Health Assessment Chapter 5
A nursing instructor is teaching about respiratory problems in the patient with chronic obstructive pulmonary disease (COPD). The instructor realizes that the student needs more teaching when the student states which of the following? "Impaired gas exchange and ineffective breathing pattern can be interchanged." "The nurse must examine the definition and defining characteristics when picking a diagnosis." "Diagnostic labels often overlap." "All respiratory diagnoses reflect a problem but each describes a different human response."
"Impaired gas exchange and ineffective breathing pattern can be interchanged." Choosing a nursing diagnosis is often difficult because many diagnostic labels overlap. Even though many respiratory diagnostic labels reflect problems, each describes a very different human response. Therefore, when picking one, the nurse must examine the defining characteristics and the definition as well.
A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data? Reports of hair loss Worried about appearance Itching sensation all over body Anxious appearance
Anxious appearance
What can the nurse use to learn new information and add to their knowledge base? Clinical experience. Past experience of other nurses. Reading a medical-surgical textbook. Doing several written care plans
Clinical experience.
The nurse is walking by a client's room and notices the client's pulse oximeter reads 89% on the monitor. What is the nurse's best action? Document the oxygen saturation level in the client's medical record. Enter the room and auscultate the client's lung sounds. Notify the healthcare provider immediately of the finding. Administer the scheduled diuretic as prescribed.
Enter the room and auscultate the client's lung sounds. The client's oxygen saturation level is low. Urgent situations warrant immediated assessment and intervention. The nurse should assess first to determine the need for interventions such as diuretic administration. The nurse then may need to contact the healthcare provider. After the client has been cared for, the nurse should document the situation.
The nurse gathers the follow data: complaint of headache and sore throat, redness noted on pharynx with white exudates on tonsils, minimal cough, temperature 100.6°F orally. It was noted that the patient had another sore throat 2 weeks ago. The most appropriate nursing diagnosis for this data would be Impaired comfort related to headache and sore throat pain Ineffective health maintenance related to repeated sore throat Infection related to elevated temperature Stress related to illness
Impaired comfort related to headache and sore throat pain The priority diagnosis is related to the chief complaint of headache and sore throat.
The nurse should perform which actions to reduce risk in the hospitalized client? (Select all that apply.) Insert indwelling urinary catheters for all hospitalized clients who are not able to ambulate. Turn clients who are bedbound once per shift and place pillows under bony prominences. Request healthcare provider orders for central line placement on clients receiving intravenous fluids. Inspection of surgical site wounds frequently to assess for redness, warmth, or edema. Place bed alarms in rooms of clients who are confused or demonstrate an unsteady gait.
Inspection of surgical site wounds frequently to assess for redness, warmth, or edema. Place bed alarms in rooms of clients who are confused or demonstrate an unsteady gait.
A client presents to the emergency department complaining of new onset chest pain. What is the priority action of the nurse? Collect client's health history. Reconcile current medications. Place on cardiac monitor. Record the client's allergies.
Place on cardiac monitor. The nurse should prioritize care and address physiological, urgent needs first. The client should be placed on the cardiac monitor. The health history and medication use data can be collected while the client is being monitored. The nurse should ask the client about any allergies first as the client may be allergic to certain stickers used for cardiac monitoring. However, any allergies can be recorded after place on continous monitoring.
Select the following nursing diagnosis that is correctly stated. Risk for Impaired Skin Integrity related to immobility, bedrest, pain in legs, and the client states "I will not go to Physical therapy." Risk for Impaired Skin Integrity related to immobility as manifested by constant bedrest and the inability to ambulate the client twice a day. Risk for Impaired Skin Integrity related to immobility secondary to right-sided paralysis, dehydration, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin. Risk for Impaired Skin Integrity related to bedrest, lack of time to ambulate client, right-sided paralysis, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin.
Risk for Impaired Skin Integrity related to immobility secondary to right-sided paralysis, dehydration, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin. A risk diagnosis describes a situation in which an actual diagnosis will most likely occur if the nurse does not intervene. In this case, the client does not have any symptoms or defining characteristics that are manifested, thus a shorter statement is sufficient: Risk for + diagnostic label + r/t + etiology.
Which assessment finding on a hospitalized adult client requires urgent intervention? Left-sided weakness after stroke that occurred 3 days ago 2+ dorsalis pedis pulse in left foot Urine output of 100 mL in 8 hours Oxygen saturation of 95% on room air
Urine output of 100 mL in 8 hours An acute change in urine output less than 50 mL (about 1-3/4 oz) over 4 hours requires urgent intervention. Some weakness is expected after a stroke. +2 pulses are normal. An oxygen saturation of 95% is not a great cause for concern in an adult.
The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client? Weight gain of 3 pounds (1.5 kilograms) over 1-2 days Ineffective health maintenance related to having last mammogram 2 years ago Knowledge deficit related to lack of information regarding low-sodium diet Anxiety related to ineffective coping during hospitalization
Weight gain of 3 pounds (1.5 kilograms) over 1-2 days Nursing diagnoses are based on alterations in body system processes, lifestyle, personal issues, and specific causes. For the client with heart failure, the problem that would have the highest priority would be the weight gain of 3 pounds (1.5 kilograms) over 1-2 days. This change can related to a decline in cardiac functioning and needs to be addressed first. Once this priority problem has been investigated, other problems can be addressed. Ineffective health maintenance can be addressed last. Knowledge deficit related to lack of information regarding low-sodium diet would be the next in priority after activity intolerance because learning how to reduce sodium could help control the heart failure. Anxiety about hospitalization and inability to attend to home and work needs would be addressed after the knowledge deficit.
The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client? Weight gain of 3 pounds (1.5 kilograms) over 1-2 days Ineffective health maintenance related to having last mammogram 2 years ago Knowledge deficit related to lack of information regarding low-sodium diet Anxiety related to ineffective coping during hospitalization
Weight gain of 3 pounds (1.5 kilograms) over 1-2 days Nursing diagnoses are based on alterations in body system processes, lifestyle, personal issues, and specific causes. For the client with heart failure, the problem that would have the highest priority would be the weight gain of 3 pounds (1.5 kilograms) over 1-2 days. This change can related to a decline in cardiac functioning and needs to be addressed first. Once this priority problem has been investigated, other problems can be addressed. Ineffective health maintenance can be addressed last. Knowledge deficit related to lack of information regarding low-sodium diet would be the next in priority after activity intolerance because learning how to reduce sodium could help control the heart failure. Anxiety about hospitalization and inability to attend to home and work needs would be addressed after the knowledge deficit.
The nurse divides collected data into subjective and objective categories. What should the nurse do next in the critical thinking process? cluster the data select nursing diagnoses choose appropriate interventions identify abnormal data and strengths
identify abnormal data and strengths Before beginning the analysis phase of the nursing process, the nurse must complete the collection of data then identify abnormal data and strengths. Clustering the data occurs after the abnormalities and strengths have been identified. Nursing diagnoses occurs after the data are clustered. Interventions are chosen according to selected nursing diagnoses.
The nursing instructor informs the students that there are pitfalls that decrease the reliability of cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of data and includes which of the following? reliable data too many or too few data valid data cues available to support the diagnosis
too many or too few data Pitfalls decrease the reliability of cues and decrease diagnostic accuracy. One set of pitfalls inculdes too many or too few data, unreliable data, or invalid data and an insufficient number of cues available to support the diagnosis. Valid data, reliable data, and cues that support the diagnosis are desirable.