Craven Ch. 12

A nurse has just taken vital signs on a newly admitted client. Vital signs would be entered on the client record as which type of data?

Objective

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

At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

Objective

The nurse is interviewing a client to obtain a nursing history. What phase of the interview process involves the nurse gathering all the information needed to form the subjective database?

Working phase

Which are subjective client data gathered during assessment?

Nausea, abdominal pain

A client comes to the health care provider's office reporting abdominal pain, for which the client has sought care before. Which type of assessment would the nurse perform?

Focused

The nurse is interviewing a client who was admitted to the acute care facility. During the interview, the client states, "Sometimes I get a bit fuzzy after I take my medicine." Which response by the nurse would be most appropriate?

"Can you tell me what you mean when you say 'fuzzy'?"

Which question or statement would be an appropriate termination of the health history interview?

"Can you think of anything else you would like to tell me?"

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?

"Client states, 'I don't see the point in trying anymore.'"

Which nursing assessment guideline is most accurate?

"Collect assessment data about the client continuously."

A nurse is conducting a health history interview for a client at an assisted-living facility. The client says, "I have been so constipated lately." How should the nurse respond?

"Do you take anything to help your constipation?"

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

A nurse is conducting an interview with a client who reports abdominal distress. What is an appropriate interview question for this client?

"What is your problem as you see it?"

The nurse identifies which types of data when performing an assessment? Select all that apply.

Subjective Objective

A nurse is conducting a physical examination and is determining the location and level of the liver. Which technique would the nurse most likely use?

Percussion

A nurse is performing a head-to-toe examination of a child. Which action would be most important for the nurse do?

Perform invasive techniques at the end of the exam.

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?

Continue the health history with questions focusing on respiratory function.

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

A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which statement by the nurse would recognize the client's value as an individual?

"Mr. Koeppe, tell me what you do to take care of yourself."

A nurse is performing an assessment on a client. Which should the nurse record as subjective data? Select all that apply.

"My leg hurts when I move." "I am so afraid of what my diagnosis is." "I am always anxious."

The charge nurse identifies the need for further education when a new nurse makes which statement?

"Physical assessment is the examination of the client for subjective data."

Which question or statement would be appropriate for eliciting further information when conducting a health history interview?

"Tell me more about what caused your pain."

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

"The client's right leg is cold to the touch, from the knee to the foot."

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which statement represents objective data the nurse is likely to gather and document during this assessment?

"Unable to palpate femoral pulse in left leg."

The nurse is performing an admission assessment on a young client admitted to the unit. 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 are examples of subjective data? Select all that apply.

A client describes pain as an 8 on the pain assessment scale A client feels nauseated after eating breakfast A client reports being cold and request and extra blanket

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

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

Which assessment data cue does the nurse recognize as subjective data?

A pain rating of 7

The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's health status. Which symptom would the nurse identify as a subjective cue?

A sharp pain in the knee

Which is the purpose of a focused assessment?

Adds depth to existing information

A client comes to the acute care facility for diagnostic testing and elective surgery. Which type of assessment would the nurse most likely complete?

Admission assessment

Which client situation most likely warrants a time-lapse nursing assessment?

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

A nurse takes an adult client's pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the nurse do next?

Ask another nurse to take the pulse.

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficent data for planning care. Which action by the nurse would be most appropriate in this situation?

Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

Which action would the nurse perform in the assessment phase of the nursing process?

Asking the client whether the client has cultural preferences

While bathing the client, the nurse observes the client grimacing. The nurse asks whether the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which action clearly demonstrates assessing?

Asking whether the client is having pain

A nurse is assessing a client using the functional health patterns model. Which would the nurse include when assessing the client's cognition and perception? Select all that apply.

Evidence of pain Sensory function Hearing Memory

A nurse is documenting assessment findings. Which finding would the nurse include as objective data? Select all that apply.

Blood pressure 128/68 mm Hg Weight 175 lb (80 kg) Bowel sounds active in all 4 quadrants

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?

The nursing and medical literature

Which is the best source of information for the nurse when collecting data for an assessment?

Client

A nurse is assessing a client admitted to the hospital with reporting left-sided weakness and difficulty speaking. Which documented statement best represents the data that should be collected in a nursing assessment?

Client is unable to communicate basic needs and cannot perform hygiene measures with left

Which entry would be an example of appropriate documentation?

