Chapter 14: Assessing

A 33-year-old client is brought to the urgent care center, doubled over in pain and crying. Upon assessment, the client admits to nausea and vomiting ×3 during the morning. Which action should the nurse prioritize after noting right lower quadrant (RLQ) rebound tenderness, blood pressure of 130/92 mm Hg, and pulse 100 beats/min and weak? Reevaluate the client in 30 minutes Notify the health care provider immediately Send the client to the closest emergency department Start an IV of normal saline

Notify the health care provider immediately

Which is the purpose of a focused assessment? Adds depth to existing information Provides breadth for future comparisons Suggests possible problems Gives a comprehensive volume of data

Adds depth to existing information

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

Validate the data.

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

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

When performing an assessment, the nurse should focus most on the developmental stage for which client? a. Young adult b. Middle-age adult c. Adolescent d. Toddler

d. Toddler

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

review as much information as possible.

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

body systems.

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

a) Focused

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should: a) inform the client of the maintenance of confidentiality. b) review literature pertinent to the client's attributes. c) implement supportive nursing interventions. d) assess personal feelings regarding similar clinical situations.

a) inform the client of the maintenance of confidentiality.

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview? a. "Is there anything else we should know in order to care for you better?" b. "What are your expectations from us and from yourself in your care?" c. "What practices have you found especially helpful in other settings?" d. "What do you envision for your care while you're here at the facility?"

a. "Is there anything else we should know in order to care for you better?"

Which are examples of subjective data? Select all that apply. a. A client reports being cold and requests an extra blanket. b. A client feels nauseated after eating breakfast. c. A nurse observes redness and swelling at an intravenous site. d. A client's blood pressure is elevated following physical activity. e. A client describes pain as an 8 on the pain assessment scale. f. A nurse observes a client wringing the hands before signing a consent for surgery.

a. A client reports being cold and requests an extra blanket. b. A client feels nauseated after eating breakfast. e. A client describes pain as an 8 on the pain assessment scale.

The nurse delegates vital signs to be taken and recorded by the unlicensed assistive personnel (UAP). The UAP reports a blood pressure of 230/120mm Hg on a client. Which is the nurse's priority action? a. Assess the client and re-evaluate the vital signs. b. notify the health care provider of the blood pressure result. c. direct the UAP to take the blood pressure in the arm with a larger cuff d. review the client's medication list and notify the nursing supervisor

a. Assess the client and re-evaluate the vital signs.

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply. a. Caring b. Competence c. Number of years in profession d. Professionalism e. Respect for client

a. Caring b. Competence d. Professionalism e. Respect for client

The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to: a. complete an exam of all body systems b. perform a review of the problem areas. c. assess only the abdomen d. don't assess

a. complete an exam of all body systems

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client? a. Explain the nurse will need to touch the client during the assessment b. Concentrate on a focused assessment of the abdomen and leave the rest of the assessment for a later time c. Evaluation

a. Explain the nurse will need to touch the client during the assessment

What must the nurse do to identify actual or potential health problems? a. Gather data from sources b. call the physician c. Meet with significant others d. Evaluate care implemented

a. Gather data from sources

The nurse is performing an admission assessment. Which are considered objective data? Select all that apply. a. Height: 6 ft (1.82 m) b. "I am afraid something serious is wrong." c. "My leg hurts." d. Weight: 195 lb (89 kg) e. 38-year-old man

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

A family presents to the emergency room with a 4-year-old child who is crying and reporting that the skin on the legs are itching and hurting. The parent explains that they were out walking in the woods when the child went running off the path and into some tall weeds. Which finding(s)s should the nurse prioritize in this assessment? Select all that apply a. Stating "My legs feel like they are burning" b. Crying and trying to scratch legs due to itching c. Respirations 18 breath/min and regular d. Redness and blisters forming on both legs e. 4-year-old at 85 percentile of growth and development

a. Stating "My legs feel like they are burning" b. Crying and trying to scratch legs due to itching d. Redness and blisters forming on both legs

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver? a. The nurse uses open-ended questions when working with a crying client. b. The nurse leaves the room when a client is crying to provide privacy. c. The nurse calls the hospital chaplain to talk with the client. d. The nurse documents the client was crying at the end of the shift.

a. The nurse uses open-ended questions when working with a crying client.

