Chapter 11

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 makes statements indicating a loss of hope." "Client states that his rehabilitation will be unsuccessful." "Client states, 'I don't see the point in trying anymore.'" "Client is demonstrating signs and symptoms of depression."

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

The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate? "I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes." "I will perform a physical assessment while I am obtaining the nursing history." "I will leave a form with you to complete the nursing history information I need." "When I perform the nursing history I will need to ask your family to leave the room."

"I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes."

A nursing instructor teaching about assessment data identifies a need for further instruction when a student makes which statement? "The client is usually the best source for collecting data." "Caregivers can be a helpful source of data when the client has a limited capacity for information." "The client is always the best source for collecting data." "Family members are a good source of data when the client is a young child."

"The client is always the best source for collecting data."

A nurse is assessing an energetic 80-year-old, admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client? A full assessment of the urinary system A focused assessment of the specific problems identified Obtaining a detailed assessment of the client's sexual history Conducting a thorough systems review to validate data on the client's record

A focused assessment of the specific problems identified

While performing an assessment on a young client the nurse is using the Functional Health Patterns Model. When recording the facts that the client exercises daily, hikes weekly, and plays on a softball team regularly, under which heading should these data be clustered ? Activity/Exercise Sleep/Rest Health Management Nutritional

Activity/Exercise

The nursing instructor is teaching about collecting data for an assessment and informs the students about the importance of validation. Which statement made by a nursing student indicates a need for further instruction? All data collected needs to be validated. Validation helps to keep data as free from error as possible. Validation is an important part of assessment. Validation is the act of confirming or verifying.

All data collected needs to be validated.

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority? Assess the client's blood pressure. Assess the client's activity level. Assess the client's medication regimen. Assess the client's diet.

Assess the client's blood pressure.

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? Tell the client the questions will be quick. Carefully review the client's record. Organize all questions into categories. Make the questions short.

Carefully review the client's record.

A client is a poor historian of his past medical history. Whom should the nurse consult about the client's past history? Family Physician Old chart Social worker

Family

The nurse is reviewing information about a client and notes the following assessment data. Which data cue does the nurse recognize as subjective data? Bilateral pedal edema 2+ Pupils equal and accommodate and react to light Wheezing throughout lung fields Pain rating is 7

Pain rating is 7

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 Termination phase Working phase Assessment phase Introduction phase

Preparatory phase Introduction phase Working phase Termination phase

A nurse is preparing to interview a client who is newly admitted to the unit. Which strategies will help establish a relaxed and comfortable environment during the interview? Select all that apply. Maintain a proper distance from the client Ask the client if the tv may be off Keep the heat on high. Leaving the door to the room open. Proper seating arrangement

Proper seating arrangement Maintain a proper distance from the client

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. erroneous data. duplicate data. a cue.

an inference.

The nurse is assessing the spine of a 63-year-old woman who states, "I hope I don't end up with a big hump on my back like my mother did." The nurse knows the patient is referring to a condition known as: spina bifida lordosis kyphosis arthritis scoliosis

kyphosis

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment? interview friends to ascertain if client drinks more than what is reported obtaining data regarding amount and frequency of drinking performing an abdominal assessment ask the client to discuss social functioning

obtaining data regarding amount and frequency of drinking

During data collection the nurse may validate data by which method? Select all that apply. clarifying the client's statements seeking consensus with colleagues about inferences using cues from one source checking consistency of cues referring to textbooks, journals, and research reports

referring to textbooks, journals, and research reports checking consistency of cues clarifying the client's statements seeking consensus with colleagues about inferences

During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should: identify actual and potential nursing diagnoses. review as much information as possible. clarify the client's health status. develop the nursing plan of care.

review as much information as possible.

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: attempts to write down everything the client says. reassures the client of good outcomes. agrees with each of the client's statements. uses broad, open statements to communicate with the client.

uses broad, open statements to communicate with the client.

