Chapter 14: Assessing PrepU

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

a. Toddler Nursing assessments vary according to the client's developmental needs. When assessing an infant, toddler, or child, the nurse should give special attention to physiologic and psychosocial aspects of growth and development to identify client problems. It is not as important to focus on developmental stage when assessing clients in the other age groups, because their developmental needs do not vary as much and do not affect the assessment as much.

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation? a. "Client states, 'I don't see the point in trying anymore.'" b. "Client makes statements indicating a loss of hope." c. "Client states that rehabilitation will be unsuccessful." d. "Client is demonstrating signs and symptoms of depression."

a. "Client states, 'I don't see the point in trying anymore.'" Subjective data should be recorded using the client's own words, using quotation marks as appropriate. Paraphrasing the client's words may lead to assumptions and misrepresentations.

An 80-year-old client presents to the clinic, reporting a headache that has continued for the past 4 days. Which question(s) should the nurse prioritize in the assessment? Select all that apply. a. "Have you experienced any falls and hit your head?" b. "Are you having any dizziness?" c. "Is the headache affecting your vision?" d. "Are you allergic to any foods or drugs?" e. "Are you having any pain in other areas of your body?"

a. "Have you experienced any falls and hit your head?" b. "Are you having any dizziness?" c. "Is the headache affecting your vision?" A focused assessment should be completed to collect data to help determine the possible cause of the headache. Asking about any falls or head injuries would help determine if the headache is related to an injury. Inquiring about dizziness and vision will assist with determining the type of headache and possible treatment. Questioning the client about allergies and pain in other areas of the body will be important but not a priority for the focused assessment centered on the headache.

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 do you envision for your care while you're here at the facility?" c. "What practices have you found especially helpful in other settings?" d. "What are your expectations from us and from yourself in your care?"

a. "Is there anything else we should know in order to care for you better?" A helpful strategy in the termination phase of an interview is to ask the client: "Is there anything else you would like us to know that will help us plan your care?" This gives the client an opportunity to add data the nurse did not think to include. Expectations and previous practices should be addressed during the working phase of an interview.

A nurse manager identifies a need for further instruction when a new nurse makes which statement? a. "The client is always the best source for collecting data." b. "The client is usually the best source for collecting data." c. "Family members are a good source of data when the client is a young child." d. "Caregivers can be a helpful source of data when the client has a limited capacity for information."

a. "The client is always the best source for collecting data." "The client is always the best source for collecting data" is a statement that requires additional instruction by the charge nurse. Although the client is usually the best source for information when collecting data during an assessment, a family member, friend, or caregiver can be especially helpful sources of data when the client is a child or has a limited cognitive capacity.

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."

a. "We need to validate the information obtained in this assessment." The assessment of a toddler should involve the parents, as they are the primary caretakers and most knowledgeable about their toddler's normal behavior and development, as well as the history of any presenting symptoms. The nurse will validate assessment data to verify information and clarify cues and inferences to determine if they are accurate and free of bias. Crackles indicate the presence of fluid in the airways. Client information is shared only with those caregivers who have a need to know the information. Nurses have a duty to teach the parents about their toddler's symptoms.

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

a. 38-year-old man b. Height: 6 ft (1.82 m) c. Weight: 195 lb (89 kg) Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person being assessed. Age, vital signs, height, and weight are objective data. Subjective data are data that the client reports or feels and are usually documented in the record with quotations. The client statements "My leg hurts" and "I am afraid something serious is wrong" are subjective data.

A 57-year-old client presents to the clinic with a report of abdominal pain. The client underwent a sigmoid colostomy 3 months ago for colon cancer. The client's recovery had been uneventful until 1 week ago. Which sign(s) or symptom(s) should the nurse prioritize in the assessment? Select all that apply. a. Absence of bowel sounds b. Tenderness around ostomy c. Redness at ostomy stie d. Semisoft fecal material in bag e. Fecal occult negative

a. Absence of bowel sounds b. Tenderness around ostomy c. Redness at ostomy site The absence of bowel sounds, tenderness and redness around the ostomy site are all red flags that there is a problem related to the previous surgery which needs to be evaluated and treated. The nurse would conduct a focused assessment to determine what needs to be addressed first and provide the best care for the client. The semisoft fecal material in the bag is an expected finding. A negative reading on the fecal occult testing would indicate there is no bleeding in the colon.

