Chapter 14 Prep U : Assessing

The nurse delegates vital signs to be taken and recorded by the unlicensed assistive personnel (UAP). The UAP reports a blood pressure of 230/120 mm Hg on a client. Which is the nurse's priority action?

assess the client and re-evaluate vital signs

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview?

avoid the impulse to interrupt

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

A nurse is conducting an interview with a client. Which example best demonstrates use of open-ended questions in an interview?

" How are you feeling?"

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?

"How do you protect yourself when having sex?"

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?

"is the anything else we should know in order to care for you better?"

The nurse is terminating an interview with a client in the behavioral health unit. Which statements by the nurse would indicate an effective termination of the interview? Select all that apply.

- "We have 5 minutes left. Do you have any Questions?" -"what are some of your most important concerns?" - "Here is my card with my phone number. Please call if you have concerns"

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

- 38 y/o male -Ht: 6ft -wt: 195lb

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?

Functional assessment

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply.

-Respect for client -Competence -Professionalism -Caring

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

As soon as possible after a client presents with care

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

Focused

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?

Hierarchy of human needs

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client?

Ineffective breastfeeding

The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

Inspection

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?

Objective

The nurse is assessing the client's abdominal wound and notes yellow-green purulent wound drainage. The nurse recognizes that the drainage is an example of:

Objective data

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case?

Obtaining data regarding the amount and frequency of drinking

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?

Pain

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client?

Risks for impaired parenting

During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

Sitting at eye level with the client

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

Who or what is the primary source of information for a nursing history?

The client

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 practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing?

Time- lapse

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?

Time- lapsed assessment

Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training?

all data collected needs to be validated

Which is the purpose of a focused assessment?

adds depth to existing information

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?

administer prescribed medication Prior to conducting the interview.

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

collection, validation, and communication of patient data

The purpose of obtaining a nursing history is to:

identify actual and potential health problems

A client has been discharged from an acute care facility with a referral for a home health nurse to make an assessment. What is the priority action by the home health nurse on the initial home visit?

establish the clients database

Question 1 See full question21sReport this Question 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

Which nursing skill uses all five senses?

observation

When assessing the firmness of a client's abdomen, the nurse should use which assessment technique?

palpation

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

review the records available on the client