Kasey's assessing set.
if a patient can't stay focused and jumps from one topic to another while speaking rapidly what would the nurse aspect is the reason for this behavior?
high anxiety
data
information
subjective data
information perceived only by the affected person
objective data
information perceptible to the senses; may be verified by another person
For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?
initial
Read the following scenario and identify the adjective used to describe the characteristics of patient data that are numbered below. Place your answers on the lines provided. The nurse is conducting an initial assessment of a 79-year-old female patient admitted to the hospital with a diagnosis of dehydration. The nurse (1) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data. (2) First the nurse asks the patient about the most important details leading up to her diagnosis. Then the nurse (3) collects as much information as possible to understand the patient's health problems; (4) collects the patient data in an organized manner; (5) verifies that the data obtained is pertinent to the patient care plan; and (6) records the data according to facility's policy. (1) ___________________ (2) ___________________ (3) ___________________ (4) ___________________ (5) ___________________ (6) ___________________
(1) Purposeful: The nurse identifies the purpose of the nursing assessment (comprehensive) and gathers the appropriate data. (2) Prioritized: The nurse gets the most important information first. (3) Complete: The nurse gathers as much data as possible to understand the patient health problem and develop a care plan. (4) Systematic: The nurse gathers the information in an organized manner. (5) Accurate and relevant: The nurse verifies that the information is reliable. (6) Recorded in a standard format: The nurse records the data according to the facility's policy so that all caregivers can easily access what is learned.
what part of a clients record include findings from the physicians?
1. medical history 2. physical exam 3. progress notes
Name four assessment techniques performed during a physical examination
inspection, percussion, palpation, auscultation
what is the purpose of assessment?
it offers guidance for which type and how much data to collect
After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data? A) Auscultation of the lungs B) Complaint of nausea C) Sensation of burning in her epigastric area D) Belief that demons are in her stomach
A) Auscultation of the lungs Objective data include techniques of inspection, palpation, percussion, and auscultation. Symptoms, values, perceptions, feelings, beliefs, attitudes, and sensations are sources of subjective data.
The nurse is conducting a nursing 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? A) Clarify discrepancies of assessment data with the client. B) Validate client data with members of the health care team. C) Document all data collected in the nursing history and physical examination. D) Seek input from family members regarding the client's breathing at home.
A) Clarify discrepancies of assessment data with the client. First, the nurse needs to validate the data with the client, who is the primary source. The nurse can validate data with the health care provider but consulting with the client is the best option. The client must give permission for family members to participate in the health history. Ultimately, the nurse documents all assessment data, both from the history and the physical exam.
A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information? A) Client's wife B) Medical documents C) Test results D) Assessment data
A) Client's wife In this case, the primary source of information is the client's wife, as she can provide a detailed description of the incident as well as provide the medical history of the client. The medical files, test results, and assessment data are secondary sources of information.
A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation? A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward. B) Encourage the novice nurse to develop his or her own tool for data collection. C) Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the correct interpretation. D) Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for communication skills.
A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward. The novice nurse can improve interpretation skills by independently observing the same situation with a peer, comparing notes afterward, and role-playing various validation techniques.
The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using? A) Human Needs (Maslow) model B) Functional Health Patterns model C) Human Response Patterns model D) Body System model
A) Human Needs (Maslow) model The nurse is following the Human Needs model based on Maslow's Hierarchy of Human Needs. The Functional Health Patterns model was developed by Gordon and is a framework that identifies 11 functional health patterns and organizes data according to these patterns. The Body System model is often used by the medical community, and it organizes data according to organ and tissue function in various body systems. The Human Response Pattern model focuses on a unitary person.
The nurse observes the client as he walks into the room. What information will this provide the nurse? A) Information regarding the client's gait B) Information regarding the client's personality C) Information regarding the client's psychosocial status D) Information on the rate of recovery from surgery
A) Information regarding the client's gait Observation includes looking, watching, examining, scrutinizing, surveying, scanning, and appraising.
The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures.