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

a. Anxiety b. Light-headedness c. Nausea Subjective data are those that only the person experiencing them can perceive and report, such as anxiety, light-headedness, and nausea. Objective data are those that someone other than the person experiencing them can observe, such as edema and laceration.

A parent arrives to the pediatric clinic with a 3-year-old child who is crying and tells the nurse the right ear hurts. Which assessment finding(s) should the nurse prioritize for further assessment? Select all that apply. a. Child pulling at right ear b. Right external ear canal red c. Right ear tender to touch d. Temporal temperature 99.2°F (37.3°C) e. Clinging to parent

a. Child pulling at right ear b. Right external ear canal red c. Right ear tender to touch A focused assessment will concentrate on the signs and symptoms of a possible ear infection, based on the initial presentation of the child. This will include the child pulling at the ear, red ear canal, and tenderness to touch the right ear. The temperature is slightly elevated but still within normal range. The child clinging to the parent is an indication the child may not be feeling well but does not specify what the specific problem is.

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply. a. Client states, "I feel so sad all of the time." b. Clothes visibly soiled and hair greasy c. Blood pressure 140/82 mm Hg d. Client states, "I am in pain." e. Ecchymosis on upper left arm

a. Client states, "I feel so sad all of the time." d. Client states, "I am in pain." Subjective data are statements by the client. Objective data are observations made by the nurse when gathering data such as vital signs and physical signs.

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? a. Clients not being fluent in the same language as the nurse b. Clients having a limited education c. Clients speaking the same language as the nurse d. Clients demonstrating mild anxiety. e. Clients fearing saying the wrong thing

a. Clients not being fluent in the same language as the nurse b. Clients having a limited education e. Clients fearing saying the wrong thing In regards to language difficulty, some examples that might interfere with a interview include the following: the client not speaking the same language as the nurse; the client having a limited education; and the client fearing saying the wrong thing. If a client speaks the same language there should not be a problem. Although being anxious might cause a problem during the interview, it is not associated with a language problem.

A 24-year-old client presents to the emergency department with signs and symptoms of a sickle cell crisis. The nurse quickly obtains the necessary laboratory tests to assist with the assessment, as well as conducts an assessment of the client to determine the proper nursing care the client will require. Which type of assessment did the nurse perform in this situation? a. Emergency b. Focused c. Initial d. Comprehensive

a. Emergency The nurse should complete an emergency assessment which will focus on the sickle cell crisis so that immediate care can be started to best treat the client. A focused assessment is conducted when more data are needed about a specific situation or health concern. The initial, comprehensive assessment is conducted to establish the client's medical and health condition. It will identify potential concerns as well as identify what the client is doing to ensure a healthy life.

A nurse is completing the assessment of an 85-year-old client who is being admitted to a memory care home for progressing dementia. The client is unable to answer some of the questions or provide some of essential information that the nurse needs to create the best nursing care plan for this client. Which source will be the best for the nurse to consult to gain this missing information? a. Family member b. Past medical records c. Social media d. Neighbors

a. Family member The nurse should consult with family members or significant others to gain this information. The best contact will be the individual who has been caring for the client most recently. Past medical records, social media, and neighbors will be limited in information about the client and most likely will be unable to provide the most accurate information.

A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? a. Focused b. Initial c. Emergency d. Time-lapse

a. Focused The nurse is performing a focused assessment, which involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the client's health. An emergency assessment is performed to identify life-threatening problems. A time-lapse assessment compares a client's current status to baseline data obtained earlier.

