PrepU quizzes Chapter 14: Assessing

The nurse is performing an admission assessment. Which are considered objective data? Select all that apply.

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

Which scenario is an example of a time-lapse reassessment?

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

Which group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

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 assessment of this client?

Auscultate the chest for breath sounds.

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?

Both during the collection and at the end of the collection

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?

Clients fearing saying the wrong thing Clients having a limited education Clients not being fluent in the same language as the nurse

While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate?

Consult with another nurse for that colleague's description of the assessment or observations.

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?

Disturbed sleep pattern

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?

Focused

What must the nurse do to identify actual or potential health problems?

Gather data from sources

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?

Objective

Which nursing skill uses all five senses?

Observation

What should the nurse do prior to performing an initial assessment on a newly admitted client?

Review the records available on the client.

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?

Safety and security

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?

Subjective

Which is the primary reason for a nurse collecting data continuously on a client?

The client's health status can change quickly.

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?

The nurse

The nurse is performing an assessment on an older adult client and notices that the blood pressure has increased from 140/82 to 198/120 mm Hg. This is a significant difference in the client's baseline. Who is ultimately responsible for reporting this significant change to the physician?

The nurse

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?

The nurse assesses the client's comfort and ability to participate in the interview.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver?

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

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

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being:

able to prioritize.

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:

complete an exam of all body systems.

The purpose of obtaining a nursing history is to:

identify actual and potential health problems.

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse:

uses broad, open statements to communicate with the client.