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 During the collection of data only In the middle of the data-gathering process At the end of the data-gathering process

Both during the collection and at the end of the collection

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? Medical record Client Primary physician Charge nurse

Client

Following a client interview, the nurse is organizing data obtained according to Gordon's functional health pattern model. Which statements reflect the focus of this model? Select all that apply. Elimination, activity, sleep, and sexuality are components of the assessment and data collection. Data are clustered or organized according to a hierarchy of basic human needs. The major body systems are assessed and data are collected. Data related to human response patterns are collected and organized. The perception of the major roles and responsibilities in the client's life is explored. Data are collected regarding the health perception/health management of the client.

Data are collected regarding the health perception/health management of the client. The perception of the major roles and responsibilities in the client's life is explored. Elimination, activity, sleep, and sexuality are components of the assessment and data

A client has just given birth to her first baby. The woman tells the nurse she doesn't know very much about newborns because of limited exposure to them. Which problem identified by the nurse would be a priority to address prior to discharge? Ineffective coping mechanisms Deficient knowledge Stress Fear Alteration in family process

Deficient knowledge

Which statement made by the nurse indicates data that would be documented as part of an objective assessment? "The UAP reports blood in the client's stool." "The client's sister reports that the client has unrelieved pain." "The client's right leg is cold to the touch, from the knee to the foot." "The client reports eating all of today's breakfast."

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

The nurse is terminating an interview with a client in the behavioral health unit. What statement by the nurse would indicate an effective termination of the interview? Select all that apply. "Are you ready to finish the interview now?" "Here is my card with my phone number. Please call if you have concerns." "I have to go and check on another client now." "We have 5 minutes left. Do you have any questions?" "What are some of your most important concerns?"

"We have 5 minutes left. Do you have any questions?" "What are some of your most important concerns?" "Here is my card with my phone number. Please call if you have concerns."

The nurse has identified a priority problem on her unit. Which statement is true regarding addressing a priority problem? The physician is responsible for determining priority of client needs. Priorities are set at predetermined intervals throughout the shift. Setting priorities involves skipping interventions. Priority of problems is established and continued according to the nursing plan of care. A priority problem requires a nursing intervention before another problem is addressed.

A priority problem requires a nursing intervention before another problem is addressed.

The nurse understands that conducting a physical examination on a client should always include which components? Select all that apply. Establishment of a database for interventions Religion of the client and client's family Appraisal of health status Economic status of client Identification of health problems

Appraisal of health status Identification of health problems Establishment of a database for interventions

Which items reflect the assessment phase of the nursing process? Select all that apply. The client states, "I rarely sleep more than 6 hours." The nurse assists the client with coughing and deep breathing every hour. The client's abdomen is firm and distended with hypoactive bowel sounds. The nurse and the client determine a tolerable pain level. Asking the client, "How would you rate your pain?"

Asking the client, "How would you rate your pain?" The client's abdomen is firm and distended with hypoactive bowel sounds. The client states, "I rarely sleep more than 6 hours."

What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall? Assess blood pressure with a large cuff. Begin client education regarding a low fat diet. Obtain an electrocardiogram daily. Assess the HDL/LDL levels.

Assess blood pressure with a large cuff.

The nurse is preparing to interview several clients during clinic hours. What language difficulty might a nurse encounter while performing various interviews in a diverse population of clients? Clients fear saying the wrong thing. Clients have a limited education. Clients demonstrate mild anxiety. Clients not fluent in same language as the nurse. Clients speak the same language as the nurse.

Clients not fluent in same language as the nurse. Clients have a limited education. Clients fear saying the wrong thing.

After performing an assessment on a client, the nurse determines that the client is having difficulty with airway clearance. The nurse supports this suspicion by listing as evidence: a nonproductive cough, crackles in lower lobes, and pulse oximeter reading of 94%. The nurse used which process? Clarifying Clustering Inferring Verifying

Clustering

The nurse is collecting data from a client during a complete assessment. What is the nurse demonstrating when the documentation of the assessment is performed in a timely precise manner? Clustering data Collection of data Validation of data Communication of data

Communication of data

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 Financial history Progress notes Medical history X-ray reports Lab reports

Consultations Lab reports Medical history Progress notes X-ray reports

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? Ask significant family members about the client's usual breathing pattern at home. Continue the health history with questions focusing on respiratory function. Prioritize documentation of objective data collected in the examination while avoiding any mention of the discrepancy. Consult with other members of the health care team about the conflicting client information.

