Ch. 14

A nurse has just taken vital signs on a newly admitted client. Vital signs would be entered on the client record as which type of data?

Objective

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

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

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

Review the records available on the client.

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

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

Which assessment data cue does the nurse recognize as subjective data?

A pain rating of 7

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 are models used in nursing to assist in clustering data? Select all that apply.

Human Needs Functional Health Patterns Human Response Body Systems

Which nursing skill uses all five senses?

Observation

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply.

Respect for client Competence Professionalism Caring

Which action would the nurse perform in the assessment phase of the nursing process?

Asking the client whether the client has cultural preferences

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question 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 performing an assessment on a client. Which should the nurse 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."

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

"The client's right leg is cold to the touch, from the knee to the foot."

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."

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

38-year-old man Height: 6 ft (1.82 m) Weight: 195 lb (89 kg)

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 is the purpose of a focused assessment?

Adds depth to existing information

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview?

Administer prescribed pain medication prior to conducting the interview.

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.

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

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficent data for planning care. Which action by the nurse would be most appropriate in this situation?

Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?

Assess the client's blood pressure.

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.

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?

The nursing and medical literature

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data?

Both during the collection and at the end of the collection

Which is the best source of information for the nurse when collecting data for an assessment?

Client

A nurse is assessing a client admitted to the hospital with reporting left-sided weakness and difficulty speaking. Which documented statement best represents the data that should be collected in a nursing assessment?

Client is unable to communicate basic needs and cannot perform hygiene measures with left hand.

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply.

Client states, "I feel so sad all of the time." Client states, "I am in pain."

The nurse notices during an assessment interview that the client cannot stay focused and jumps from one topic to another. The client also is speaking very rapidly and at times incoherently. What should the nurse suspect is the main cause of this behavior?

High anxiety

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

Collection, validation, communication of client data

The nurse is collecting data from a client during a complete assessment. Which skill is the nurse demonstrating when documenting the assessment data?

Communication

While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate?

Consult with another nurse for that colleague's description of the assessment or observations.

A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrintestinal symptoms or should be reported to the physician. Which action should the nurse perform next?

Consult with another nurse.

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

Consultation

The nurse is conducting a health 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?

Continue the health history with questions focusing on respiratory function.

The night shift nurse is caring for a hospitalized client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client?

Disturbed sleep pattern

A client comes to the emergency department with a stab wound and is bleeding profusely. Which type of assessment should the nurse perform on this client immediately?

Emergency

A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client?

Focused

A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client'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

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

Focused

What must the nurse do to identify actual or potential health problems?

Gather data from sources

Which piece of client information is subjective?

Generalized myalgia or muscle pain

A nurse is performing an assessment on a client in which the nurse categorizes the data according to various categories of functions. Which assessment model is the nurse using?

Gordon's functional health patterns

The nurse is conducting a health history on a newly admitted client. Which aspects of the client should the nurse include while doing the history? Select all that apply.

Health status Strengths Health problems Health risks

After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data?

Hierarchy of Human Needs

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.

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client?

Ineffective Breastfeeding

For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

Initial

Which is the most appropriate reason for a nurse to ask a client what the client would like to be called?

It communicates respect for the client.

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

Laboratory test results Breath sounds on auscultation A client's temperature

The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next?

Notify the physician of the change and document the finding.

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What 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

The nurse is planning on doing a nursing/health history on a new client by performing an interview. Which elements are considered phases of the nursing interview? Select all that apply.

Preparatory phase Introduction phase Working phase Termination phase

A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method?

Presence of peristalsis

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client?

Risk for Impaired Parenting

A client is admitted for removal of a cancerous tumor of the lung. The client expresses concern to the nurse about how the cancer and the treatment will affect the client's family. The client explains that the client's spouse has never worked outside the home and that the client is concerned that their financial situation will be compromised by this illness. Which would be the best nursing diagnosis for this client?

Risk for Interrupted Family Processes

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data?

Safety and security

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

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

The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment?

Supplement the client's information by speaking with family or friends.

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

The client

Who or what is the primary source of information for a nursing history?

The client

The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source?

The client tells the nurse that there is a burning sensation when voiding.

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

The client's health status can change quickly.

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

The nurse is admitting a client to a medical unit. The nurse delegates the measurement of the vital signs to an unlicensed assistive person (UAP) while the nurse collects data. After completing the admission process, the client reports a severe headache, so the nurse reassesses the vital signs and find the client's blood pressure extremely elevated. Whose responsibility is the accuracy of the blood pressure measurement?

The nurse

The nurse is performing an assessment on an older adult client and notices that the blood pressure has increased from 140/82 to 198/120 mm Hg. This is a significant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the physician?

The nurse

Following a client interview, the nurse is organizing data obtained according to Gordon's functional health patterns model. Which statements reflect the focus of this model? Select all that apply.

The nurse collects data regarding the client's health perception and health management. The nurse explores the client's perception of the client's major roles and responsibilities in life. The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality.

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training?

The nurse introduces oneself to the client by pointing to the nurse's name badge.

A nurse practitioner in private practice with a physician 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

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?

Time-lapsed assessment

When performing an assessment, the nurse should focus most on the developmental stage for which client?

Toddler

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.

While doing an assessment, the nurse identifies questionable data. Which should the nurse do first?

Validate the questionable data.

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 physician.

The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side." This statement is an example of:

a cue.

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.

During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to:

body systems.

A nurse is asking questions about a client's sexual history. It is important for the nurse to:

collect data in a quiet, private environment.

The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to:

complete an exam of all body systems.

The purpose of obtaining a nursing history is to:

identify actual and potential health problems.

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.

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse:

uses broad, open statements to communicate with the client.