Ch. 14 Assessment

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.

The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate? A. "I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes." B. "I will leave a form with you to complete the nursing history information I need." C. "When I perform the nursing history, I will need to ask your family to leave the room." D. "I will perform a physical assessment while I am obtaining the nursing history."

A. "I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes." Nurses are responsible for completing nursing histories, and it usually takes approximately 30 to 60 minutes to obtain data such as history of present illness, past medical history, support network, and other pertinent data. The physical assessment is performed separately. Family members can offer valuable information, as long as the client gives permission for them to remain present during the history taking.

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

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.

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques? A. "When did you first notice the rash on your leg?" B. "Have you ever heard the saying 'no pain no gain?'" C. "Why do you feel that way about your cancer diagnosis?" D. "Do you have any additional questions for me?"

A. "When did you first notice the rash on your leg?" An example of appropriate communication is the statement, "When did you first notice the rash on your leg?" This is an example of a direct question that can be asked to validate information or clarify information. The other sentences demonstrate poor communication techniques. The nurse should avoid cliches, questions that require a "yes" or "no" answer, intimidating "why" and "how" questions, probing questions, and using judgmental comments.

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 blood pressure with a large cuff. B. Obtain an electrocardiogram daily. C. Assess cholesterol levels. D. Begin client education regarding a low-fat diet.

A. 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.

Which is an important element of implementation? A. Documentation B. Nursing orders C. Client database D. Critical thinking

A. Documentation An important element of implementation is documentation. The client database includes all the information that is obtained from the medical and nursing history, physical examination, and diagnostic studies, which are more closely related to assessment and diagnosis rather than implementation. Critical thinking is intentional, contemplative, and outcome-directed thinking that is useful throughout the nursing process and not specifically an element of implementation. Nursing orders are specific nursing directions provided so that all health care team members understand what to do for the client; therefore, these are not an important element of implementation.

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. Focused B. Emergency C. Time-lapse D. Head-to-toe

A. 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 are models used in nursing to assist in clustering data? Select all that apply. A. Functional Health Patterns B. Human Needs C. Change Theory D. Human Response E. Body Systems

A. Functional Health Patterns B. Human Needs D. Human Response E. Body Systems Models used for organizing or clustering data when doing an assessment are the Human Needs, the Functional Health Patterns, the Human Response, and the Body Systems models. The Change Theory model is not related but instead explains how change takes place and how change can be instituted.

Which are examples of subjective data? Select all that apply. A. Light-headedness B. Laceration C. Anxiety D. Nausea E. Edema

A. Light-headedness C. Anxiety D. Nausea

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.

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 caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next? A. Notify the physician of the change and document the finding. B. Recheck the client's pulse in 2 hours. C. Recheck the client's pulse at the next scheduled assessment time and document the findings on the chart. D. Document the findings on the chart and recheck in 1 hour. E. Notify the physician after the next scheduled assessment time if the pulse is unchanged.

A. Notify the physician of the change and document the finding. When a pulse deficit is present, the radial pulse rate is always lower than the apical pulse rate. The nurse should document and report to the physician any new finding of a pulse deficit immediately so that evaluation and follow-up can occur. The nurse should not wait until after rechecking the pulse to document the finding or report it to the physician.

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. Objective B. Subjective C. Primary D. Secondary

A. 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. Observation B. Documentation C. Listening D. Caring

A. 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.

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. Pain B. Low anxiety C. Hunger D. Sleepiness

A. 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 are assessment techniques the nurse uses when performing a physical examination? Select all that apply. A. Palpation B. Inspection C. Auscultation D. Documentation E. Percussion

A. Palpation B. Inspection C. Auscultation E. Percussion Four methods are used to collect data during the physical assessment: inspection, palpation, percussion, and auscultation. Documentation is done at the end, but it is not a method used for assessment.

The nurse is summarizing the key points of the interview. This nursing activity occurs during which phase? A. Termination phase B. Preparatory phase C. Introductory phase D. Working phase

A. Termination phase The nurse highlights the key points of the interview during the termination phase. During the preparatory phase the nurse prepares the setting for the interview and reviews any available information about the client. Introductions take place during the introductory phase, and the nurse outlines expectations for the interview. The nurse collects subjective data during the working phase.