A) Measure the client's oral temperature. An inference must be followed by a validation process. In this case, the inference of fever is best validated or rejected by measuring the client's temperature. This should precede interventions such as blood work or even providing a warm blanket.
The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures
A) Measure the client's oral temperature. An inference must be followed by a validation process. In this case, the inference of fever is best validated or rejected by measuring the client's temperature. This should precede interventions such as blood work or even providing a warm blanket.
The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's health status. Which of the following would the nurse identify as a subjective cue? A) Sharp pain in the knee B) Small bloody drainage on dressing C) Temperature of 102 degrees F D) Pulse rate of 90 beats per minute
A) Sharp pain in the knee Sharp pain in the knee is an example of a subjective cue. Subjective cues are imperceptible, immeasurable, and abstract. Small bloody drainage on dressing, a temperature of 102 degrees F, and a pulse rate of 90 beats per minute are examples of objective cues.
An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first? A) The client's airway should be assessed. B) The nurse should determine the reason for admission. C) The nurse should review the client's medications. D) The client's past medical history is assessed.
A) The client's airway should be assessed. Emergency assessment takes place in life-threatening situations in which the preservation of life is the top priority. Often, the client's difficulty involves airway, breathing, and circulatory problems.
A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future? A) The nurse should practice interviewing strategies. B) The nurse should modify data collection tool. C) The nurse should determine specific purpose of data collection. D) The nurse should update the database.
A) The nurse should practice interviewing strategies. Strong interviewing skills are needed to obtain the necessary patient data. A common cause of data omission is the nurse's failure to know what information is wanted or not following up on client cues. The nurse only needs to modify the data collection tool if the database is inappropriately organized. If irrelevant or duplicate data is collected, the nurse should determine specific purpose of data collection. Data collection should be ongoing. If the nurse notices that data collection stopped after the initial assessment data were collected, the nurse should update the database.
A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status? A) To identify a life-threatening problem B) To establish a database for medical care C) To practice respiratory assessment skills D) To facilitate the resident's ability to breathe
A) To identify a life-threatening problem When a life-threatening physiologic or psychological crisis occurs, the nurse performs an emergency assessment to identify life-threatening problems. Emergency assessments are not used to establish a database for medical care, practice assessment skills, or help a physiologic process (such as breathing).
When documenting subjective data, the nurse should do which of the following? A) Use the client's own words placed in quotation marks. B) Paraphrase the information stated by the client. C) Validate the information with the client's family prior to documentation. D) Record the information using nonspecific words.
A) Use the client's own words placed in quotation marks. Subjective data should be recorded using the client's own words, whenever possible. Quotation marks should be used around the client's statement. The tendency to use nonspecific terms that are subject to individual definition or interpretation should be avoided.
Which of the following examples of client data needs to be validated? Select all that apply. A) A client has trouble reading an informed consent, but states he does not need glasses. B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall. C) A nurse examining a client with a respiratory infection documents fever and chills. D) A client in a nursing home states that she is unable to eat the food being served. E) A pregnant client is experiencing contractions that are two minutes apart.
A, B Because validation of all data is neither possible nor necessary, nurses need to decide which items need verification. For example, data need to be verified when there are discrepancies: A patient tells the nurse he is fine and has no concerns, but the nurse notes that he demonstrates tense body musculature and seems curt in his responses. When there is a discrepancy between what the person is saying and what the nurse is observing, validation is necessary to determine accuracy. Data also need verification when they lack objectivity.
Which of the following are examples of common factors in a client that may influence assessment priorities? Select all that apply. A) Diet and exercise program B) Standing in the community C) Ability to pay for services D) Developmental stage E) Need for nursing
A, D, E The purpose for which the assessment is being performed offers the best guideline about what type and how much data to collect. Assessment priorities are influenced by the client's health orientation, developmental stage, culture, and need for nursing. After the comprehensive nursing assessment has been completed, client health problems dictate assessment priorities for future nurse-client interactions.
