Chapter 11 - Assessing

3. Draw curtains around the client and nurse to provide as much privacy as possible.

A client comes into the emergency department with a non-life-threatening wound to the hand that will require stitches. The department is quite busy with other clients, their families, and other people in the waiting room. The best way for the nurse to conduct an interview with this client is to: 1. Have the client wait until the department quiets down, since the wound is not too serious. 2. Tell the client to wait in the waiting room and fill out the paperwork. 3. Draw curtains around the client and nurse to provide as much privacy as possible. 4. Make sure the client's back is to the rest of the room so as not to be heard by passersby.

3. inference

A client comes to the emergency department with injuries to her upper shoulders and back area. When questioned about how the injuries occurred, the client becomes less talkative and states that she "fell." The client has a history of frequent ED visits, always with believable excuses about how her injuries occurred. The nurse begins to suspect that this client is a victim of abuse. This is an example of the nurse making which of the following? 1. Observation of cues 2. Validation 3. Inference 4. Judgment

2. After the client has settled in and been oriented to the room

A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this client's interview? 1. As soon as the client gets to the floor 2. After the client has settled in and been oriented to the room 3. When the family is available to help 4. After the client has been medicated

3, 4, 5, 2, 1 (ECG monitor shows tachycardia, client reports being restless, O2 tubing is not attached to wall regulator, the IV pump is running on battery, Family is at bedside.)

A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least priority). Choice 1. Family is at bedside. Choice 2. The IV pump is running on battery. Choice 3. ECG monitor shows tachycardia. Choice 4. Client reports being restless. Choice 5. O2 tubing is not attached to wall regulator.

1. Sit next to the client, a few feet apart.

A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, the nurse should: 1. Sit next to the client, a few feet apart. 2. Sit behind a desk. 3. Stand at the side of the client's chair. 4. Stand at the counter to take notes during the interview.

2. "You're right. Let me know if there's anything you need right now."

A client was admitted just prior to the shift change. The admitting nurse reported most of the information to oncoming staff, but did not have all of the client's past records. The second nurse is completing the assessment and database and continues to question the client about much of the same information as the previous nurse. The client says, "Why don't you people talk to each other and quit asking the same things over and over?" The best response of the nurse is: 1. "In order to make sure all of your information is complete, I need to ask these questions." 2. "You're right. Let me know if there's anything you need right now." 3. "I'll be done shortly, just give me a few more minutes." 4. "You shouldn't be upset. We're only doing our jobs."

1. A focus on client needs

A major characteristic of the nursing process is which of the following? 1. A focus on client needs 2. Its static nature 3. An emphasis on physiology and illness 4. Its exclusive use by and with nurses

2. Use the translation services supplied by the hospital.

A nurse has been assigned a new client who cannot speak English. In order that the client receives accurate information, the nurse should: 1. Have a member of the housekeeping staff who speaks the same language translate. 2. Use the translation services supplied by the hospital. 3. Make sure a family member who does speak English is available. 4. Conduct the interview using hand gestures.

1. Retake the vital signs.

A nurse has delegated to a nurse's aide to obtain vital signs for a newly admitted client. The aide reports the following: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. To validate the data, the best action by the nurse is: 1. Retake the vital signs. 2. Call the physician. 3. Continue with the physical assessment as soon as possible. 4. Report the findings to the charge nurse.

4. 24 hours

A nurse has just been informed that a new admission is coming to the unit. According to the 2005 JCAHO requirements, how long does the nurse have to complete a physical assessment and have a documented history and physical on the chart? 1. 1 hour 2. 12 hours 3. 48 hours 4. 24 hours

3. Whirring of ventilators

A nurse has worked in the trauma critical care area for several years. Which of the following noises may become indiscriminate for this particular nurse? 1. A client with audible breathing 2. Moaning of a client in pain 3. Whirring of ventilators 4. Co-workers discussing their clients' conditions

1, 4, 5 (1. Looking directly at the client to ensure good eye contact. 4. Sitting in a chair next to the client who is in bed 5. Keeping arms unfolded and in a relaxed position.)

A nurse implementing effective communication guidelines during an assessment interview when: Select all that apply. 1. Looking directly at the client to ensure good eye contact. 2. Managing the conversation to avoid periods of silence. 3. Providing personal experiences to help the client focus. 4. Sitting in a chair next to the client who is in bed. 5. Keeping arms unfolded and in a relaxed position.