The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment? A. Time-lapsed assessment B. Initial assessment C. Emergency assessment D. Patient centered assessment method (PCAM)

A. Time-lapsed assessment A nurse is comparing 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, such as homebound clients with visiting nurses, are scheduled for periodic time-lapsed assessments to reassess their health status and to make necessary revisions in the care plan. This assessment can be comprehensive or focused. An initial assessment would be performed on admission. An emergency assessment is generally focused on any life-threatening client issues. PCAM is a tool health care providers can use to assess client complexity using the social determinants of health. These determinants may explain why some clients engage and respond well in managing their health while others with the same or similar health conditions do not experience the same outcomes.

When performing an assessment, the nurse should focus most on the developmental stage for which client? A. Toddler B. Adolescent C. Young adult D. Middle-age adult

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.

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. Validate the data. B. Chart the data. C. Ignore the client's answer. D. Ignore the client's nonverbal behavior.

A. 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.

Nurses use the nursing process to plan care for clients. In which cases is the nursing process applicable? Select all that apply. A. when clients are totally dependent on the nurse for care B. when nurses work with clients who are able to participate in their care C. when families are clearly supportive and wish to participate in care D. when families are not supportive and do not wish to participate in care.

A. when clients are totally dependent on the nurse for care B. when nurses work with clients who are able to participate in their care C. when families are clearly supportive and wish to participate in care D. when families are not supportive and do not wish to participate in care. The nursing process is used in all nursing care situations. This includes working with clients and families who are able and willing to participate in their care, and working with clients who are not able to participate in their care because of being totally dependent on the nurse for care.

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 makes statements indicating a loss of hope." B. "Client states, 'I don't see the point in trying anymore.'" C. "Client is demonstrating signs and symptoms of depression." D. "Client states that rehabilitation will be unsuccessful."

B. "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

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

B. A client feels nauseated after eating breakfast. D. A client describes pain as an 8 on the pain assessment scale. 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.

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. 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. C. Document that the client refused the interview. D. 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. 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.

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

B. 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.

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply. A. Number of years in profession B. Caring C. Competence D. Professionalism E. Respect for client

B. Caring C. Competence D. Professionalism E. Respect for client 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.

Which items reflect the assessment phase of the nursing process? Select all that apply. A. The nurse assists the client with coughing and deep breathing every hour. B. The client states, "I rarely sleep more than 6 hours." C. The client's abdomen is firm and distended with hypoactive bowel sounds. D. The nurse and the client determine a tolerable pain level. E. The nurse asks the client, "How would you rate your pain?"

B. The client states, "I rarely sleep more than 6 hours." C. The client's abdomen is firm and distended with hypoactive bowel sounds. E. The nurse asks the client, "How would you rate your pain?" Assessment data would include the client statement regarding sleep, the nurse's question about a pain rating, and physical assessment data of the abdomen. Seeking input from the data in setting goals would occur during the outcome identification and planning phase. Assisting the client with coughing and deep breathing would occur during the implementation phase.

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

B. 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.

A nurse is beginning the preparatory phase of the nursing interview for a client who fractured the left leg in a fall. Which nursing actions occur in this phase of the nursing interview? Select all that apply. A. The nurse recapitulates the interview, highlighting key points. B. The nurse ensures that the interview environment is private and comfortable. C. The nurse arranges the seating in the interview room to facilitate an easy exchange of information. D. The nurse assesses the client's comfort and ability to participate in the interview. E. The nurse prepares to meet the client by reading current and past records and reports. F. The nurse initiates the interview by stating the nurse's name and status.

B. The nurse ensures that the interview environment is private and comfortable. C. The nurse arranges the seating in the interview room to facilitate an easy exchange of information. E. The nurse prepares to meet the client by reading current and past records and reports. Providing a private and comfortable environment, arranging seating, and reading current and past records about a client all take place during the preparatory phase of the nursing interview. The nurse states the nurse's name and assesses the client's comfort and ability to participate during the introductory phase. The nurse recapitulates the interview during the concluding phase.

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition? A. The client's chart B. The nursing and medical literature C. The client D. The client's physician

B. The nursing and medical literature In addition to information about medical diagnoses, treatment, and prognosis, a literature review of nursing and medical references offers nurses important information about nursing diagnoses, developmental norms, and psychosocial and spiritual practices that are helpful when assessing and caring for clients. Consulting with the client, physician, or client's chart would not give as comprehensive of a review.

