Ch 1 Analyzing data to make accurate clinical judgment

A client admitted with hyperthyroidism develops life-threatening symptoms—high fever (104° F/40° C), tachycardia (150 bpm), and elevated blood pressure (200/105 mm Hg)—prior to receiving radioactive iodine treatment. What type of assessment should the nurse perform on this client?

emergency Because these symptoms are life threatening, an emergency assessment (assessing the client's airway, breathing, and circulation) should be completed to ensure prompt treatment is provided. A focused assessment is completed in nonemergency situations and addresses a specific issue. A comprehensive assessment is completed at the time of admission. A partial or ongoing assessment is completed after a comprehensive assessment; the nurse reassesses areas of concern for improvement.

Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next?

evaluation Because the nurse administered the insulin, the effectiveness of the insulin needs to be evaluated. The nurse already assessed the client, diagnosed the client with hyperglycemia, and implemented a plan to treat the hyperglycemia.

A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?

"I'm sorry, but assessment is ongoing and continuous." Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ongoing and continuous throughout all the phases of the nursing process.

A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse?

Assess the nasogastric tube for proper functioning. Drainage should taper off gradually, not increase or decrease abruptly. The nurse needs to assess proper functioning of the nasogastric tube. The nurse should not intervene before assessing the tube. The nurse should not wait another hour to evaluate output. The nurse does not have enough information to develop a plan.

When assisting a client with health promotion, what must the nurse also nurture?

A healthy environment In order to assist a client with health promotion, a healthy environment must also be nurtured

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?

Empathy Empathy is an intuitive awareness of what the client is going through; it helps the nurse to be effective in providing for the client's needs while remaining compassionately detached. Inspection and palpation are skills that help the nurse in collecting objective data of the client's physical characteristics. Sympathy is a feeling that would make the nurse as emotionally distraught as the client; this hampers the ability of the nurse to provide client care.

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?

Ask the client about the most recent experiences of pain. Data are best validated by the client. Other sources are valid and useful, but the client is the ultimate source, especially in the case of subjective data.

What is the primary function of the health care team?

To decide the best overall care The health care team meets to collaborate on clients and decide the best overall care. This occurs throughout the lifespan, from the inception of life until death. The health care team is a partnership. The group includes the nurse, physician, nutritionist, social worker, physical therapist, occupational therapist, speech therapist, and/or dentist. They all work together on the same team for the benefit of the client.

What are nurses able to detect through the health assessment?

Areas in need of health adjustments Through the health assessment nurses are able to detect areas in need of health adjustments.

What are the areas of independent nursing practice? Select all that apply.

Deciding when physical procedures should be performed on a client Deciding what client teaching is necessary Deciding when a client needs to be turned Independent nursing interventions include client teaching, therapeutic communication, and physical procedures such as turning clients or assisting them with ambulation. The medications a client receives and the diagnosis of the client are medical decisions, not nursing decisions.

When doing an overall assessment of a client, the nurse is able to use findings for which primary purpose?

Identify in what areas the client needs the most care. During the overall assessment of the client, the nurse is able to use the findings and decide in which areas the client is in need of the most care. The nurse should not identify conditions that the health care provider may have missed or identify the client's medical diagnosis, as making medical diagnoses are not within the nursing scope of practice. The nurse may provide education to the client's family throughout the client's care; however, the nurse should not delegate education of the family to the client, because this is the nurse's responsibility.

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and the nursing care plan needs to be revised. The assessment stage involves collecting subjective and objective data. The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment. The implementation phase involves carrying out the plan to meet the determined outcome criteria.

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should

avoid premature judgments about the client. After reviewing the record or discussing the client's status with others, remember to keep an open mind and to avoid premature judgments that may alter your ability to collect accurate data. Validate information with the client and be prepared to collect additional data.

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)

focused or problem-oriented assessment. A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.

When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?

Diagnosis Diagnosis occurs when the data has been analyzed and a professional judgment occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan. Evaluation assesses whether the outcome criteria have been met.

The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority?

significantly impaired hearing As a nurse, it is vital to sift through all the client information and make decisions on what information will impact client safety and quality of care. The ability to identify what is important on a daily basis for each individual client is paramount for nursing care. Of the data provided, the client's impaired hearing poses the greatest safety risk and has the greatest impact on the client's quality of life and so has priority. While the other options could be potential factors related to quality of life and safety, the nurse will need to assess them further.

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?

Ongoing An ongoing or client assessment occurs after the comprehensive database is established. It is a mini overview of the client's body systems. The initial assessment was completed upon admission. A focused assessment is completed when the database for a client already exists and the client is experiencing a specific problem. An emergency assessment is completed in a life-threatening situation.

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

Head-to-toe A head-to-toe or comprehensive assessment is the most organized system for gathering comprehensive physical data.

How does a nurse decide what health-promotion activities are necessary for a particular client?

Nurses collaborate with clients to identify areas in which clients are willing to make changes Rather than addressing all areas associated with healthy behaviors and overwhelming clients, nurses collaborate with them to identify areas in which clients are willing to make changes. When caring for a client, a nurse does not address healthy behaviors only; nurses do not address only areas where clients are willing to make changes, nor do they construct their own theories to identify perceptions, barriers, and positive outcomes.

The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following?

