NURS 121 PrepU Chapter 14

What should the nurse do prior to performing an initial assessment on a newly admitted client?

Review the records available on the client.

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

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

Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training?

All data collected need to be validated.

Which statement by a nurse best indicates an accurate understanding of the different types of assessments?

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

Which are examples of subjective data? Select all that apply.

A client describes pain as an 8 on the pain assessment scale. A client feels nauseated after eating breakfast. A client reports being cold and requests an extra blanket

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

A focused assessment of the specific problems identified

Which scenario is an example of a time-lapse reassessment?

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?

A priority problem requires a nursing intervention before another problem is addressed.

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.

Which scenario is an example of a time-lapse reassessment?

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

Which are examples of subjective data? Select all that apply.

Anxiety Light-headedness Nausea

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview?

Avoid the impulse to interrupt.

The nurse is preparing to interview several clients during clinic hours. What language difficulty might a nurse encounter while performing various interviews in a diverse population of clients?

Clients not being fluent in the same language as the nurse Clients having a limited education Clients fearing saying the wrong thing

Which group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data

Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist?

Consultation

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

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 sits in a chair placed at a 45-degree angle to the bed.

Which are assessment techniques the nurse uses when performing a physical examination? Select all that apply.

Inspection Palpation Percussion Auscultation

A client presents to an outpatient health care office for the first time. What step would the nurse take first, prior to taking a health assessment from the client?

Introduce oneself to the client.

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 quadrant (RLQ) rebound tenderness, blood pressure of 130/92 mm Hg, and pulse 100 beats/min and weak?

Notify the health care provider immediately

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

the nurse is interviewing an 80-year-old client admitted to the hospital for evaluation of diabetes. The client reports enjoying being in the hospital because the client lives alone and does not have many friends. The client reports having a spouse die 1 year ago and no longer being able to drive. The client relies on a daughter, who lives one hour away, to shop for the client once a week. The client states, "My daughter can never stay long and is just in and out in no time." Which nursing diagnoses would be appropriate for this client? Select all that apply.

Risk for Loneliness powerlessness

During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

Sitting at eye level with the client

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.

Stating "My legs feel like they are burning" Redness and blisters forming on both legs Crying and trying to scratch legs due to itching

Which is the primary reason for a nurse collecting data continuously on a client?

The client's health status can change quickly.

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 immediately to the client's health care provider.

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being:

able to prioritize

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?

objective

The nurse is assessing the client's abdominal wound and notes yellow-green purulent wound drainage. The nurse recognizes that the drainage is an example of:

objective data

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client?

pain

When assessing the firmness of a client's abdomen, the nurse should use which assessment technique?

palpation

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

secondary

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 nurse

A nurse practitioner in private practice with a health care provider 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?

time-lapse

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 best thing for the nurse to do next?

validate the data