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client? a. Ineffective Breastfeeding b. Disturbed Sleep Pattern c. Impaired Comfort d. Risk for Impaired Parenting e. Readiness for Enhanced Parenting

a. Ineffective Breastfeeding The frequency of breastfeeding is the likely cause of the infant's inability to gain weight. Feeding should be priority for a newborn. Although the infant does demonstrate an impaired sleep pattern and impaired comfort, these are not as important as the infant's inability to gain weight. There is no evidence that the mother is at risk for impaired parenting.

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. a. Medical history b. Physical exam c. Care plan d. Progress notes e. Laboratory values

a. Medical history b. Physical exam d. Progress notes The parts of the record that include findings of physicians as they assess and treat the client include medical history, physical exam, and progress notes. The care plan is done by nursing and the laboratory values are entered by the laboratory.

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

a. Respect for client b. Competence c. Professionalism e. Caring The nurse's interpersonal competence is critical beginning with the very first assessment. The client's initial impression is crucial. The nurse's competence, professionalism, and interpersonal qualities of caring and respect invite confidence and assure the client that help is available. The length of time as a nurse does not influence competence and professionalism.

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? a. The nurse assesses the client's comfort and ability to participate in the interview. b. The nurse recapitulates the interview, highlighting important points. c. The nurse asks the client if there is anything else that needs to be divulged d. The nurse gathers all the information needed to form the subjective database.

a. The nurse assesses the client's comfort and ability to participate in the interview. During the introductory phase of the interview, the nurse determines if the client is going to be able to participate in the interview. The highlighting of important points occurs in the termination phase of the interview. Ensuring the environment is comfortable and private occurs during the preparatory phase, and the gathering of information occurs during the working phase. Asking the client if any other information needs to be divulged occurs in the termination phase.

The nurse is interviewing a client who is newly admitted to the unit. Which technique(s) used by the nurse will facilitate communication during the interview? Select all that apply. a. Use broad opening statements. b. Share observations. c. Use silence. d. Use reassuring clichés. e. Give approval.

a. Use broad opening statements. b. Share observations. c. Use silence. Using broad opening statements, sharing observations, and using silence are just a few of the techniques nurses use to establish rapport, elicit clients' thoughts and feelings, and encourage conversation and understanding. Using reassuring clichés is not a therapeutic communication technique. during this intervention. It is not up to the nurse to approve of client actions; this is a judgmental response.

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

a. Validate inferences with the client. The nurse should validate inferences made from assessment data to ensure accuracy. Incorrect cues and inferences lead to the development of inappropriate nursing diagnoses and client plans of care. Making inferences can be helpful as long as the nurse validates them. It is not necessary to document inferences. Often, the nurse must share inferences with the client to validate them.

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

a. a cue. Cues and inferences describe the early analysis of data. "The client does not respond when I speak while standing on the client's right side," is a cue that something may be wrong. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. A nurse can observe a cue directly but not an inference. The information in this case is based on the nurse's direct observation, not interpretation or inference, and thus cannot be a misinterpretation. There is no evidence that the nurse's observation duplicates other data collected.

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: a. body systems. b. functional health patterns. c. human response patterns. d. human needs.

a. body systems. The categorization of assessment findings according to systems (in this case, musculoskeletal, gastrointestinal, and respiratory) is characteristic of a body systems model for organizing data. Although systematic, this strategy tends to ignore spiritual and psychosocial considerations. Human needs are based on food, water, and shelter. Human response patterns involve the subjective awareness of information. The functional health patterns model is used to provide a more comprehensive nursing assessment of the patient focusing on sleep, roles, exercise, relationships, etc.

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

a. inspection When the nurse performs a physical assessment, four techniques: inspection, palpation, percussion, and auscultation will be used. In most cases the nurse will perform them in sequence. Because palpation and percussion can alter bowel sounds, the nurse will inspect, auscultate, percuss, then palpate an abdomen.

