NUR 209

A nurse is documenting assessment findings. Which finding would the nurse include as objective data? Select all that apply.

Blood pressure 128/68 mm Hg Weight 175 lb (80 kg) Bowel sounds active in all 4 quadrants

A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem?

"I get out of breath when I walk a few steps."

The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? Select all that apply.

38-year-old man height 6' (1.82m) weight 195 lb (89kg)

A student takes an adult client's pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the student do next?

Ask the instructor or a staff nurse to take the pulse.

A nurse takes the vital signs of a new hospital client admitted for severe abdominal pain. Which initial step of the nursing process is this nurse performing?

Assessment

A nurse is engaged in diagnostic reasoning to propose appropriate nursing diagnosis for a client. Place the steps in the order that they would occur from first to last during this process.

Correct response: Organizing the existence of cues, Generating possible diagnoses, Comparing cues to possible diagnoses, Conducting a focused data collection, Validating diagnoses

Which activity is the clearest example of the evaluation step in the nursing process?

Correct response: checking the client's blood pressure 30 minutes after administering captopril.

The night shift RN is caring for a hospitalized adult 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?

Disturbed sleep pattern

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?

Focused

Which statement appropriately identifies an at-risk nursing diagnosis for a woman 78 years of age who is confined to bed?

Risk for impaired skin integrity related to bed rest

The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source?

The client tells the nurse that there is a burning sensation when voiding.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

The nurse should determine the reason for the client's refusal.

During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis?

The parent states, "I cannot allow anyone else to help because they won't do it right."

Nurses collect objective and subjective data when performing client assessments. What is an example of objective data?

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

A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as:

abandonment

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:

complete postoperative assessment.

A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged to implement the new strategies for ambulation the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

developing the plan without client input

The nurse writes the following on the client's chart: The client will have complete healing of the surgical incision on the right lower quadrant of the abdomen in 3 weeks. This is a(an):

outcome identification

The RN is admitting a client to a medical unit. The nurse delegates the measurement of the vital signs to unlicensed assistive personnel (UAP) while she collects data. After completing the admission process the client reports a severe headache, so the nurse reassesses the vital signs to find the client's blood pressure extremely elevated. Whose responsibility is the accuracy of the blood pressure measurement?

the nurse