Fundamentals chapter 16

Which method of data collection will the nurse use to establish a patient's database?

Performing a physical examination

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?

Problem-oriented assessment

A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?

The patient is apprehensive about discharge.

The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?

The patient's room with the door closed

Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?

"Validation involves comparing data with other sources for accuracy."

The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?

"What reasons do you think are contributing to your fatigue?"

A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?

Ask about the chief concerns or problems.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make?

Ask the NAP to record the patient's vital signs before administering medications

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations?

Ask the patient about the facial grimacing with movement.

While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?

Ask the patient about usual sleep patterns and the onset of having difficulty resting

While completing an admission database, the nurse is interviewing a patient who states "I am allergic to latex." Which action will the nurse take first?

Ask the patient to describe the type of reaction

A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.) a. Patient's temperature b. Patient's wound appearance c. Patient describing excitement about discharge d. Patient pacing the floor while awaiting test results e. Patient's expression of fear regarding upcoming surgery

C, E

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Completes a comprehensive database

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

Consider cultural differences during this assessment

2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?

Focus on the patient's presenting situation.

A nurse is conducting a nursing health history. Which component will the nurse address?

Patient expectations

A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information

Perform a thorough nursing health history

The nurse is gathering data on a patient. Which data will the nurse report as objective data?

Respirations 16

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing c and notices old and new drainage.

A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented.The patient's daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse? a. The

The nurse speaks only to the patient's daughter.