Ch. 14 Assessment PrepU

Which nursing skill uses all five senses? Observation

Observation is the conscious and deliberate use of the five senses (sight, smell, hearing, taste, and touch) to gather data.

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.

A nurse who is unsure of the significance of a particular finding should consult with another nurse. In some instances, years of experience are needed to distinguish significant from insignificant findings. Calling the family is not appropriate at this point as there is no information to report to them. Charting the information is important after the consultation with another nurse. Waiting to see whether the pain subsides is not appropriate; a timely assessment is needed for this client.

Which action would the nurse perform in the assessment phase of the nursing process? Asking the client whether the client has cultural preferences

Assessing the client involves gathering information about the client's physical and emotional health; cognition; spiritual, cultural, or religious preferences; and sociodemographics. Developing a plan to manage the client's health problems falls within the planning phase of the nursing process. Coming up with the nursing diagnosis falls within the diagnosing phase of the nursing process. Determining whether the client's goals for wellness have been met occurs in the evaluation phase of the nursing process.

Nurses understand the problem that clients have when they are repeatedly asked the same questions. To best avoid this problem, which intervention should nurses perform when beginning to collect assessment data? Carefully review the client's record.

Before beginning to collect data on a client, the nurse should review the client's record for data. Then the nurse can identify lower-priority data that are not important for the client's assessment. The nurse should avoid telling the client the questions will be quick or making the questions shorter, as proper assessment may not be quick and may necessitate longer questions. A nurse could organize the questions into categories, but reviewing the client's record would be more effective for avoiding duplication of information and ensuring that the assessment is efficient and comprehensive.

The nurse is caring for an older adult client admitted to the hospital for a respiratory condition. What type of data should the nurse review prior to caring for this client? Select all that apply. Consultations Lab reports Medical history Progress notes X-ray reports

Before caring for a client, the nurse should look at all the data previously collected that pertain to the client's condition, including data from consultations, lab and X-ray reports, reports of other therapies (e.g., physical therapy), and other health care professionals working with the client.

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

Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief.

The nurse records the name, age, and genetic background of the client. The data are components of which tool? Health history

Components of a health history tool include the client's profile, which consists of name, age, sex, genetic background, marital status, religion, occupation, and education. These are subjective data that are collected from the client. The physical assessment gathers objective data observed by the nurse, such as vital signs, height, and weight. This data are being collected in the health history assessment and are not being evaluated.

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.

Cues and inferences describe the early analysis of data. "The client does not respond when I speak while standing on the client's right side," is a cue that something may be wrong. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. A nurse can observe a cue directly but not an inference.

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.

Data need to be validated when there are discrepancies (e.g., the client says there is no pain but the nonverbal behavior indicates that the client is experiencing pain). The nurse should not ignore the client's answer or the client's nonverbal behavior. The nurse should chart the assessment, but the priority is to validate the differences in the verbal communication and nonverbal behavior.

The nurse is caring for a patient with an IV infusion and notes an elevated BP, increased pulse and respirations, dyspnea, crackles, and neck vein distention. Based on the assessment, the nurse suspects: fluid overload

Elevated BP, increased pulse and respirations, dyspnea, crackles, and neck vein distention are symptoms of fluid overload.

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.

Family and friends can be an invaluable source of assessment data, especially in the care of clients who have cognitive deficits. It would be inappropriate to limit an assessment to solely objective data. Using previous medical records and breaking up the assessment are appropriate measures, but they do not supersede the importance of using family and friends as data sources.

A client is a poor historian of the client's past medical history. Whom should the nurse consult about the client's past history? Family

Family members or significant others, if available, can provide information for a client who is confused or incapacitated. They can also be of assistance should there be gaps or conflicts within available medical records. Should these persons not be available, the only remaining option for medical history would be medical records or the client's primary physician if available.

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.

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. It is appropriate to note inconsistencies between objective and subjective data.

A woman has delivered a healthy newborn and is scheduled to go home today, her third post-partum day. Her vital signs are stable. How often would the nurse expect to take the vital signs of a stable in-patient? Every 8 hours

Most in-patient settings have a policy regarding the frequency of vital sign assessment, minimally every 8 hours for stable patients.

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

Systematic guidelines for nursing assessments help ensure that comprehensive, holistic data are collected. Gordon's functional health patterns model identifies 11 functional health patterns and organizes data within these patterns. Maslow's hierarchy has five levels of human needs, such as food, water, and shelter, and organizes data accordingly. A medical model organizes data collection by body system.

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

The Joint Commission has mandated that each client have a documented nursing admission (initial) assessment that follows institutional policies. An initial assessment is comprehensive and covers both a client's physical and psychosocial health. A focused assessment is one that addresses one specific problem that has already been identified; this type of assessment is not mandated by the Joint Commission.