Continue the health history with questions focusing on respiratory function.

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 Every 2 hours No further vitals are needed Every 1 to 2 hours Every 12 hours

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 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? Emergency Focused Time-lapse Head-to-toe

Focused

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? Time-lapse assessment Emergency assessment Focused assessment Initial assessment

Focused assessment

The nursing student is learning how to do a complete assessment by organizing the data into the different body systems. What model is the student using to perform this type of assessment? Prevention model Gordon's functional health patterns model Medical model Maslow's hierarchy model

Gordon's functional health patterns model 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 into body systems. There is no assessment known as the prevention model.

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

Health history

The nurse is conducting a health history on a newly admitted client. Which aspect of the client should the nurse include while doing the history? Select all that apply. Health problems Health risks Health status Financial status Strengths

Health status Strengths Health problems Health risks

A nursing student is conducting an interview with a client. Which example best demonstrates use of open-ended questions in an interview? Do you smoke? Do you use any illicit drugs? How are you feeling? Are you feeling well?

How are you feeling?

The nursing instructor is teaching about the different models used in nursing to assist in clustering data. Which models should the instructor include during the teaching session? Select all that apply. Change Theory Model Human Response Model Human Needs Model Body Systems Model Functional Health Patterns Model

Human Needs Model Functional Health Patterns Model Human Response Model Body Systems Model

In order for a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment? Physical Focus Psychosocial Initial

Initial

The nursing instructor is demonstrating to the class how to perform a physical assessment. Which assessment technique should be demonstrated by the nursing instructor? Select all that apply. Documentation Inspection Percussion Palpation Ausculation

Inspection Palpation Percussion Ausculation

While performing the nursing history the nurse notes that the client states he is having very little pain, but is occasionally grimacing and rubbing his shoulder throughout the interview. The nurse acknowledges this behavior and questions the client, and then proceeds with other phases of the interview. This action takes place during which phase of the nursing interview? Maintenance Introductory Preparatory Concluding

Maintenance Watching the client to determine if nonverbal cues match their verbal communication typically occurs during the maintenance, or working, phase of the interview. Initial observations are noted during the introductory phase, but they are further addressed in the maintenance phase.

The nurse must be familiar with the client record in order to provide care effectively. Which parts of the client record include only the findings of physicians? Select all that apply. Care plan Physical exam Medical history Laboratory values Progress notes

Medical history Physical exam Progress notes

At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented? Covert Symptomatic Subjective Objective

Objective

The nursing instructor is teaching about physical assessment and the best methods to use for performing an assessment. The instructor identifies a need for further education when one of the students makes which statement? Physical assessment is the examination of the client for objective data. Physical assessment should be documented in a timely manner Physical assessment is the examination of the client for subjective data. Physical assessment is ongoing to detect changes in the client's condition

Physical assessment is the examination of the client for subjective data.

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next? Cover the infant Ask the parent if the child has been exposed to cold temperatures Recheck the temperature paying close attention to technique Assess the skin for signs of cyanosis

Recheck the temperature paying close attention to technique

The RN is interviewing an 80-year-old woman admitted to the hospital for evaluation of her diabetes. The client states she enjoys being in the hospital because she lives alone and does not have many friends. She states her husband died 1 year ago and she is no longer able to drive. She relies on her daughter who lives one hour away to shop for her once a week. The client states, "My daughter can never stay long, she is just in and out in no time." Which nursing diagnoses would be appropriate for this client? Select all that apply. Risk for Loneliness Chronic Low Self-esteem Disturbed Body Image Impaired Memory Powerlessness