Which statement made by the nurse indicates data that would be documented as part of an objective assessment? a. "The client's sister reports that the client has unrelieved pain." b. "The client's right leg is cold to the touch, from the knee to the foot." c. "The client reports nausea following eating." d. "The client reports having heartburn after breakfast."

b. "The client's right leg is cold to the touch, from the knee to the foot." Objective data are information that is observable and measurable, such as observing that the client's right leg is cold to the touch. Subjective data relate to phenomena that only the client can experience, such as unrelieved pain, nausea, or heartburn.

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

b. A focused assessment of the specific problems identified The priority assessment at this time is a focused assessment of the client's primary concern. A focused assessment may be performed during the initial assessment if the client's health problem is apparent. A full assessment of the urinary system may be appropriate but is not the priority. A detailed assessment of the client's sexual history is not warranted, and although a thorough systems review is conducted, it is not the priority at this time.

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview? a. Inform the client that the interview must proceed before getting anything that will alter sensorium. b. Administer prescribed pain medication prior to conducting the interview. c. Document that the client refused the interview. d. Use the information that is on the electronic health record and eliminate the need for the interview.

b. Administer prescribed pain medication prior to conducting the interview. The nurse should make every effort to make the client comfortable prior to interviewing, including obtaining an prescription for and administering pain medication; if the pain persists, obtain only vital data and defer the remainder of the interview until the client is more comfortable. The information on the electronic health record is not inclusive of the subjective data from the client. The client is not refusing the interview, and the nurse can always come back later to complete it.

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 d. Anytime before the client is discharged

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

Which is the best source of information for the nurse when collecting data for an assessment? a. Primary physician b. Client c. Charge nurse d. Medical record

b. Client The client is the primary, and usually best, source of information when doing an assessment. The medical record may also provide information, but only if the client has been at the health care facility before; even then, the client is likely to have more current information than the medical record. Although the charge nurse is responsible for the care of all clients on the unit, the charge nurse is not likely to know the details of any one client's information. The primary physician would provide medical care based on the medical assessment and would not have more information than the client about the client's current health status.

A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrointestinal symptoms or should be reported to the physician. Which action should the nurse perform next? a. Call the family. b. Consult with another nurse. c. Chart the information. d. Wait and see whether the pain subsides.

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

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? a. Head-to-toe b. Focused c. Emergency d. Time-lapse

b. Focused In a focused assessment, the nurse gathers information about a specific problem that has already been identified. A head-to-toe assessment is an initial, complete assessment, typically to assess for any problems that have not been identified yet. An emergency assessment is used to identify a life-threatening problem. A time-lapse reassessment is scheduled to compare current status with the baseline obtained earlier.

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

b. Focused The nurse conducts a focused assessment of the client with a specific identified problem. An initial assessment is conducted by the nurse to establish a baseline database and identify current health problems. The nurse performs an emergency assessment during a crisis to identify life-threatening problems. A time-lapse assessment is one in which the nurse reassesses a client to evaluate the client's progress since a previous assessment for the same condition.

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data? a. Subjective b. Objective c. Physical d. Unreliable

b. Objective Objective data are data that are observable and measurable and can be seen, heard, felt, or measured by someone other than the client. Subjective data are information perceived only by the affected person. Physical and unreliable are not types of data.

A client comes to the emergency department with flulike symptoms. The nurse records the vital signs and listens to the client's lung sounds. Vital signs and lung sounds are examples of which type of data? a. Subjective b. Objective c. Intuitive d. Hunches

b. Objective Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Subjective data are data that the client feels or states and are usually documented in quotations. Intuition is the ability to understand something immediately, without the need for conscious reasoning. A hunch is a feeling or guess based on intuition rather than known facts.

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood cell count. The nurse is gathering which type of data when looking up the lab value? a. Subjective b. Objective c. Primary d. Secondary

b. Objective Reports of laboratory studies and other diagnostic tests are considered objective data, which can either confirm or refute other data collected during the nursing exam and history. Subjective data are about a client's feeling or what the client states. Primary data are collected by an investigator conducting research. Common sources of secondary data for social science include censuses, information collected by government departments, organizational records, and data that were originally collected for other research purposes.

