Prep U - Ch 11 : Nursing Process

The nurse is interviewing a client who was admitted to the acute care facility. During the interview, the client states, "Sometimes I get a bit fuzzy after I take my medicine." Which response by the nurse would be most appropriate?

"Can you tell me what you mean when you say 'fuzzy'?"

How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation?

"Client states, 'I don't see the point in trying anymore.'"

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which of the following questions is the most appropriate conclusion to the interview?

"Is there anything else we should know in order to care for you better?"

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?

"Mr. Koeppe, tell me what you do to take care of yourself."

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?

"Unable to palpate femoral pulse in left leg."

Which of the following patient situations most likely warrants a time-lapsed nursing assessment?

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

A student takes an adult patient's pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the student do next?

Ask the instructor or a staff nurse to take the pulse.

During the nursing examination, the nurse notices that the patient, an elderly female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation?

Ask the patient if it is okay to interview her husband for the answers to the interview questions.

The nurse is interviewing a client with complaints of chills, fever, malaise, and cough. During the working phase of the client interview, the nurse:

Asks the client to describe symptoms.

A nursing student is learning about how to perform a thorough assessment in a health assessment class. Which of the following is the best source of information for the student to learn data collection for an assessment?

Client

A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which of the following?

Client The client is the primary source of information. The spouse, medical records and primary care physician are considered secondary sources.

A client reports to a health care facility with complaints of abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data?

Client himself

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

Collection, validation, communication of client data

A 50-year-old female patient is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information?

Consult nursing and medical literature.

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?

Focused assessment

An older adult male with a history of benign prostatic hyperplasia presents to the emergency room with complaints of urinary retention. The nurse collects data related to the patient'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 assessment

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?

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.

When charting the assessment of a client, the nurse writes,"Client is depressed." This documentation is an example of which of the following?

Interpretation of data

A nurse is assessing a client admitted to the health care facility with angina. Which of the following would be most appropriate for the nurse to use to collect subjective data?

Interview

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?

Measure the client's oral temperature.

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

Objective

While examining a client, the nurse assesses the temperature of the client's skin. The nurse most likely would be using which technique?

Palpation

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?

Sharp pain in the knee

The nursing instructor is teaching the students how to do an interview on a client. Which of the following statements made by a student indicates a need for further instruction?

Show your name badge to the client so they can read who you are

After suffering a wrist fracture in a recent fall, a female client 77 years of age is strongly suspected of having osteoporosis. Which of the following data best demonstrates the nursing focus of assessment?

The client claims her mobility and independence have declined in recent years.

The nurse is performing a physical assessment of a client admitted with emphysema. How will the nursing physical assessment differ from a medical physical assessment?

The nurse's physical assessment will focus on the client's functional abilities.

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?

Time-lapsed

When performing an assessment, the nurse should focus on the developmental stage for which of the following clients?

Toddler

When documenting subjective data, the nurse should do which of the following?

Use the client's own words placed in quotation marks.

The nurse is performing a physical assessment of a newly admitted client. During the assessment the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client is there is any pain the answer is "no." What is the best thing for the nurse to do next?

Validate the data Data needs to be validated when there are discrepancies such as the client saying there is no pain but the nonverbal behavior indicates that they are experiencing pain.

Of the following data, what type would be collected during a physical assessment?

color, moisture, and temperature of the skin

A nursing student is performing an assessment on a client. Which of the following would the student record as subjective data? Select all that apply.

• "My leg hurts when I move." • "I am so afraid of what my diagnosis is." • "I am always anxious."

The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? Select all that apply.

• 38 year-old man • Height: 6' • Weight 195 pounds

Nurses collect objective and subjective data during the patient interview. Which patient data is subjective data? (Select all that apply.)

• A patient describes his pain as an 8 on the pain assessment scale. • A patient feels nauseated after eating his breakfast. • A patient complains of being cold and requests an extra blanket.

Which of the following are examples of common factors in a client that may influence assessment priorities? Select all that apply.

• Diet and exercise program • Developmental stage • Need for nursing

Which of the following qualities does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply.

• Professionalism • Respect for client • Caring • Competence