Risk for Loneliness Powerlessness

The nurse is assessing a man in an outpatient setting. Which of the following assessment findings would lead to the priority nursing diagnosis for this client? Client states,"I don't want to live anymore. My family hates me and I am so tired of being sick. I have a gun and I am seriously thinking of killing myself." The patient reports a 30-year heavy smoking habit and having a cough for about six months. Ascultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminshed bowel sounds. His lips are slightly bluish in color. Risk for Suicide Impaired Gas Exchange Ineffective Health Maintenance Stress Overload Risk-Prone Health Behavior

Risk for Suicide

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problem seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? Love and Belonging Self-Esteem Self-Actualization Safety and Security Physiologic

Safety and Security

The nurse is performing an assessment on a newly admitted client. The client states, "I feel really nervous." This is an example of which type of data? Intuition Subjective Hunch Objective

Subjective

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

Subjective Objective

The nurse is assessing a male client with a diagnosis of vascular dementia. As a result of his cognitive deficit, the client is unable to provide many of the data that are required on the hospital's nursing admission history document. How should the nurse best proceed with this assessment? Supplement the client's information by speaking with family or friends. Obtain the client's records from admissions to other institutions. Perform the assessment in several short episodes rather than at one sitting. Limit the assessment to objective data.

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

The nurse is summarizing the key points of the interview. This nursing activity occurs during which phase? Preparatory phase Termination phase Introductory phase Working phase

Termination phase

After sustaining a wrist fracture in a recent fall, a client is suspected of having osteoporosis. Which data best demonstrates the nursing focus of assessment? The client demonstrates an unsteady gait and spinal kyphosis. The client's serum calcium levels are below the reference range. The results of the client's bone scan indicate decreased bone density. The client claims mobility and independence have declined in recent years.

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

The nurse assessing a client and obtaining data from the client. However, the nurse identifies that other sources of client information can include what sources? Select all that apply. Other clients in the facility who have interacted with the client The client's health record Family members accompanying the client Other health care professionals The client's support people

The client's support people The client's health record Family members accompanying the client Other health care professionals

Nurses collect objective and subjective data when performing client assessments. What is an example of objective data? A client with inner ear infections reports dizziness. A client states that she is feeling very anxious about her tests. The skin of a client who has liver failure has a yellowish tint. A client receiving chemotherapy reports nausea.

The skin of a client who has liver failure has a yellowish tint

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 keep the nurse focused and with the client To improve nurses' skills through practice To establish a database for nursing interventions To identify any health problems To appraise the client's health status

To appraise the client's health status To identify any health problems To establish a database for nursing interventions

When performing an assessment, the nurse should focus on the developmental stage for which client? Young adult Toddler Adolescent Middle-age adult

Toddler

While admitting a teenage client who has a diagnosis of anorexia, the client informs the nurse of a 5-pound weight loss within the last 6 months. What should the nurse do with this data? Validate the weight loss with the client. Ignore this information completely and continue collecting data. Inform the client that this cannot be correct. Record it in the client's record.

Validate the weight loss with the client.

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques? "Have you ever heard the saying 'no pain no gain?'" "When did you first notice the rash on your leg?" "Why do you feel that way about your cancer diagnosis?" "Do you have any additional questions for me?"

When did you first notice the rash on your leg?"

The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on his right side." This statement is an example of: a cue. a misinterpretation. an inference. duplicate data.

a cue.

When collecting subjective and objective data for a database in a client's home, it is important to: evaluate the care provided by the physician. collect a 24-hour diet recall. ask the social worker to verify the collected data. ask the client to turn off the television.

ask the client to turn off the television.

The nursing student demonstrates accurate application of the assessment phase of the nursing process by performing which action? asking the client whether the client has cultural preferences coming up with the nursing diagnosis based on potential health risk determining if the client's goals for wellness have been met developing a plan to manage the client's health problems

asking the client whether the client has cultural preferences

During the initial assessment of a newly admitted client, the nurse has clustered the client's range of motion (ROM) with his gait, his bowel sounds with his usual elimination pattern, and his chest sounds with his respiratory rate. The nurse is most likely organizing assessment data according to: human response patterns. human needs. body systems. functional health patterns.

body systems.