Which of the following data regarding a client with a diagnosis of colon cancer are subjective? Select all that apply. A) The client's chemotherapy causes him nausea and loss of appetite. B) The client became teary when his daughter from out of state came to the bedside. C) The client's ileostomy put out 125 mL of effluent in the past four hours. D) The patient is unwilling to manipulate or empty his ostomy bag. E) The patient has been experiencing fatigue in recent weeks.
A, E Reports of nausea, anorexia, and fatigue are subjective data that depend on the client's self-report. Weeping, ostomy output, and an inability to perform a kinesthetic task are observable assessment findings that would be characterized as objective.
Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients? A) "Assessment data about the client should be collected continuously." B) "Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses." C) "Assess your client at least hourly if the client's vital signs are unstable, and every two hours if the vital signs are stable." D) "Assessment data should be collected prior to the physician rounding on the unit."
A. "Assessment data about the client should be collected continuously." Data about the client are collected continuously because the client's health status can change quickly.
Which of the following questions or statements would be an appropriate termination of the health history interview? A) "Well, I can't think of anything else to ask you right now." B) "Can you think of anything else you would like to tell me?" C) "I wish you could have remembered more about your illness." D) "Perhaps we can talk again sometime. Goodbye."
B) "Can you think of anything else you would like to tell me?" The successful interview is concluded carefully. After summarizing the data, it is helpful to ask the client if he or she has anything else to tell the nurse. This gives the client the chance to add data the nurse did not think to include.
When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? A) Complete B) Focused C) General D) Time-lapse
B) Focused In focused assessments, the nurse determines whether the problem still exists and whether the status of the problem has changed.
A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do? A) Initial assessment B) Focused assessment C) Emergency assessment D) Time-lapsed assessment
B) Focused assessment A focused assessment is completed by the nurse to gather data about a specific problem that has already been identified. It is also used to identify new or overlooked problems.
A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment? A) Initial assessment B) Focused assessment C) Time-lapsed reassessment D) Emergency assessment
B) Focused assessment The nurse is performing a focused assessment to determine whether the problem still exists, and whether the status ofthe problem has changed. An initial or admission assessment is the initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction. Time-lapsed reassessment is performed after the initial assessment when substantial periods of time have elapsed between assessments. An emergency assessment is performed any time a physiologic, psychological, or emotional crisis occurs.
A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data? A) Blood pressure B) Nausea C) Heart rate D) Respiratory rate
B) Nausea Subjective data are those which the client can feel and describe. Nausea is subjective data, as it can only be described and not measured. Blood pressure, heart rate, and respiratory rate are measurable factors and are therefore objective data.
A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make? A) Number of rooms in the house B) Safety of the immediate environment C) Frequency of home visits to be made D) Friendliness of the client and family
B) Safety of the immediate environment The nurse should also observe the safety of the immediate environment. Observation is the conscious and deliberate use of the five senses to gather data. Each time a client is observed, the nurse observes current responses, ability to provide self-care, the immediate environment, and the larger environment.
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond? A) "Do you have a family history of chest problems?" B) "Why don't you use a laxative every night?" C) "Do you take anything to help your constipation?" D) "Everyone who ages has bowel problems."
C) "Do you take anything to help your constipation?" A possible cause of omission of pertinent data is failing to follow up on cues during data collection. The nurse should ask about what the client uses to self-treat her constipation in order to identify further important information. It is not correct to ignore the statement, ask "why" questions, or make assumptions.
A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of the following statements by the nurse would recognize the client's value as an individual? A) "Can you tell me how long your father has been this way?" B) "Sarah, I have to go and read your father's old charts before we talk." C) "Mr. Koeppe, tell me what you do to take care of yourself." D) "Mr. Koeppe, I know you can't answer my questions, but it's okay."
C) "Mr. Koeppe, tell me what you do to take care of yourself." Clients such as older adults with dementia, and their children, cannot be relied on to report accurately. However, they should be encouraged to respond to interview questions as best as they can. Bypassing the client communicates that the nurse does not have time or has doubts in the client's ability to communicate.
Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview? A) "Why didn't you go to the doctor when you began to have this pain?" B) "Are you feeling better now than you did during the night?" C) "Tell me more about what caused your pain." D) "If I were you, I would not wait to get medical help next time."
