Chapter 3

The patient comes to the emergency department complaining of chest pain. Which question by the nurse will encourage the patient to provide the most details about the pain?

"Can you give a description of the pain you are having?"

The nurse is conducting an interview with a patient in a clinic setting. Which questions will be effective for obtaining information from the patient? Select all that apply.

"How did this happen to you?" "What was your first symptom?" "When did you start having symptoms?"

The nurse is conducting a patient interview in an acute care setting. Which statements made by the nurse during the interview are appropriate? Select all that apply.

"I can see you are in pain. I will bring pain medication and complete the interview later." "If it is a good time for you, we can complete your interview now." "Have you noticed any changes in your ability to sleep or patterns of sleeping?"

Nurses are aware that documentation is essential in monitoring and validating appropriate patient care. Which statement is the best example of high-quality nursing documentation?

"Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting."

The nurse is performing an initial interview with an older adult patient. Which statement by the patient indicates a need for a special needs assessment by the nurse?

"I have fallen twice at home in the past 6 months, but I have not injured myself."

The nurse on a medical-surgical unit receives the third admission over a period of 1.5 hours. A certified nursing assistant (CNA) offers to assist the nurse with the assessment process. Which response by the nurse is the most appropriate?

"If you could obtain and record the vital signs, it would be a big help."

A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching?

"My patient was really quiet and didn't say much, so I charted that he acted depressed."

The nurse is obtaining the health history of a client. Which question is an example of the nurse using an open-ended question?

"What happens when you have a headache?"

A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate a need for further instruction?

"When I give my patient his pain medication, I will have time to ask questions."

The nurse is interviewing a patient with a recent onset of migraine headaches. The patient is very anxious and cannot seem to focus on what the nurse is saying. Which comment by the nurse is best when beginning to gather data about the headaches?

"When did your migraines begin?"

A patient comes to the emergency department to be evaluated after feeling ill at home. Which is the first question the nurse asks in the initial nursing interview with the patient?

"Why did you come to the hospital today?"

The nurse is obtaining information from a newly admitted patient during the initial nursing assessment. Which difference does the nurse recognize between the nursing history and the medical history?

A nursing history focuses on the patient's responses and needs to the health problem.

The nurse is preparing to conduct an admission interview with an adult client who is alert and oriented. The client's spouse and two children are visiting and are watching television. Which action by the nurse is conducive to a successful interview?

Ask if the client is willing to answer questions after the family leaves.

Nurses use the professional standards of nursing assessment when formulating patient care. Which statements regarding professional standards of nursing assessment are true? Select all that apply.

Assessment is a professional nursing responsibility. Assessment helps the nurse identify problems and priorities. Assessments can be delegated according to state practice acts and agency policies.

The nurse recognizes which examples of objective data? Select all that apply.

Blood pressure of 120/80 mm Hg Moderate amount of yellow drainage from right ear

The nurse obtains information from a patient during admission. The patient is noted to be alert and oriented, be married, have a history of heart disease. Obtaining this information is an example of which process?

Collecting data

For which reason does the nurse use nondirective interviewing as an assessment technique?

Facilitates open communication

The nurse is providing care to a patient who has left-sided weakness because of a recent stroke. Which type of special needs assessment is most important for the nurse to perform?

Functional

A patient comes to the urgent care clinic because of injury from stepping on a rusty nail. Which type of assessment does the nurse perform?

Initial focused

The nurse is interviewing a patient being admitted for gastrointestinal issues. The patient informs the nurse that he has persistent vomiting and diarrhea. Which type of assessment is the nurse performing by asking, "When did you first begin to have the vomiting and diarrhea?"?

Initial focused assessment

The nurse is aware that patient data are often difficult to analyze. Which is the most obvious reason for using a framework for collecting and recording patient data?

Organizes and clusters data efficiently

The nurse is conducting an assessment interview with a newly admitted client. When asking open-ended questions, which action by the nurse indicates an active listening behavior?

Leaning toward the patient

A nurse, with a large caseload of patients, needs to delegate some assessment tasks to other members of the healthcare team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) instead of a registered nurse (RN). Which sources does the nurse consult for clarification related to delegation? Select all that apply.

Nurse practice act of the nurse's state American Nurses Association (ANA) Scope and Standards of Practice

The nurse is providing care for a variety of patients in an acute care facility. Which of the following constitutes an ongoing assessment?

Obtaining a patient's temperature 1 hour after giving acetaminophen

The nurse manager in an acute care facility is orienting new graduate nurses to a patient care unit. While reviewing The Joint Commission standards, a discussion begins about assessment. Which type of assessment is to be performed on all patients in compliance with The Joint Commission?

Pain

Which of the following are cues rather than inferences? Select all that apply.

Patient ate 50% of the meal. Patient states, "I slept well." Patient's white blood cell (WBC) count is 15,000/mm3.

The nurse manager is reviewing documentation performed by newly hired nurses. Which of the examples does the nurse manager recognize as high-quality nursing documentation? Select all that apply

Patient states, "I feel dizzy in the morning." Patient is alert and oriented to person, place, and time. Patient expresses no complaints of pain at this time.

Each time the nurse comes into contact with a patient, a systematic observation is made. For which reason is this type of assessment performed so frequently?

Repetition makes it less likely the nurse will miss an assessment area.

During the assessment process, the patient tells the nurse, "I am having numbness and tingling in my right arm." Which type of data does the nurse recognize on the basis of the patient's statement?

Subjective data

The nurse is currently performing the initial assessment on a newly admitted client. The nurse receives notification of another client's admission to the unit. Which professional standard influences the nurse's decision about who will be assigned to perform the assessment of the second client?

The American Nurses Association (ANA)

The nurse is collecting data on a new patient at an adult clinic. Which data does the nurse need to validate?

The client reports eating processed foods on a low-sodium diet.

After collecting data on a client, the nurse reviews and sorts the information. Which example includes both objective and subjective data?

The client's cholesterol is elevated, and he admits to liking and eating fried food.

During the initial assessment of a newly admitted client, the nurse asks about use of nutritional and herbal supplements. For which reason is it important for the nurse to obtain this specific information?

To be aware of potential interaction with prescribed medication

After completing an initial patient assessment, for which reason does the nurse utilize a nursing assessment model?

To sort and cluster assessment data into specific categories

The nurse prefers to review patient data on a graphic flow sheet, when possible. Which situation is the best example of the reason a graphic flowsheet is superior to other methods of recording data?

Visually reflects the patterns of a patient's fever