Chapter 1: Analyzing Data to Make Accurate Clinical Judgments

Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of a. Healthy People 2030 b. the nursing process c. the Department of Health and Human Services d. the three levels of preventative care

a. Healthy People 2030 Healthy People 2030 is a government project intended to increase the quality of life for people in the United States.

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.

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.

A client who underwent abdominal surgery this morning reports feeling weak and dizzy. The nurse also observed a decrease in urine output in the last hour. What action should the nurse take first? a. Reevaluate the nursing plan. b. Administer IV fluids. c. Assess the client. d. Evaluate the outcome.

Assess the client. Because the client is reporting new symptoms and there is a decrease in urine output, the nurse should first assess the client, then develop a plan, implement the plan (administer intravenous fluids), and evaluate the outcome.

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.

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.

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? a. Empathy b. Inspection c. Sympathy d. Palpation

a. 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.

The nurse prepared to complete a comprehensive health assessment on a client in the community. What should the nurse expect to complete when performing this assessment? Select all that apply. a. Physical examination b. Medication administration c. Wellness teaching d. Outcome identification e. Health history

a. Physical examination e. Health history A comprehensive health assessing includes a health history and physical examination. Wellness teaching cannot be done until the client's needs are identified. Outcome identification is a part of planning. Medication administration is a part of implementation.

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the 'assessment' is to

arrive at conclusions about the client's health 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.

When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what? a. Assessment b. Diagnosis c. Planning d. Evaluation

b. 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.

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? a. assessment b. planning c. diagnosis d. evaluation

d. 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.

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.

When assisting a client with health promotion, what must the nurse also nurture? a. Family communication b. Knowledge of the Healthy People 2020 indicators c. A healthy environment d. School/work attendance

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

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?

Inspection Interviewing, therapeutic communication, caring, empathy, and listening skills are needed to obtain subjective data. Inspection, palpation, percussion, and auscultation are used to collect objective data.

The client has a murmur. This is what type of data?

Objective Objective data includes data that is measurable. Subjective data is what the client states, feels or senses. Focused and comprehensive are types of assessments

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

To establish a database against which subsequent assessments can be measured A health assessment is performed to gain further insight into the current condition and to establish a database that subsequent assessments can be measured against.

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) a. ongoing or partial assessment. b. emergency assessment. c. focused or problem-oriented assessment. d. initial comprehensive assessment.

c. 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.

Consider the nurse's role in the health assessment of a client. What action will the nurse perform initially when admitting a client to a long-term care facility?

collecting information regarding the client's health status Regardless of the care setting, the nurse's initial role in health assessment is to collect data. While all the remaining options are relevant to quality client care, they are not associated directly with the nurse's role concerning health assessment.

During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?

environmental The environment influences conditions to promote health. Physical health is the way the body works and adapts. Social well-being identifies relationships that support health. Developmental level focuses on thinking, problem solving, and decision making.

A new order for an antibiotic is received for a client. The nurse reviews the client's electronic medical record. The record states the client has no known allergies. What action should the nurse take?

Ask the client if they have allergies. Once the nurse has reviewed the client's chart, the nurse should confirm (validate) the information with the client. The nurse should not assume all information is correct in the chart; validation of client data is essential in order to make valid nursing judgments. The nurse would not administer the medication until the client confirms that there are no allergies. Double-checking the admission notes for allergies will not validate that the client does not have allergies.

A client has been admitted with new onset hypertension with a past medical history of asthma, type 2 diabetes, and hypercholesterolemia. After developing a nursing care plan, the nurse reports findings to the health care provider. After receiving medication orders from the health care provider, the nurse administers several medications for hypertension. What is the next best action of the nurse?

Evaluate patient outcome. The nurse should evaluate the effectiveness of the antihypertensive medications. The plan of care will not be updated until the interventions are evaluated. Nursing diagnosis and comprehensive assessments have already been completed.

Which of the following is the best example of assessment in everyday life?

Measuring the remaining tread on a car tire to determine whether it is time to replace it As a professional nurse, you will constantly observe situations and collect information to make nursing judgments. This occurs no matter what the setting: hospital, clinic, home, community, or long-term care. You conduct many informal assessments every day. For example, when you get up in the morning, you check the weather and determine what would be the most appropriate clothing to wear. Measuring the remaining tread on a car tire to determine whether it is time to replace it is an example of assessment, as it involves gathering information (the height of the tire tread) to make a decision (whether to buy new tires). The other answers do not involve gathering information to make a decision.