C) "Tell me more about what caused your pain." Avoid questions that impede communication during the interview, including those that can be answered by yes or no, why or how questions, and giving advice.
The nurse is reviewing information about a client and notes the following documentation Client is confused. The nurse recognizes this information is an example of what? A) Subjective data B) A data cue C) An inference D) Primary data
C) An inference Making a judgment that the client is confused is an inference. An inference must be validated with subjective and/or objective data cues. Sources of data cues can be primary or secondary.
While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which of the following actions clearly demonstrates assessing? A) The nurse bathing the client B) The nurse documenting the incident C) The nurse asking if the client is having pain D) The nurse removing the wash basin
C) The nurse asking if the client is having pain The nurse asking if the client is having pain clearly demonstrates assessing. Bathing the client and removing the wash basin demonstrate implementation. Documentation is part of every step of nursing process.
A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment? A) Comprehensive B) Focused C) Time-lapsed D) Emergency
C) Time-lapsed The time-lapsed assessment is scheduled to compare a client's current status to baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses, are scheduled for periodic time-lapsed assessments to reassess health status and to make necessary revisions in the plan of care.
Of the following information collected during a nursing assessment, which are subjective data? A) vomiting, pulse 96 B) respirations 22, blood pressure 130/80 C) nausea, abdominal pain D) pale skin, thick toenails
C) nausea, abdominal pain Subjective data are information perceived only by the affected person. They cannot be perceived or verified by another person. Other terms for subjective data are symptoms or covert data.
A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply. A) Carrying out a physician's order to intubate a client B) Educating a novice nurse on the principles of triage C) Using the nursing process to diagnose a blocked airway D) Interviewing privately a client suspected of being a victim of abuse E) Checking with the family about the data supplied by a client suffering from dementia
C, D, E Since the entire nursing process rests on the initial and ongoing assessment of the client, it is imperative to use excellent critical thinking skills when gathering, validating, analyzing, and communicating data. The nurse using critical thinking skills assesses information systematically using the nursing process, detects biases, makes judgments about the significance of data, and identifies assumptions and inconsistencies. Carrying out physician's orders and educating a novice nurse involve the implementation stage of the nursing process.
A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? A) "My leg hurts so bad. I can't stand it." B) "Appears anxious and frightened." C) "I am so sick; I am about to throw up." D) "Unable to palpate femoral pulse in left leg."
D) "Unable to palpate femoral pulse in left leg." Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client. Objective data are also called signs or overt data. The only objective data in this question would be that the nurse is unable to palpate a femoral pulse.
The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment? A) To gather data about a specific and current health problem B) To identify life-threatening problems that require immediate attention C) To compare and contrast current health status to baseline data D) To establish a database to identify problems and strengths
D) To establish a database to identify problems and strengths An initial assessment is performed shortly after the client is admitted to a health care agency or service. The purpose of the initial assessment is to establish a complete database for problem identification and care planning.
What is the primary purpose of validation as a part of assessment? A) To identify data to be validated B) To establish an effective nurse-client communication C) To maintain effective relationships with coworkers D) To plan appropriate nursing care
D) To plan appropriate nursing care Validation is the act of confirming or verifying to plan appropriate nursing care. Validation is an important part of assessment because invalid information can lead to inappropriate nursing care. Validation does not identify data to be validated, nor does it establish effective nurse-client communication or relationships with coworkers.
A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself? A) Standing at the end of the bed B) Standing at the side of the bed C) Sitting at least six feet from the beside D) sitting at a 45-degree angle to the bed
D) sitting at a 45-degree angle to the bed If the patient is in bed, placing a chair at a 45-degree angle is helpful in facilitating an easy exchange of information. If the nurse stands at the side or foot of the bed and physically looks down at the client, a superior-inferior relationship is communicated and can negatively affect the interview.
