Prep U Chapter 14: Assessing

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 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.

While doing an assessment, the nurse identifies questionable data. Which should the nurse do first? a. disregard the questionable data b. validate the questionable data c. inform the physician of the questionable data d. inform the client that data are not correct

b. validate the questionable data

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 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)

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

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

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

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 d. blood pressure 140/82 mm Hg e. client states, "I am in pain." f. ecchymosis on upper left arm

a. client states, "I feel so sad all of the time." e. client states, "I am in pain."

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. ask if the client would like the door opened or closed when finished c. point out potential nursing care plan goals while assessing d. concentrate on a focused assessment of the abdomen and leave the rest of the assessment for a later time

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

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. hierarchy of Human Needs b. functional Health Patterns c. human Response Patterns d. body Systems Model

a. 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. palpation c. auscultation d. percussion

a. inspection

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.

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.

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 nurse is collecting data from a client during a complete assessment. Which skill is the nurse demonstrating when documenting the assessment data? a. clustering b. communication c. validation d. collection

b. communication

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

Which nursing skill uses all five senses? a. documentation b. observation c. listening d. caring

b. observation

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. primary b. secondary c. tertiary d. quaternary

b. secondary

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? 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

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?"

Which are examples of subjective data? Select all that apply. a. a nurse observes a clients 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 a 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 a 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

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 client is receiving home car due to an unstable blood pressure. Which nursing intervention is a priority? a. assess the clients diet b. asses 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

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

The nurse is conducting interview and notices that the client answers every question with a "year" 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

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

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.

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 just coming on shift performs a focused physical assessment on each client, based on the client's diagnosis. c. a nurse in a long-term skilled nursing facility assesses a new resident's baseline health status. 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.

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data? a. during the collection of data only b. at the end of the data-gathering process c. in the middle of the data-gathering process d. both during the collection and at the end of the collection

d. both during the collection and at the end of the collection

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

d. gather data from sources

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 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