Which nursing skill uses all five senses? a. Documentation b. Observation c. Listening d. Caring

b. Observation Observation is the conscious and deliberate use of the five senses (sight, smell, hearing, taste, and touch) to gather data. Documentation uses sight (seeing the client's chart) and touch (typing on a keyboard or writing with a pen). Listening involves just hearing what the client is saying. Caring need not involve any of the senses but is displaying kindness and concern for others.

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? a. Physiologic b. Safety and security c. Love and belonging d. Self-esteem e. Self-actualization

b. Safety and security Physiologic needs are the physical requirements for human survival. Physiologic needs include breathing, water, food, sleep, clothing, shelter, and sex. Once a person's physiologic needs are relatively satisfied, the person's safety needs take precedence and dominate behavior. Safety and security needs include personal security, emotional security, financial security, health and well-being, and safety against accidents or illness and their adverse impacts. After physiologic and safety needs are fulfilled, the third level of human needs is interpersonal and involves feelings of love and belonging. These include relationships with friends, intimacy, and family. Self-esteem needs are ego needs or status needs, such as for getting recognition, status, importance, and respect from others. All humans have a need to feel respected; this includes the need to have self-esteem and self-respect. Self-actualization is what a person's full potential is and the realization of that potential.

During the interview component of the health assessment, how does the nurse convey to the client that the information is important? a. Nodding frequently during the interview b. Sitting at eye level with the client c. Standing next to the client while interviewing d. Limiting questions to those with yes or no answers

b. Sitting at eye level with the client When the client responds to a question, the nurse conveys interest by maintaining eye contact, occasionally nodding, or verbally responding to the client's remarks. This is best accomplished by selecting a seat at eye level to allow direct engagement with the client during the interview. Standing during the interview can limit the interaction between nurse and client. Questions should be open-ended to elicit the most information and engage the client. Yes or no (close-ended) questions do not encourage the client to provide the level of detail the nurse is attempting to collect.

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. 4-year-old at 85 percentile of growth and development b. Stating "My legs feel like they are burning" c. Redness and blisters forming on both legs d. Respirations 18 breath/min and regular e. Crying and trying to scratch legs due to itching

b. Stating "My legs feel like they are burning" c. Redness and blisters forming on both legs e. Crying and trying to scratch legs due to itching This client needs an emergency assessment to ensure the child did not encounter any poisonous vegetation such as poison ivy. Reports of burning, redness, blisters, and itching all indicate a possible reaction to poisonous foliage and require immediate attention and care. The other findings will be assessed after the emergent situation is stabilized.

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg? a. Explanatory b. Subjective c. Objective d. Severe

b. Subjective Cues may be signs (objective) or symptoms (subjective). Objective cues, called signs, are observable, perceptible, and measurable by someone other than the person experiencing them. Subjective cues, called symptoms, are only observable, perceptible, and measurable by the person experiencing them. The pain described by the client in this question is a subjective cue, as only the client is able to perceive it. Explanatory suggests that the client would offer an explanation or comparison to describe the pain in the right leg. Severe is an adjective that might be the equivalent of 8/10 on the pain scale as reported by the client.

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments? a. The physician b. The nurse c. The case manager d. The nursing supervisor

b. The nurse The question focuses on independent actions that nurses can perform. Interventions for which the nurse may be legally responsible include increasing the frequency of assessments and initiating necessary changes in the treatment regimen. Nurses are responsible for alerting the appropriate professional (e.g., the physician) whenever assessment data differs significantly from the baseline. The nursing supervisor would be alerted if the professional does not evaluate the client. The case manager would be alerted when the client was ready for discharge.

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

b. The nurse uses open-ended questions when working with a crying client. Any nurse who wishes to be an effective caregiver must first learn how to be an effective communicator. Good communication skills enable nurses to get to know their clients and, ultimately, to diagnose and to meet their needs for nursing care. By asking open-ended questions the nurse can gain more information as to why the client is crying. Without understanding the "why" behind the crying the nurse cannot determine if the hospital chaplain might be needed. Providing privacy for the client can be thoughtful but not a way to learn more.