The client's motivation for change The Health Belief Model is based on three concepts: the existence of sufficient motivation, the belief that one is susceptible or vulnerable to a serious problem, and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. As a result, implementation of this model should begin with an appraisal of the client's motivation to change. This consideration would precede the other listed variables, although each may affect care.

The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next?

Validate that the client understands how to use the inhalers. The nurse should not assume that the client knows how to administer their medications. The nurse should always validate information, for example, that the client knows how to properly administer the inhalers. If the nurse does not validate that the client knows how to properly administer medication, the treatment may be ineffective.

A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing?

Ongoing Ongoing, follow-up or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline. An emergency assessment is a very rapid assessment performed in life-threatening situations such as drowning, choking, or cardiac arrest. It is used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. A focused assessment gathers information specific to the problem and does not cover any other areas. A comprehensive assessment is not necessary at this time because the client already has a documented problem.

What is one of the broad goals within nursing?

To treat human responses Four broad goals are within nursing: (1) to promote health (state of optimal functioning or well-being with physical, social, and mental components); (2) to prevent illness; (3) to treat human responses to health or illness; and (4) to advocate for individuals, families, communities, and populations. The other options listed are not broad goals. Nursing, focuses on promoting health; while cost-effective care is strived for, is not a part of the broad goal, therefore, this is not a broad goal within nursing. Nursing looks to develop specific nursing diagnoses, not broad. Promoting self-care is important, but does not correctly answer the question.

The result of a nursing assessment is the

formulation of nursing diagnoses. Analysis of data (often called nursing diagnosis) is the second phase of the nursing process. Analysis of the collected data goes hand in hand with the rationale for performing a nursing assessment. The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment data.

An assessment that concentrates on patterns of role performance that all humans share is called what?

Functional A functional assessment focuses on the functional patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs.

A nurse performs a comprehensive assessment on a client. Which is included only in a comprehensive assessment?

Complete health history The comprehensive assessment includes a complete health history and physical assessment. It is done annually on an outpatient basis, following admission to a hospital or long-term care facility, or as defined in a facility's standards of care in the acute care setting. Circulatory assessment, assessment of the airway, and disability assessment are part of an emergency assessment.

A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next?

Evaluate outcome. Because the nurse implemented an intervention (in this case, applied oxygen), the nurse would next evaluate the effectiveness of the intervention. The first step in the nursing process is gathering data (objective and subjective) and then validating and documenting the data. The second step is analyzing the data, clustering client cues to identify client concerns and prioritize client concerns (diagnosis). The third step is developing a plan with interventions. In the fourth step the nurse implements the interventions, and in the last step the nurse evaluates the effectiveness of the interventions.

Revising the plan as needed occurs in what part of the nursing process?

Evaluation Evaluation assesses whether the outcome criteria have been met and revising the plan as necessary. Diagnosis occurs when the data has been analyzed and a professional judgement occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan.

A nurse analyzes the data obtained from an initial assessment of a new client: weight gain of 15 lbs in 3 months, intolerance to cold, constipation, and lethargy. The nurse determines the client may have hypothyroidism and develops several nursing diagnoses with interventions to address the client concerns. Which action should the nurse take next?

Implement interventions. Because the nurse has already assessed the client, analyzed the data, clustered the client cues, identified client concerns, and developed a plan with interventions, the next step in the nursing process would be to implement the interventions. The nurse would reassess the client after the interventions were implemented and evaluate the outcomes.

Which of the following is the best example of holistic data collection by a nurse?

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings The purpose of a nursing health assessment is to collect holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. Thus the nurse performs holistic data collection. The mind, body, and spirit are considered to be interdependent factors that affect a person's level of health. The nurse, in particular, focuses on how the client's health status affects his activities of daily living and how the client's activities of daily living affect his health. For example, a client with asthma may have to avoid extreme temperatures and may not be able to enjoy recreational camping. If this client walks to work in a smoggy environment, it may adversely affect his asthma. The other answers pertain only to the physiologic functioning of the client and not the other aspects.

A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time?

emergency Assessments pre- and post-procedure are essential to determine if there are deviations from the client's baseline. Because the airway is impaired, which is life-threatening, the nurse would conduct an emergency assessment on the client. Ongoing or partial, comprehensive, and focused assessments would not be appropriate in this situation. Priority assessments after a thyroidectomy include monitoring vital signs (decreased blood pressure and elevated heart rate may indicate internal or external bleeding); assessing reflexes (because some of the parathyroid gland is removed, the client is at risk for hypocalcemia, which will cause hyper-reflexes, tetany; calcium gluconate should be available on the unit); and monitoring airway and breathing (increased swelling/edema could cause narrowing of the airway; a tracheostomy set should be kept at the bedside of these clients).

A nurse is performing a focused assessment on a client admitted with symptoms of meningitis who underwent a lumbar puncture this morning and is now reporting a headache and photophobia. The nurse identifies clear drainage on the dressing and redness and swelling around the site. The nurse documents which of the following objective findings in the chart? Select all that apply.

swelling redness around the site clear drainage on dressing Objective data are referred to as signs that can be observed and measured, for example, skin color, posture, heart rate, and blood pressure. Swelling, redness around the site, and drainage on the dressing can all be observed and measured. Subjective data are referred to as what the client reports but the nurse cannot measure. The nurse may be able to observe that the client looks uncomfortable from a headache and obtain a pain rating scale but neither a headache nor photophobia cannot be directly observed or measured.