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

The client's physician may invite a specialist to assess and treat the client. The focus of this part of the record is additional findings related to the client's medical diagnosis and treatment; it is found in the section called "Consultation." Laboratory reports are related to the laboratory values of the client. Progress notes are the part of a medical record where health care professionals describe details to document a client's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. The medical history or case history of a client is information gained by a physician by asking specific questions, either of the client or of other people who know the person and can give suitable information.

While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, "The client's hearing may be impaired on the right side." This statement is an example of: an inference.

The judgment a nurse makes about a cue is known as an inference.

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficient 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.

The nurse is responsible for collecting data in a timely manner. If the client is too fatigued, the nurse must ask for permission to obtain answers from the client's spouse prior to continuing to do so. Asking the client to wake up is disregarding the client's needs. Waiting until the following day is too long for the collection of important data.

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 nursing health history captures and records the uniqueness of the client and should be obtained as soon as possible after a client presents to the health care facility for care. If the nurse waits until the client is ready, this may occur too late and the problem may become more problematic. Twenty-four hours is also too long. Waiting until the client is discharged is inappropriate because important medical as well as psychological information may be missed or not communicated.

Which statements accurately describe the unique focus of nursing assessments? Select all that apply. Nursing assessments focus on the client's responses to health problems. The findings from a nursing assessment may contribute to the identification of a medical diagnosis. An initial assessment establishes a complete database for problem solving and care planning.

The nursing physical assessment focuses primarily on the client's functional abilities, which provides the nurse with an appraisal of the client's health status, the identification of health problems, and the establishment of a database for nursing interventions. In addition, the nurse's findings from the assessment should be conveyed to the physician, as these findings may aid the physician with medically diagnosing the 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 nursing physical assessment focuses primarily on the client's functional abilities, which provides the nurse with the appraisal of the client's health status, the identification of health problems, and the establishment of a database for nursing interventions. Identifying that the client is unable to communicate basic needs and perform hygiene measures with the left hand demonstrates this concept. The purpose of the physician's physical assessment is to identify pathologic conditions and their causes. The interpretation of the neurologic examination and the brain scan, and the probability of the cause being a stroke, are part of the physician's physical assessment.

A new graduate nurse states that it does not make sense to have to perform such an extensive assessment on clients when they are not feeling well. Which response by the nurse preceptor is an appropriate explanation for conducting a comprehensive physical assessment on clients? Select all that apply. To appraise the client's health status To identify any health problems To establish a database for nursing interventions

The purpose of the nursing physical assessment includes the appraisal of health status, the identification of health problems, and the establishment of a database for nursing interventions. The assessment provides objective and subjective data critical information for a nursing care plan and interventions.

The nurse identifies which types of data when performing an assessment? Select all that apply. Critical thinking Hunches Objective Intuition Subjective

There are two types of data used when doing an assessment: subjective and objective. The others are not types of data but tools that nurses can use while collecting data.

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.

Validation is the act of confirming or verifying. The purpose of validation is to keep data as free from error as possible. It is an important part of assessment. However, it is neither possible nor necessary to validate all data; nurses should decide which items need verification.

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.

When a pulse deficit is present, the radial pulse rate is always lower than the apical pulse rate. The nurse should document and report to the physician any new finding of a pulse deficit immediately so that evaluation and follow-up can occur. The nurse should not wait until after rechecking the pulse to document the finding or report it to the physician.

Other than the client, what sources of client information should the nurse consider when assessing a client? Select all that apply. The client's support people The client's health record Family members accompanying the client Other health care professionals

When assessing, the primary source of client information is the client. Other sources the nurse should consider include the client's support people, the client record, family members accompanying the client, and other health care professionals.

When collecting subjective and objective data for a database in a client's home, it is important to: ask the client to turn off the television.

When collecting data for a nursing history and assessment in the home environment, distractions such as a television should be minimized. It is not required or appropriate to have a social worker verify your information, nor is it necessary to evaluate the care provided by the physician. There may be an isolated scenario requiring a 24-hour dietary recall, but this would certainly not be routine.

A physical examination on a client should always include which components? Select all that apply. Appraisal of health status Identification of health problems Establishment of a database for interventions

When conducting a physical examination, the nurse should include appraisal of health status, identification of health problems, and establishment of a database for interventions. The nurse should collect information regarding the client's religious preference and socioeconomic status, which is used in developing the plan of care, during the client's interview, not during the physical examination.

Four methods are used to collect data during the physical assessment:

inspection, palpation, percussion, and auscultation.