Send the client to the closest emergency department Reevaluate the client in 30 minutes

Notify the health care provider immediately

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 in 2 hours. Recheck the client's pulse at the next scheduled assessment time and document the findings on the chart. Document the findings on the chart and recheck in 1 hour. Notify the physician of the change and document the finding. Notify the physician after the next scheduled assessment time if the pulse is unchanged.

Notify the physician of the change and document the finding.

Which nursing skill uses all five senses? Documentation Observation Listening Caring

Observation

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case? Obtaining data regarding the amount and frequency of drinking Interviewing friends to ascertain the client's exercise habits Asking the client to discuss social functioning Performing an abdominal assessment

Obtaining data regarding the amount and frequency of drinking

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is mostlikely the cause of this action by the client? Hunger Low anxiety Pain Sleepiness

Pain

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client? Risk for Loneliness Acute Pain Risk for Impaired Parenting Ineffective Breastfeeding Ineffective Infant Feeding Pattern

Risk for Impaired Parenting

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? Physiologic Safety and security Love and belonging Self-esteem Self-actualization

Safety and security

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

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. Limit the assessment to objective data. Obtain the client's records from admissions to other institutions. Perform the assessment in several short episodes rather than at one sitting.

Supplement the client's information by speaking with family or friends.

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

The nurse

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 assesses the client's comfort and ability to participate in the interview. 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 recapitulates the interview, highlighting key points.

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.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver? The nurse leaves the room when a client is crying to provide privacy. The nurse uses open-ended questions when working with a crying client. The nurse documents the client was crying at the end of the shift. The nurse calls the hospital chaplain to talk with the client.

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

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

The nursing and medical literature

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 Lapse

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

Time-lapse

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client? Developmental stage assessment Time-lapsed assessment Emergency assessment Focused assessment

Time-lapsed assessment

When performing an assessment, the nurse should focus most on the developmental stage for which client? Toddler Young adult Middle-age adult Adolescent

Toddler

When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind? Validate inferences with the client. Do not share inferences with the client. Document all inferences. Avoid making any inferences.

Validate inferences with the client.

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 bestthing 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

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action? Verbally report the finding to the charge nurse at the change of shift. Inform the unlicensed assistive personnel to document the finding. Verbally report the finding immediately to the client's physician. Reassess the client's temperature in 2 hours and chart this data.

Verbally report the finding immediately to the clients physician

The nurse watches a 43-year-old client walk into the room and notes the client is slightly limping on the left foot when walking. The nurse also notes the client has difficulty sitting in the chair and sits down carefully with the left leg slightly held forward. The client notes having had difficulty walking for the past year and it is getting worse. A previous ultrasound of the foot revealed a Morton neuroma. The client reports continued pain in the left foot when walking or standing for long periods of time. A physical examination reveals pain and tenderness on palpation of the upper left foot, skin is cool to touch with no redness noted, pedal pulse is 78 beats/min and regular. Which action by the nurse demonstrates the observation phase of an assessment? Watching client walk into room Palpating the skin for pain and temperature Reviewing past records for ultrasound Measuring the pedal pulse

Watching client walk into room

Which is the bestsource of information for the nurse when collecting data for an assessment? Primary physician Client Charge nurse Medical record

client