A new graduate nurse states that it does not make sense to have to perform such an extensive assessment on clients when they are not feeling well. Which response by the nurse preceptor is an appropriate explanation for conducting a comprehensive physical assessment on clients? Select all that apply. A. To improve nurses' skills through practice B. To appraise the client's health status C. To identify any health problems D. To establish a database for nursing interventions E. To keep the nurse focused and with the client

B. To appraise the client's health status C. To identify any health problems D. To establish a database for nursing interventions The purpose of the nursing physical assessment includes the appraisal of health status, the identification of health problems, and the establishment of a database for nursing interventions. The assessment provides objective and subjective data critical information for a nursing care plan and interventions. The nursing physical assessment does not keep the nurse focused on the client; it is the nurse's responsibility to care for the client. The assessment does not improve nurses' skills but rather assists with the attainment of data for the care plan.

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

B. 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 is performing an admission assessment. Which are considered objective data? Select all that apply. A. "I am afraid something serious is wrong." B. Weight: 195 lb (89 kg) C. "My leg hurts." D. 38-year-old man E. Height: 6 ft (1.82 m)

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

Which scenario is an example of a time-lapse reassessment? A. A nurse just coming on shift performs a focused physical assessment on each client, based on the client's diagnosis. B. 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. C. 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 in a long-term skilled nursing facility assesses a new resident's baseline health status.

C. A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before. The four types of assessment a nurse may perform are initial, focused, time-lapse, and emergency. A time-lapse reassessment is performed to reevaluate any changes in the client's health from a previous assessment. It is used to monitor the status of an already identified problem for a client with whom the nurse is already familiar. In this question the only scenario that depicts these components is that of the client with mobility issues. The assessment of the client who is found down on the floor is an emergency assessment. The assessment of each client based on the client's specific diagnosis is a focused assessment. The baseline assessment of the new resident in the long-term care facility is an initial assessment.

While performing an assessment on a young client, the nurse is using the Functional Health Patterns Model. When recording the facts that the client exercises daily, hikes weekly, and plays on a softball team regularly, under which heading should these data be clustered ? A. Nutritional B. Health Management C. Activity/Exercise D. Sleep/Rest

C. Activity/Exercise When using the Functional Health Patterns Model, the nurse should record the amount of activity, exercise, leisure, recreation, and activities of daily living under the Activity/Exercise heading. Nutritional is related to food intake and food preferences. Sleep/rest is about how much sleep or rest the client reports obtaining daily or weekly. Health management refers to an annual examination, as well as specialists whom a client sees or who are allowed by health care insurance.

Which action would the nurse perform in the assessment phase of the nursing process? A. Coming up with a nursing diagnosis based on a potential health risk B. Determining whether the client's goals for wellness have been met C. Asking the client whether the client has cultural preferences D. Developing a plan to manage the client's health problems

C. Asking the client whether the client has cultural preferences Assessing the client involves gathering information about the client's physical and emotional health; cognition; spiritual, cultural, or religious preferences; and sociodemographics. Developing a plan to manage the client's health problems falls within the planning phase of the nursing process. Coming up with the nursing diagnosis falls within the diagnosing phase of the nursing process. Determining whether the client's goals for wellness have been met occurs in the evaluation phase of the nursing process.

Which is the best source of information for the nurse when collecting data for an assessment? A. Primary physician B. Medical record C. Client D. Charge nurse

C. 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.

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? A. Document on the client's chart that the assessment data may be biased. B. Inform the client of these potential biases and obtain the client's opinion. C. Consult with another nurse for that colleague's description of the assessment or observations. D. Verify the information with one or two family members without informing the client.

C. Consult with another nurse for that colleague's description of the assessment or observations. When a nurse suspects that the nurse's own personal bias or stereotyping is influencing data collection, the nurse should consult with another nurse. It is also best to describe the observed behavior, rather than interpret the behavior. The nurse should obtain information from the family after obtaining permission from the client. The nurse does not need to chart the biases in the client's electronic record.

Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist? A. Laboratory reports B. Medical history C. Consultation D. Progress notes

C. Consultation The client's physician may invite a specialist to assess and treat the client. The focus of this part of the record is additional findings related to the client's medical diagnosis and treatment; it is found in the section called "Consultation." Laboratory reports are related to the laboratory values of the client. Progress notes are the part of a medical record where health care professionals describe details to document a client's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. The medical history or case history of a client is information gained by a physician by asking specific questions, either of the client or of other people who know the person and can give suitable information.