A nurse working in a long-term care facility is performing a comprehensive assessment on an 84-year-old male resident. Highlight the findings that will require 'follow-up'. Client is awake, alert, and oriented . Client walks with a cane. Abdomen is soft and nontender, last bowel movement was charted 7 days ago . No urine output has been charted in the last 24 hours . Skin is warm, dry, pink, and intact . Vital signs: temperature, 97.9°F (36.6°C); heart rate 120 beats/min and irregular ; oxygen saturations 88% on room air .

last bowel movement was charted 7 days ago No urine output has been charted in the last 24 hours heart rate 120 beats/min and irregular oxygen saturations 88% on room air Because there are no reported deficiencies in the client's neurologic status, these findings do not need to be validated. The integumentary system being warm, dry, pink, and intact is an expected finding that does not need to be validated.

A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify?

Expansion of health care networks Opportunities for nurses with advanced assessment skills will be enhanced by the expansion of health service networks, increasing complexity of acute care, growing aging population with complex morbidities, expanding health care needs of single parents, increasing impact of children and homeless on communities, intensifying mental health issues, and increasing reimbursement for health care promotion and preventive services. Public mistrust of physicians is not a noted phenomenon.

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.

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?

Nursing intervention Nursing interventions are used to monitor health status; prevent, resolve, or control a problem; assist with ADLs; or promote optimum health and independence. Nursing goals are the client's desired outcomes. Nursing evaluation is deciding whether the nursing goals have been reached. Nursing assessment is an overview of the client's health status and current problems.

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment? a. To determine any changes from the baseline data b. To collect subjective data related to the client's overall health c. To perform a rapid assessment for prompt treatment d. To evaluate whether outcomes of treatment are met

To determine any changes from the baseline data Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment (emergency assessment). Evaluation is done after an intervention to determine whether the outcomes have been achieved.

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? a. Ask the client about the most recent experiences of pain. b. Collaborate with the physician who is treating the client. c. Meet with the client's spouse and daughter to discuss the client's pain. d. Review the client's medication administration record for analgesic use.

a. 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.

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? a. Validate that the client understands how to use the inhalers. b. Leave the inhalers with the client to self-administer. c. Ask the client if they need any assistance with the inhalers. d. Provide privacy for the client to administer the inhalers.

a. 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 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? a. emergency b. ongoing or partial c. focused d. comprehensive

a. 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).

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? a. significantly impaired hearing b. greatly concerned about cost of services c. widowed 2 years ago d. lives alone

a. 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.

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing? a. Emergency b. Ongoing or partial c. Initial comprehensive d. Focused or problem-oriented

b. Ongoing or partial 'An ongoing, follow-up or partial assessment of the client consists of data collection that occurs after the comprehensive database is established. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data. In addition, a brief reassessment of the client's body systems and holistic health patterns is performed to detect any new problems.' An initial comprehensive assessment involves collection of subjective data about the client's perception of own health of all body parts or systems, past health history, family history, and lifestyle and health practices. '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 and consists of a thorough assessment of a particular client problem, and does not cover areas not related to the problem.' An emergency assessment is a very rapid assessment performed in life-threatening situations.

A client has been admitted with new onset hypertension with a past medical history of asthma, type 2 diabetes, and hypercholesterolemia. After developing a nursing care plan, the nurse reports findings to the health care provider. After receiving medication orders from the health care provider, the nurse administers several medications for hypertension. What is the next best action of the nurse? a. Develop a nursing diagnosis. b. Perform a comprehensive assessment. c. Evaluate patient outcome. d. Update the plan of care.

c. Evaluate patient outcome. The nurse should evaluate the effectiveness of the antihypertensive medications. The plan of care will not be updated until the interventions are evaluated. Nursing diagnosis and comprehensive assessments have already been completed.

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. a. headache b. photophobia c. redness around the site d. clear drainage on dressing e. swelling

c. redness around the site d. clear drainage on dressing e. swelling 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.