1, 2, 4, 5 (1. Reports from physical therapy the client received as an outpatient 2. Documentation of the nurse's physical assessment 4. A list of current medications 5. Information about the client's cultural preferences.)

A nurse is performing an initial assessment on a new admission. Which of the following is part of the database? Select all that apply. 1. Reports from physical therapy the client received as an outpatient. 2. Documentation of the nurse's physical assessment. 3. Physician's orders. 4. A list of current medications. 5. Information about the client's cultural preferences. 6. Discharge instructions.

Reports from physical therapy the client received as an outpatient Documentation of the nurse's physical assessment A list of current medications Information about the client's cultural preferences

A nurse is performing an initial assessment on a new admission. Which of the following is part of the database? (Select all that apply.) ______ Reports from physical therapy the client received as an outpatient ______ Documentation of the nurse's physical assessment ______ Physician's orders ______ A list of current medications ______ Information about the client's cultural preferences ______ Discharge instructions

3. implementation

A nurse is providing a back rub to a client just after administering a pain medication, with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is this nurse implementing? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation

3. Emergency assessment

A nurse is working in the operating room with a client just prior to the procedure. While setting up for the procedure, the nurse notices that the client has become unresponsive and respirations have become shallow. What type of assessment would be necessary in this situation? 1. Initial assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed assessment

1, 2, 5 (1. Develop a list of problems, 2. Identify client strengths, 5. Identify problems that can be prevented.)

A nursing student is learning how to implement the nursing process in the clinical area. The purpose of the diagnosis phase includes which of the following? (Select all that apply.) 1. Develop a list of problems. 2. Identify client strengths. 3. Develop a plan. 4. Specify goals and outcomes. 5. Identify problems that can be prevented.

1. "Hello, I'm your nursing student and I'll be helping to take care of you today."

A nursing student is meeting an assigned client for the first time. In order to begin the establishment of rapport, the best statement by the student is: 1. "Hello, I'm your nursing student and I'll be helping to take care of you today." 2. "You're lucky, you have students and nurses taking care of you today." 3. "Good morning, is there anything you need right now?" 4. "Hi. If you need anything, either your nurse or I will get it for you."

3. parents

An infant has been admitted to the pediatric unit. The parents are quite worried and upset, and the grandmother is also present. In this situation, what would be the best source of data? 1. Medical record from the child's birth 2. Grandmother, since the parents are upset 3. Parents 4. Admitting physician

4. Value/belief pattern

During an assessment interview, the nurse understands that the client has decided not to take the physician's advice about an elective surgical procedure. The client shares that this is "just not part of what I have in mind for my life's goals." This would fall into which of Gordon's functional health patterns? 1. Cognitive/perceptual pattern 2. Coping/stress-tolerance pattern 3. Health-perception/health-management pattern 4. Value/belief pattern

2. "What kind of questions do you have about your surgery?"

During an initial interview, the client makes this statement: "I don't understand why I have to have surgery, I'm really not that sick or in pain right now." The nurse's best response is: 1. "It's OK to be worried. Surgery is a big step." 2. "What kind of questions do you have about your surgery?" 3. "I think these are things you should be asking your doctor." 4. "Have you had surgery before?"

3. Confirms data are complete and accurate

In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following? 1. Collects subjective data. 2. Applies a framework to the collected data. 3. Confirms data are complete and accurate. 4. Records data in the client record

1, 2, 3, 4 (1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature. 2. Advocating for a client who is mentally incapable of expressing her needs. 3. Deciding to increase a client's nasal oxygen based on his current pulse oxygenation levels. 4. Documenting all clients' pain level responses after the administration of pain medication.)

Nursing activities that represent the various characteristics of the nursing process includes the nurse's: Select all that apply. 1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature. 2. Advocating for a client who is mentally incapable of expressing her needs. 3. Deciding to increase a client's nasal oxygen based on his current pulse oxygenation levels. 4. Documenting all clients' pain level responses after the administration of pain medication. 5. Attending in-services on a new hydraulic lift to be used to support safe client care.

1. "I'm going to set up your physical assessment now. Do you have any questions?"

The nurse has just completed an admission interview with a new client. Which response by the nurse is an example of a remark used during the closing phase of the interview? 1. "I'm going to set up your physical assessment now. Do you have any questions?" 2. "Tell me more about how you feel." 3. "Could you give examples of what types of other treatments you've had?" 4. "Is there anything you're worried about?"