A client is a poor historian of the client's past medical history. Whom should the nurse consult about the client's past history? A. Old chart B. Physician C. Family D. Social worker

C. Family Family members or significant others, if available, can provide information for a client who is confused or incapacitated. They can also be of assistance should there be gaps or conflicts within available medical records. Should these persons not be available, the only remaining option for medical history would be medical records or the client's primary physician if available. A social worker would not likely know a client's past medical history, aside from that already available in the client's medical records.

The nurse records the name, age, and genetic background of the client. The data are components of which tool? A. Evaluation of data B. Physical assessment C. Health history D. Objective data gathering

C. Health history Components of a health history tool include the client's profile, which consists of name, age, sex, genetic background, marital status, religion, occupation, and education. These are subjective data that are collected from the client. The physical assessment gathers objective data observed by the nurse, such as vital signs, height, and weight. This data are being collected in the health history assessment and are not being evaluated.

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. Standing next to the client while interviewing C. Sitting at eye level with the client D. Limiting questions to those with yes or no answers

C. 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 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. Severe B. Explanatory C. Subjective D. Objective

C. 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.

The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment? A. Obtain the client's records from admissions to other institutions. B. Perform the assessment in several short episodes rather than at one sitting. C. Supplement the client's information by speaking with family or friends. D. Limit the assessment to objective data.

C. Supplement the client's information by speaking with family or friends. Family and friends can be an invaluable source of assessment data, especially in the care of clients who have cognitive deficits. It would be inappropriate to limit an assessment to solely objective data. Using previous medical records and breaking up the assessment are appropriate measures, but they do not supersede the importance of using family and friends as data sources.

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. Emergency assessment B. Developmental stage assessment C. Time-lapsed assessment D. Focused assessment

C. 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 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: A. perform a review of the problem areas. B. focus on only the systems that the client is comfortable with. C. complete an exam of all body systems. D. examine certain body systems.

C. complete an exam of all body systems. The nursing physical assessment that involves the examination of all body systems is called the review of systems. An assessment only on a specific problem area is a focused assessment. Nurses do not assess clients by focusing on the system that the client is most comfortable with. Examining a certain body system is not relevant in nursing.

The nurse is assessing the spine of a 63-year-old woman who states, "I hope I don't end up with a big hump on my back like my mother did." The nurse knows the patient is referring to a condition known as: A. scoliosis B. spina bifida C. kyphosis D. arthritis E. lordosis

C. kyphosis

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: A. attempts to write down everything the client says. B. agrees with each of the client's statements. 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.

Which statement by a nurse best indicates an accurate understanding of the different types of assessments? A. "It is up to the nurse to decide which assessment to perform." B. "How much time the nurse has and how the client is feeling determine which type of assessment to perform." C. "The physician informs the nurse of which type of assessment to perform for each client." D. "The purpose for the assessment offers guidance for which type and how much data to collect."

D. "The purpose for the assessment offers guidance for which type and how much data to collect." The purpose for which the assessment is being performed offers the best guidance for what type and how much data to collect. The type of nursing assessment the nurse should conducted should not depend on (a) the nurse's preference, (b) how much time the nurse has, or (c) what the physician wants. It is important to take into account how the client is feeling when preparing to assess, but the client's feelings should not dictate which assessments the nurse performs.

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. Obtaining a detailed assessment of the client's sexual history B. Conducting a thorough systems review to validate data on the client's record C. A full assessment of the urinary system D. A focused assessment of the specific problems identified

D. 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.

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

D. 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. Gives a comprehensive volume of data D. Adds depth to existing information

D. Adds depth to existing information

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 quiet spaces and pauses. C. Fill in the words for the client. D. Avoid the impulse to interrupt.

D. 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.

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. At the end of the data-gathering process B. In the middle of the data-gathering process C. During the collection of data only D. Both during the collection and at the end of the collection

D. Both during the collection and at the end of the collection Not all data need to be validated, but the nurse may validate data during the collection or at the end of the data-gathering process. When it is clear that the data are correct, the nurse may analyze the data and formulate nursing diagnoses.

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. Tell the client the questions will be quick. B. Organize all questions into categories. C. Make the questions short. D. Carefully review the client's record.

D. 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.

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. Wait and see whether the pain subsides. C. Chart the information. D. Consult with another nurse.

D. 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.

While doing an assessment, the nurse identifies questionable data. Which should the nurse do first? A. Inform the client that the data are not correct. B. Inform the physician of the questionable data. C. Disregard the questionable data. D. Validate the questionable data.