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition? a. The nursing and medical literature b. The client c. The client's chart d. The client's physician

a. The nursing and medical literature

The nurse is assessing a client in an outpatient setting. The client states, "I do not 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 client reports a 30-year heavy smoking habit and having a cough for about 6 months. Auscultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminished bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing concern for this client? a. suicide attempt risk b. risky health behavior c. excessive stress d. neglect in self-care e. altered health maintenance

a. suicide attempt risk

When is the best time for a nurse to take a client's health history? a. After the client is settled and feels ready b. As soon as possible after a client presents for care c. Within 24 hours of admission Anytime before the client is discharged

b. As soon as possible after a client presents for care

At the end of the shift, the nurse documents that the client has voided 475mL during the shift via an indwelling urinary catheter. what type of data has the nurse documented? a. Subjective b. Objective C. covert d. symptomatic

b. Objective

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing? a. focused assessment b. functional assessment c. database assessment d. comprehensive assessment

b. functional assessment

The nurse auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding? a) "We need to validate the information obtained in this assessment." b) "Crackles indicate that your child may have an allergy." c) "We will share this assessment finding with the physical therapist." d) "This is a normal finding and nothing of concern."

c) "We need to validate the information obtained in this assessment."

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information? a) If the client is in bed, the nurse stands at the side of the bed. b) If both the nurse and client are seated, their chairs are at right angles to each other, 30 cm apart. c) If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. d) If the client is in bed, the nurse stands at the foot of the bed.

c) If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing? a) Complete b) Focused c) Time-lapse d) Emergency

c) Time-lapse

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action? a) Inform the unlicensed assistive personnel to document the finding. b) Verbally report the finding to the charge nurse at the change of shift. c) Verbally report the finding immediately to the client's physician. d) Reassess the client's temperature in 2 hours and chart this data.

c) Verbally report the finding immediately to the client's physician.

The purpose of obtaining a nursing history is to: a) assist the physician to establish a medical diagnosis. b) minimize the time required to establish a nursing diagnosis. c) identify actual and potential health problems. d) focus on objective physical data specific to the client.

c) identify actual and potential health problems.

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. which action will the nurse take when conducting the respiratory of this client? a. Collaborate with the client to form goals b. Apply supplemental oxygen by face mask as needed c. Auscultate the chest for breath sounds. d. Document "impaired oxygenation" on the nursing care plan

c. Auscultate the chest for breath sounds.

Which are examples of subjective data? Select all that apply. a. Laceration b. Edema c. Nausea d. Anxiety e. Light-headedness

c. Nausea d. Anxiety e. Light-headedness

When assessing the firmness of a client's abdomen, the nurse should use which assessment technique? a. Auscultation b. Inspection c. Palpation d. Percussion

c. Palpation

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source? a. Tertiary b. Primary c. Secondary d. Quaternary

c. Secondary

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

d) uses broad, open statements to communicate with the client.

Which scenario is an example of a time-lapse reassessment? a. Seeing a client down on the floor, the nurse assesses the client's airway, breathing, and circulation, calls for help, and begins a quick neurological exam. b. A nurse in a long-term skilled nursing facility assesses a new resident's baseline health status. c. A nurse just coming on shift performs a focused physical assessment on each client, based on the client's diagnosis. d. A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.

d. A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.

Which client situation most likely warrants a time-lapse nursing assessment? . A client is being admitted to a general medicine unit after spending several days in the intensive care unit. b. The nurse has responded to the call light of a hospital client who is reporting shortness of breath and chest pain. c. A nurse is auscultating the lungs and measuring the oxygen saturation of a client who has pulmonary edema. d. An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

d. An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

Which group of terms best defines assessing in the nursing process? a. problem-focused, time-lapsed, emergency-based b. Nurse-focused, establishing nursing goals c. Designing a plan of care, implementing nursing interventions d. Collection, validation, communication of client data

d. Collection, validation, communication of client data

After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data? a. Body Systems Model b. Functional Health Patterns c. Human Response Patterns d. Hierarchy of Human Needs

d. Hierarchy of Human Needs

The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first? a) inspection b) auscultation c) palpation d) percussion

inspection

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

time-lapsed