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? a. Developmental stage assessment b. Time-lapsed assessment c. Emergency assessment d. Focused assessment

b. Time-lapsed assessment A time-lapsed assessment is scheduled to compare a client's current status to the baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time are scheduled for this type of check. An emergency assessment is conducted if the client is having an emergency such as chest pain or hemorrhaging from the hand. Focused assessment is performed on clients focusing on the system or systems involved in the client's problem. Developmental stage assessment is the process of mapping a child's performance compared with children of similar age.

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? a. Chart the data. b. Validate the data. c. Ignore the client's answer. d. Ignore the client's nonverbal behavior.

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

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: a. a cue. b. an inference. c. duplicate data. d. erroneous data.

b. an inference. The judgment a nurse makes about a cue is known as an inference. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. The nurse can observe a cue directly, but not an inference. The key is the verb used —"hearing may be impaired." The statement is not erroneous or duplicate data.

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is: a. the focus assessment done when admitted to the ER. b. the initial comprehensive client assessment. c. the health record from a previous admission. d. the client record from the physician's office.

b. the initial comprehensive client assessment. The initial comprehensive client assessment results in the baseline data that enables the nurse to make judgments, plan care, and refer clients to other health care workers if necessary.

A nurse is asking questions about a client's sexual history. Which is the best question for the nurse to ask to determine the client's use of safer sexual practices? a. "How many sexual partners have you had in the past 6 months?" b. "Do you use condoms?" c. "How do you protect yourself when having sex?" d. "Are you in a committed relationship?"

c. "How do you protect yourself when having sex?" An open-ended question is the best type to use to gather the most information. Asking how the client uses protection during sex will obtain information about safer sex practices. Asking how many sexual partners the client has had or if the client is in a committed relationship will not help to ascertain the information. Asking, "Do you use condoms" is a closed-ended, yes or no question that will not provide comprehensive information.

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

c. A client describes pain as an 8 on the pain assessment scale. d. A client feels nauseated after eating breakfast. f. A client reports being cold and requests an extra blanket. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. A client's pain, nausea, and chills can only be felt by that person. Data collected about a client, such as the client wringing the hands, redness and swelling at an intravenous site, and a blood pressure measurement, are considered objective data. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client.

Which statement is true regarding addressing a priority problem? a. Addressing priority problems involves skipping interventions. b. Priority problems are identified at predetermined intervals throughout the shift. c. A priority problem requires a nursing intervention before another problem is addressed. d. The priority of problems is established and continued according to the nursing plan of care.

c. A priority problem requires a nursing intervention before another problem is addressed. A priority problem requires a nursing intervention before another problem is addressed, but addressing priority problems does not entail skipping any interventions. The priority of problems can change as a client's condition changes. There are no predetermined times or intervals at which to identify priority problems. This is why critical thinking plays a central role in nursing.

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

c. Adds depth to existing information A focused assessment adds depth to existing information or the initial database gathered by the nurse. A database assessment provides breadth for future comparisons. A focused assessment does not suggest possible problems facing the client but rather rules out or confirms the client's problems. A focused assessment is not voluminous and comprehensive, like a database assessment, but limited and to the point.

Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training? a. Validation is an important part of assessment. b. Validation helps to keep data as free from error as possible. c. All data collected need to be validated. d. Validation is the act of confirming or verifying.

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

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? a. Assess cholesterol levels. b. Obtain an electrocardiogram daily. c. Assess blood pressure with a large cuff. d. Begin client education regarding a low-fat diet.

c. Assess blood pressure with a large cuff. When assessing an obese client, a larger blood pressure cuff will likely be needed to prevent false high readings. It is not in the nurse's scope of practice to determine when and if cholesterol levels and an electrocardiogram are ordered. Diet education may or may not be warranted depending on the cause of the obesity.

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

c. Assess the client's blood pressure. The priority intervention for the client with an unstable blood pressure is to first measure the blood pressure. Once the nurse is certain that this is within safe parameters, the nurse should assess the client's diet, activity level, and medication regimen.