D. Validate the questionable data. Questionable data are verified (validated) as part of the assessment step of the nursing process. It is not necessary to inform the physician or the client that the data are questionable as it is the nurse's responsibility to validate the data. The questionable data should not be disregarded.

The nurse is conducting a health history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next? A. Prioritize documentation of objective data collected in the examination while avoiding any mention of the discrepancy. B. Consult with other members of the health care team about the conflicting client information. C. Ask significant family members about the client's usual breathing pattern at home. D. Continue the health history with questions focusing on respiratory function.

D. Continue the health history with questions focusing on respiratory function. First, the nurse needs to validate the data with the client, who is the primary source. The nurse can validate data with the health care provider but consulting with the client is the best option. The client must give permission for family members to participate in the health history. Ultimately, the nurse documents all assessment data, both from the history and the physical exam. It is appropriate to note inconsistencies between objective and subjective data.

A nurse providing care to a client questions judgments and considers other ways of thinking about the client's situation. Which behavior is the nurse demonstrating in the care of the client? A. Reflection in action B. Reflective skepticism C. Thoughtful practice D. Critical reflectivity

D. Critical reflectivity Critical reflectivity (becoming aware of one's awareness and critiquing it) occurs when a person questions judgments and considers other ways of thinking about the situation. Thoughtful practice is caregiving to promote the humanity, dignity, and well-being of the client. Reflection in action requires the person to engage in exploring experiences to lead to new understandings and appreciations during the situation or during clinical practice. Reflective skepticism involves adopting an attitude of doubt about supposed truths.

When using the nursing process, the nurse notes that there is a great deal of overlapping of the steps, with each step flowing into the next. What is the term for this characteristic of the nursing process? A. Systematic B. Universally applicable C. Interpersonal D. Dynamic

D. Dynamic The nursing process is described as a dynamic process because the steps are not a stagnant process. The nurse moves from one step to the next, with steps overlapping at times; in some nursing situations, all five stages occur almost simultaneously. Interpersonal refers to the nurse working with the client, with the client being the center focus of care. Systematic refers to how the nursing process directs each step of nursing care in a sequential, ordered manner. The nursing process is universally applicable because it is a way of problem solving in any nursing care situation.

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

D. 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.

When the nurse inspects a postoperative incision site for infection, which type of assessment is the nurse performing? A. Time-lapse B. Complete C. General D. Focused

D. Focused There are four types of assessment that a nurse may make, based on when the nurse is seeing the client. In focused assessments, the nurse determines whether the problem still exists; the status of the problem is also assessed as well as precise details in its improvement or worsening. A complete (general or initial) assessment would be done at the time of admission. A time-lapse assessment allows the nurse to reassess a client and condition that is already known to re-evaluate its status. The fourth type would encompass emergency assessment and may include a head-to-toe assessment.

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 the client is in bed, the nurse stands at the side of the bed. C. If both the nurse and client are seated, their chairs are at right angles to each other, 30 cm apart. D. 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 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.

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. Quaternary B. Tertiary C. Primary D. Secondary

D. Secondary The primary source of information is the client. The client's spouse, friends, and test results would be secondary sources of data. There are no tertiary or quaternary sources of assessment data.

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 case manager B. The physician C. The nursing supervisor D. The nurse

D. 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.

During admission, a teenage client who has a diagnosis of anorexia informs the nurse of a 5-pound weight loss within the last 6 months. What should the nurse do with this data? A. Record it in the client's record. B. Ignore this information completely and continue collecting data. C. Inform the client that this cannot be correct. D. Validate the weight loss with the client.

D. Validate the weight loss with the client. When a client reports data that appear to be distorted, either intentionally or unintentionally, the nurse—to ensure accuracy—needs to continually verify and validate all data. It would not be appropriate to tell the client the data are not correct or to ignore the data, as doing either could undermine the client's trust in the nurse and/or cause conflict with the client. The nurse should not just document this information, as it needs to be validated.

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being: A. purposeful. B. factual. C. complete. D. able to prioritize.

D. able to prioritize. It is essential to get the most important information first when doing an assessment. This is prioritizing. Being purposeful is when a nurse completes a task that has meaning for the client. Complete means that the information obtained is comprehensive. Factual is concerned with what is actually the case rather than interpretations of or reactions to a situation (for example, a diagnosis as opposed to a hunch).

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

D. 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.