Which of the following are examples of objective data? client describing his pain mother describing her child's asthma attack laboratory results breath sounds a client's temperature

laboratory results breath sounds a client's temperature

The nursing student is learning about the different types of assessments, when each type is used, and exactly how much information should be collected each time. Which statement made by the nursing student best indicates an understanding of the different types of assessments? "How much time the nurse has and how the client is feeling will decide which type of assessment is best." "The purpose for the assessment offers guidance for which type and how much data to collect." "The physician will tell the nurse which type of assessment for each client is needed." "It is up to the nurse to decide which assessment is easier to perform."

"The purpose for the assessment offers guidance for which type and how much data to collect."

A nurse is conducting an interview with a client who reports abdominal distress. What is an appropriate interview question for this client? "You haven't eaten anything that could have been spoiled, have you?" "What is your problem as you see it?" "Do you think you might have appendicitis?" "When was your last bowel movement?"

"What is your problem as you see it?" Asking the question, "What is your problem as you see it?" is an exploratory and open-ended question that encourages the client to provide his own feelings and interpretation of the current problem. Asking the client if he has eaten something that could have been spoiled or asking if he may have appendicitis are leading questions that block the client's own feelings and response. Asking the client if he is "feeling poorly besides your stomach ache" may be misinterpreting what the client is feeling and disregards the current report.

The assessment phase of the nursing process has to be well organized to prevent omission of pertinent information. What is an advantage of using the functional health framework? the nurse can systematically examine every part of the body. It focuses on the client's major anatomic systems. It allows the nurse to collect data about the past and present condition of each organ or body system. Client strengths and assets can be identified.

Client strengths and assets can be identified.

Question 20 of 20 A nurse is assessing a client admitted to the hospital with reporting left-sided weakness and difficulty speaking. Which assessment contains the data that best represent a nursing assessment? Brain scan shows evidence of a clot in the middle cerebral artery. Client is unable to communicate basic needs and cannot perform hygiene measures with left hand. Neurologic examination reveals partial paralysis and aphasic speech. Left-sided weakness and speech deficit indicate probable stroke.

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

A nurse who recently graduated is performing an assessment on a client who is admitted for nausea and vomiting. While performing the assessment, the client reports mild chest pain. The nurse does not know if the chest pain is related to the GI symptoms or should be reported to the physician. What is the nurse's next best action? Wait and see if the pain subsides Chart the information Consult with another nurse Call the family

Consult with another nurse

While caring for a client who has a problem related to digestion, a nurse has been referred by the primary care provider to be seen by a gastroenterologist. Which part of the client record should the nurse look at to see the recommendations made by the gastrointestinal specialist? Progress notes Laboratory reports Medical history Consultation

Consultation

The nurse is assessing a 3-week-old infant. Which of the following assessment findings would define the priority nursing diagnosis for this patient? The infant has not gained weight since birth. Bowel sounds are present in all quadrants. Breath sounds are clear to auscultation. Mom reports child cries much of the night but sleeps better in the daytime. Mom reports child only breastfeeds about four times in a 24-hour period and she doesn't seem to have much milk. Readiness for Enhanced Parenting Impaired Comfort Disturbed Sleep Pattern Risk for Impaired Parenting Ineffective Breastfeeding

Ineffective Breastfeeding

Which action is taken during the maintenance phase of an interview? Select all that apply. Observe the client's behavior, and listen attentively. Keep focused on the task or goals to ensure that needed data are obtained and goals are achieved. The nurse assesses her own feelings or reactions to previous clients that might interfere with the nurse-client relationship. Establish a verbal contract with the client, incorporating the goals of the interview. Review goal or task attainment.

Keep focused on the task or goals to ensure that needed data are obtained and goals are achieved. Observe the client's behavior, and listen attentively.