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview? a. Focus mainly on verbal comments. b. Fill in the words for the client. c. Avoid the impulse to interrupt. d. Fill in quiet spaces and pauses.

c. Avoid the impulse to interrupt. When doing an interview with a client, the nurse must listen actively for feelings, in addition to the verbal comments made by the client. The nurse should demonstrate patience if the client has a memory block and should avoid the impulse to fill in words or interrupt the client. Pauses in the conversation should be allowed, as silence gives both parties time to gather thoughts.

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

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

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

c. Collection, validation, communication of client data Assessing is the systematic and continuous collection, validation, and communication of client data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem-focused, time-lapsed, and emergency-based describe types of assessments. Assessments are nurse-focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are.

Which piece of client information is subjective? a. A temperature of 102°F (38.9°C) b. Leukoplakia on the client's oral mucosa c. Generalized myalgia or muscle pain d. Ptosis, a drooping of the eyelid, on the right side

c. Generalized myalgia or muscle pain Symptoms such as muscle pain or myalgia are considered subjective cues in a client's health history, as only the client can determine its presence. Signs of illness, such as temperature, leukoplakia, and ptosis, are considered objective cues in a health history. Objective signs are observable, perceptible, and measurable.

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 foot 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 side 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. If the client is in bed, the nurse sitting in a chair placed at a 45-degree angle to the bed ensures the nurse is sitting at eye-level with the client, which promotes communication. If the nurse is standing at the foot or at the side of the client's bed, an authoritative position is established, which does not promote good communication. If both the nurse and the client are seated, being 30 cm apart intrudes upon personal space; ideally the nurse and client should be about 1 m apart.

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client? a. Hunger b. Low anxiety c. Pain d. Sleepiness

c. Pain Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief. Sleepiness would be observed if the client did not respond in a timely manner. A client with low anxiety is relaxed and would answer the question with intention and thoughtfulness. A hungry client would be short-tempered and angry.

Which is the primary reason for a nurse collecting data continuously on a client? a. It gives the nurse more information to document on the client. b. It makes the client feel as if the nurse is spending more time with the client. c. The client's health status can change quickly. d. Most facilities require it for reimbursement.

c. The client's health status can change quickly. Data about the client is collected continuously because the client's health status can change quickly. It is not done as busy work nor is it to make the client feel good. Reimbursement is related to having certain assessments done, but is not based on continuous assessments of the client's condition.

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 The four types of nursing assessment include complete, focused, time-lapse, and emergency. In time-lapse assessments, the nurse reassesses a client and condition that is already known to re-evaluate the client's status. In this case the nurse is revisiting the client's feelings and plans to change her life situation by leaving her abusive husband. In emergency assessments, the nurse assesses the client for life-threatening problems which are acutely present. In focused assessments, the nurse focuses on assessing a specific problem that is already known to exist to further refine planning interventions. In complete (general or initial) assessments, the nurse does a thorough assessment of all aspects of a client's health status on the client's admission to a health care facility.

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. Verbally report the finding to the charge nurse at the change of shift. b. Inform the unlicensed assistive personnel to document the finding. 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 nurse should report any abnormal assessment findings or changes in the client's health status to the client's physician or the charge nurse immediately for prompt and appropriate treatment of the health alterations. The unlicensed assistive personnel should not document the findings as this is the nurse's responsibility. The nurse should not just reassess the client's temperature in 2 hours and chart that data; immediate reporting of the data to the physician or charge nurse is necessary.

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

c. inform the client of the maintenance of confidentiality. During the introductory phase, the nurse should inform the client how the information will be used and that confidentiality will be maintained. The alternate responses are not associated with the interview process and experience for the client.

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. uses broad, open statements to communicate with the client. d. reassures the client of good outcomes.

c. uses broad, open statements to communicate with the client. The nurse should use broad, open statements to facilitate communication during an interview. Using close-ended questions, which prompt yes or no answers, should be avoided, as it does not provide the level of the detail the nurse is seeking. The nurse should pay full attention to the client; paying too much attention to note-taking or making computer entries will interfere with good communication. The nurse should avoid providing false reassurance and agreeing with every statement the client makes.