True or false: all data collected needs to be validated
False
minimum data set
a standard established by health care institutions that specifies the information that must be collected from every patient
A nurse is caring for a client admitted to the hospital with difficulty urinating, bloody urine, and a burning sensation while urinating. what is the priory assessment for this client?
a focused assessment of the identified problems
The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all that apply. a) A patient tells the nurse that she is feeling nauseous. b) A patient's ankles are swollen. c) A patient tells the nurse that she is nervous about her test results. d) A patient complains that the skin on her arms is tingling. e) A patient rates his pain as a 7 on a scale of 1 to 10. f) A patient vomits after eating supper.
a, c, d, e. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting.
The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. a) "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b) "It's hospital policy. I know it must be tiresome, but I will try to make this quick!" c) "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." d) "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." e) "We need to check your health status and see what kind of nursing care you may need." f) "We need to see if you require a referral to a physician or other health care professional."
a, e, f. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.
A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? a) "You made an inference that she is fine because she has no complaints. How did you validate this?" b) "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." c) "Sometimes everyone gets lucky. Why don't you try to help another patient?" d) "Maybe you should reassess the patient. She has to have a problem—why else would she be here?"
a. The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving.
Validation
act of confirming or verifying
database
all the pertinent patient information that enables a comprehensive and effective plan of care to be designed and implemented
time-lapsed assessment
an assessment that is scheduled to compare a patient's current status to baseline data obtained earlier
focused assessment
assessment conducted to assess a specific problem; focuses on pertinent history and body regions but may also be used to address the immediate and highest priority concerns for an individual patient
nursing history
assessment of the patient by interview to identify the patient's health status, strengths, health problems, health risks, and need for nursing care
A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? a) Maslow's human needs b) Gordon's functional health patterns c) Human response patterns d) Body system model
b. Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.
A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? a) "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" b) "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c) "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." d) "Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."
b. Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking.
The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? a) Inform the charge nurse. b) Inform the surgeon. c) Validate the finding. d) Document the finding.
c. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy.
Initial Assessment
comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgment about a patient's health status, ability to manage one's own health care, and need for nursing, and to plan individualized, holistic health care for the patient
observation
conscious and deliberate use of the five senses to gather data
a nurse is taking care of a patient who was admitted for N/V and during the assessment the patient reports mild chest pain. the nurse is unsure whether the chest pain is from the gastrointestinal symptoms or other reasons. what should the nurse do?
consult with another nurse
A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? a) Correct the initial assessment form. b) Redo the initial assessment and document current findings. c) Conduct and document an emergency assessment. d) Perform and document a focused assessment of skin integrity.
d. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.
The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? a) Comprehensive b) Initial c) Time-lapsed d) Quick priority
d. Quick priority assessments (QPAs) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care facility or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.
When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? a) Thank the wife for being present. b) Ask the wife if she wants to remain. c) Ask the wife to leave. d) Ask the patient if he would like the wife to stay.
d. The patient has the right to indicate whom he would like to be present for the nursing history and exam. The nurse should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife.
True or false: the client is ALWAYS the best source for collecting data
false
a client has a poor past medical history. whom should the nurse consult about the clients past medical history?
family
a client come to the emergency room with a productive cough and elevated temperature. what type of assessment would the nurse perform?
focused
review of systems
physical examination of all body systems in a systematic manner as part of the nursing assessment
interview
planned communication for a specific purpose (e.g., data collection)
cue
significant information that is helpful in making decisions
Physical Assessment
systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care, usually performed in a head-to-toe format; a collection of objective data about changes in the patient's body systems
inference
the judgment reached about a cue
assessing
to systematically and continuously collect, validate, and communicate patient data
patient-centered assessment method (PCAM)
tool for assessing patient complexity using the social determinants of health that often explain why patients with the same or similar health conditions differ in their ability to manage their health and in their outcomes
True or false: anxiety, nausea, and light headedness are examples of subjective data
true
emergency assessment
type of rapid focused assessment conducted when addressing a life-threatening or unstable situation
when making and inference from the cues obtained during an assessment the nurse should always do what?
validate the inferences with the client
during admission a teenage client who is diagnosed with anorexia informs the nurse of a 5 pound weight loss. what should the nurse do with this data?
validate this weight loss with the client