3. objective data

The nurse is collecting information from a client's family. The client is confused and not able to contribute to the conversation. The spouse states, "This is not his normal behavior." The nurse documents this as which of the following? 1. Inference 2. Subjective data 3. Objective data 4. Secondary subjective data

1. Assessment

The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation

1. "How would you describe your sleep pattern?"

The nurse is taking a health history from a client who has complications from chronic asthma. Which of the following is an example of an open-ended question? 1. "How would you describe your sleep pattern?" 2. "Can you describe your coughing pattern?" 3. "Is there anything that makes your breathing worse?" 4. "What medications are you on?"

2. "leave me alone"

The nurse is taking information for the client's database. The client is not very talkative; is pale, diaphoretic, and restless in the bed; and tells the nurse to just "leave me alone." Which of the following is an example of subjective data regarding this client? 1. Restlessness 2. "Leave me alone" 3. Not talkative 4. Pale and diaphoretic

3. Evaluation

The nurse makes the decision to look at alternatives for wound care with a client who has a stasis ulcer that has been treated over the past 2 weeks. The nurse was hopeful to see some improvement by this time. This represents which phase of the nursing process? 1. Diagnosis 2. Implementation 3. Evaluation 4. Assessment

4. observing

The nurse makes this entry in the client's chart: "Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. However, is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse." This is an example of which method of data collection? 1. Examining 2. Interviewing 3. Listening 4. Observing

3. "Tell me about your reactions to the diagnosis."

The nurse wishes to determine the client's feelings about a recent diagnosis. Which interview question is most likely to elicit this information? 1. "What did the doctor tell you about your diagnosis?" 2. "Are you worried about how the diagnosis will affect you in the future?" 3. "Tell me about your reactions to the diagnosis." 4. "How is your family responding to the diagnosis?"

4. Collection of all necessary information for a thorough appraisal

The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1. Correlation of the data with other members of the health care team 2. Demonstration of cost-effective care 3. Utilization of creativity and intuition in creating a plan of care 4. Collection of all necessary information for a thorough appraisal

3. "How has the pain impacted your life?"

Wanting to know more about the client's pain experience, the nurse continues to explore different questioning techniques. Which of the following is the best example of an open-ended question for this situation? 1. "Is your pain worse at night?" 2. "What brought you to the clinic?" 3. "How has the pain impacted your life?" 4. "You're feeling down about having pain, aren't you?"

3. Identify client needs and deliver care to meet those needs.

When learning how to implement the nursing process into a plan of care for a client, the student nurse realizes that part of the purpose of the nursing process is to: 1. Deliver care to a client in an organized way. 2. Implement a plan that is close to the medical model. 3. Identify client needs and deliver care to meet those needs. 4. Make sure that standardized care is available to clients.

1. identifying major problems and needs

Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process? 1. Identifying major problems or needs 2. Organizing data in the client's family history 3. Establishing short-term and long-term goals 4. Administering an antibiotic

3. review results of laboratory tests

Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care? 1. Proposes hypotheses. 2. Generates desired outcomes. 3. Reviews results of laboratory tests. 4. Documents care.

2. spouse states the client has lost all appetite

Which of the following elements is best categorized as secondary subjective data? 1. The nurse measures a weight loss of 10 pounds since the last clinic visit. 2. Spouse states the client has lost all appetite. 3. The nurse palpates edema in lower extremities. 4. Client states severe pain when walking up stairs.

1. Establish a database of client responses to his or her health status

Which of the following is the purpose of assessing? 1. Establish a database of client responses to his or her health status. 2. Identify client strengths and problems. 3. Develop an individualized plan of care. 4. Implement care, prevent illness, and promote wellness.

2, 4, 5 (2. Ensure that no one can overhear the interview conversation. 4. Keep approximately 3 feet from the client during the interview. 5. Use a standard form to be sure all relevant data are covered in the interview)

Which of the following represent effective planning of the interview setting? Select all that apply. 1. Keep the lighting dimmed so as not to stress the client's eyes. 2. Ensure that no one can overhear the interview conversation. 3. Stand near the client's head while he or she is in the bed or chair. 4. Keep approximately 3 feet from the client during the interview. 5. Use a standard form to be sure all relevant data are covered in the interview.

4. Observed data should be interpreted in relation to other sources of collected data.

Which of the following would be true regarding use of the observing method of data collection? 1. When observing, the nurse uses only the visual sense. 2. Observing is done only when no other nursing interventions are being performed at the same time. 3. Data should be gathered as it occurs, rather than in any particular order. 4. Observed data should be interpreted in relation to other sources of collected data.