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

d. Assess the client and re-evaluate the vital signs. The nurse is responsible for all delegated tasks. When the blood pressure is grossly elevated, the nurse should assess the client, re-evaluate the blood pressure, and notify the health care provider if findings are abnormal. The nurse should re-evaluate the blood pressure, not the UAP. The nurse should assess and re-evaluate the blood pressure before notifying the health care provider. The nurse's priority is to assess the client and provide interventions accordingly, not to notify the supervisor.

The night shift nurse is caring for a hospitalized client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client? a. Social isolation b. Powerlessness c. Chronic pain d. Disturbed sleep pattern e. Hyperthermia

d. Disturbed sleep pattern The client has problems sleeping due to the unfamiliar environment. Although hospitalized, the client doesn't report isolation, powerlessness, or chronic pain.

For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment? a. Focused b. Psychosocial c. Physical d. Initial

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

A client presents to an outpatient health care office for the first time. What step would the nurse take first, prior to taking a health assessment from the client? a. Ask a family member to be present for the assessment. b. Tell the client the amount of time planned for the assessment. c. Inform the client of the procedures done in the assessment. d. Introduce oneself to the client.

d. Introduce oneself to the client. The nurse should introduce oneself to the client first and then explain the nature and purpose of the health assessment. The purpose is to establish rapport with the client, clarify roles, and alleviate anxiety. There is no indication in the scenario as to why a family member would need to be present. Although there is no time limit on a nursing assessment, the nurse could inform the client of the approximate time, especially if the client appears to be fatigued, anxious, or in pain; however, the nurse should do this after introducing oneself.

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training? a. The nurse sits on eye level with the client. b. The nurse verifies the client's name. c. The nurse asks the client what name the client would like to be called. d. The nurse introduces oneself to the client by pointing to the nurse's name badge.

d. The nurse introduces oneself to the client by pointing to the nurse's name badge. When conducting an interview, the nurse should sit at eye level with the client, verbally introduce oneself, and state one's position. This sends the message that the nurse accepts responsibility and is willing to be accountable. The nurse should not simply point to the nurse's name badge in introducing oneself. The nurse should verify the client's name and ask what the client would like to be called.

Which is an example of objective data? a. A client receiving chemotherapy reports nausea. b. A client reports feeling very anxious about tests the client is undergoing. c. A client with inner ear infections reports dizziness. d. The skin of a client who has liver failure has a yellowish tint.

d. The skin of a client who has liver failure has a yellowish tint. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client. Reports of nausea, feeling very anxious, and dizziness are subjective data. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person.

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. comprehensive assessment b. database assessment c. focused assessment d. functional assessment

d. functional assessment The nurse is performing a functional assessment that focuses on areas that relate to the physical performance of activities, such as how the client is able to meet activities of daily living, demonstration of cognitive abilities, and social functioning. A comprehensive assessment encompasses all of the assessment data for the client. The focused assessment relies on one area of functioning such as the respiratory system if a client is having an asthma attack. The database assessment is performed during the initial history and physical portion of the client's illness and represents a comprehensive and all inclusive initial collection of data.

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. focus on objective physical data specific to the client. d. identify actual and potential health problems.

d. identify actual and potential health problems. The purpose of the nursing health history is to identify the patient's strengths and weaknesses; health risks, such as hereditary and environmental factors; and potential and existing health problems. This interview does not typically include physical assessment of a client. As part of the nursing assessment and overall nursing process, its purpose is not to influence time within the process. The physician's medical work-up provides the data to develop the medical diagnoses.

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. risky health behavior b. altered health maintenance c. neglect in self-care d. suicide attempt risk e. excessive stress

d. suicide attempt risk The client who talks of suicide and has a plan to implement it should be taken seriously, making this the priority nursing concern The other concerns are important but could be addressed after making interventions for suicide prevention.