The nurse is caring for a patient for the third day in a row on the hospital unit. At his evening vital sign assessment, the nurse notices the radial pulse is much slower than his apical pulse. This finding is new. Which of the following would the nurse do next? Recheck his pulse at the next schedule assessment time and document the findings on the chart. Notify the physician after the next scheduled assessment time if the pulse is unchanged. Document the findings on the chart and recheck in 1 hour. Recheck his pulse in 2 hours Notify the physician of the change and document the finding.

Notify the physician of the change and document the finding.

Nurses perform assessments on clients as part of their routine care. Which statements accurately describe the unique focus of these nursing assessments? Select all that apply. The findings from a nursing assessment may contribute to the identification of a medical diagnosis. Nursing assessments focus on the client's responses to health problems. The focus of a nursing assessment is on actual, not potential, health problems. Nursing assessments duplicate medical assessments. An initial assessment establishes a complete database for problem solving and care planning. Nursing assessments target data pointing to pathologic conditions

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.

A nurse is interviewing a new client admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview? The nurse assesses the client's comfort and ability to participate in the interview. The nurse asks the client if there is anything else that needs to be divulged The nurse recapitulates the interview, highlighting important points. The nurse gathers all the information needed to form the subjective database.

The nurse assesses the client's comfort and ability to participate in the interview.

A nurse is beginning the preparatory phase of the nursing interview for a client who fractured the left leg in a fall. Which nursing actions occur in this phase of the nursing interview? Select all that apply. The nurse initiates the interview by stating his/her name and status. The nurse recapitulates the interview, highlighting key points. The nurse ensures that the interview environment is private and comfortable. The nurse assesses the client's comfort and ability to participate in the interview. The nurse prepares to meet the client by reading current and past records and reports. The nurse arranges the seating in the interview room to facilitate an easy exchange of information.

The nurse ensures that the interview environment is private and comfortable. The nurse arranges the seating in the interview room to facilitate an easy exchange of information. The nurse prepares to meet the client by reading current and past records and reports.

The nurse is reviewing the laboratory report section of a client's record. For what reason is this important for the nurse to review? Select all that apply. To confirm previously collected data To help establish a diagnosis To monitor clients' responses to treatment To help clients feel that something is being done for them To conflict with previously collected data

To confirm previously collected data To conflict with previously collected data To help establish a diagnosis To monitor clients' responses to treatment

The nurse is reviewing the laboratory report section of a client's record. For what reason is this important for the nurse to review? Select all that apply. To help clients feel that something is being done for them To monitor clients' responses to treatment To confirm previously collected data To conflict with previously collected data To help establish a diagnosis

To confirm previously collected data To conflict with previously collected data To help establish a diagnosis To monitor clients' responses to treatment

The nursing instructor is teaching the students about assessments. Which traits does the instructor list as being most important in order for an assessment to be successful? Competence and forceful Enthusiastic and aggressive Low-key and timid Trust and confidence

Trust and confidence

The nurse is interviewing a client that is newly admitted to the unit. Which techniques used by the nurse will facilitate communication during the interview? Select all that apply. Use broad opening statements. Share observations. Give approval. Use silence. Use reassuring clichés.

Use broad opening statements. Share observations. Use silence.

When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind? Document all inferences. Validate inferences with the client. Avoid making any inferences. Do not share inferences with the client.

Validate inferences with the client.

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? Ignore the client's nonverbal behavior. Ignore the client's answer. Validate the data. Chart the data.

Validate the data.

A nurse is asking questions about a client's sexual history. It is important for the nurse to: evaluate the client's past history of sexual dysfunction. collect data in a quiet, private environment. provide a time that enhances openness. pull the curtains in a semiprivate room.

collect data in a quiet, private environment.

A client has been discharged from an acute care facility with a referral for a home health nurse to make an assessment. What is the priority action by the home health nurse on the initial home visit? receive a report from the nursing staff. care of the client's physical pain. evaluate the care previously provided. establish the client's database.

establish the client's database.

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: acute myocardial infarction fluid overload dehydration imminent stroke air embolism

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