Client stated, "I am so down today, and I just don't have any energy."

A nurse who provides care on a postsurgical unit is expecting 3 clients to be admitted to the unit from postanesthetic recovery within a short time span. The admission assessment document that is used on the unit is extensive and requires a significant amount of time to complete. Which principle should guide the nurse's assessments?

Collect data that are helpful when planning and delivering care.

A nurse is engaged in the assessment phase of the nursing process. Which activity would the nurse most likely perform? Select all that apply.

Collect data. Validate data. Organize data.

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

Collection, validation, communication of client data

Which types of data would be collected during a physical assessment?

Color, moisture, and temperature of the skin

The nurse is interviewing a client who was admitted to the health care facility with difficulty breathing. When beginning the interview, the nurse observes that the client is too breathless to answer. What would be most appropriate for the nurse to do?

Defer the non-urgent questions until a more suitable time.

Which are examples of common factors in a client that may influence assessment priorities? Select all that apply.

Diet and exercise program Developmental stage Need for nursing

A client who is bleeding profusely from a stab wound is brought to the emergency department. Which type of assessment is most appropriate for this client?

Emergency

Which is recommended when conducting a client-nurse interview?

Focus full attention on the client.

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?

Focused

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

A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment?

Focused

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

Focused

Which piece of client information is subjective?

Generalized myalgia or muscle pain

The nurse is conducting a health history on a newly admitted client. Which aspects of the client should the nurse include while doing the history? Select all that apply.

Health status Strengths Health problems Health risks

Which are assessment techniques the nurse uses when performing a physical examination? Select all that apply.

Inspection Palpation Percussion Auscultation

Which statement describes the physical exam technique of auscultation?

It is the technique of listening to body sounds with a stethoscope placed on the body surface to amplify sounds

The nurse enters a client's room to find the client diaphoretic (sweat-covered) and shivering and infers that the client has a fever. How should the nurse best follow up this cue and inference?

Measure the client's oral temperature.

Which statements accurately describe the unique focus of nursing assessments? Select all that apply.

Nursing assessments focus on the client's responses to health problems. The findings from a nursing assessment may contribute to the identification of a medical diagnosis. An initial assessment establishes a complete database for problem solving and care planning.

A client comes to the emergency department with flulike symptoms. The nurse records the vital signs and listens to the client's lung sounds. Vital signs and lung sounds are examples of which type of data?

Objective

While examining a client, the nurse assesses the temperature of the client's skin. The nurse most likely would be using which technique?

Palpation

A nurse is caring for a client with an acute kidney infection. Which assessment technique would be most appropriate to use to evaluate tenderness over the kidneys?

Percussion

A nurse is preparing to interview a client who is newly admitted to the unit. Which strategies will help establish a quiet, relaxed, and comfortable environment during the interview? Select all that apply.

Providing a proper seating arrangement Maintaining a proper distance from the client

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

Respect for the client Competence Professionalism Caring

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?

Secondary

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?

Supplement the client's information by speaking with family or friends.

The nurse is summarizing the key points of the interview. This nursing activity occurs during which phase?

Termination phase

A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which source?

The client

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

The client

After sustaining a wrist fracture in a recent fall, a client is suspected of having osteoporosis. Which data best demonstrates the nursing focus of assessment?

The client claims mobility and independence have declined in recent years.

The nurse has obtained subjective and objective assessment data for a client. Which client data require validation? Select all that apply.

The client has trouble reading an informed consent document but denies needing glasses. The client has ecchymosis on the arms and legs due to a fall.

The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source?

The client tells the nurse that there is a burning sensation when voiding.

Which data regarding a client with a diagnosis of colon cancer are subjective? Select all that apply.

The client's chemotherapy causes nausea and loss of appetite. The client has been experiencing fatigue in recent weeks.

A client is brought to the emergency department in an unconscious condition. The client's spouse hands over the previous medical files and points out that the client suddenly fell unconscious after trying to get out of bed. Which is a primary source of information in this case?

The client's spouse

Other than the client, what sources of client information should the nurse consider when assessing a client? Select all that apply.

The client's support people Other health care professionals The client's health record Family members accompanying the client

Which items reflect the assessment phase of the nursing process? Select all that apply.

The nurse asks the client, "How would you rate your pain?" The client's abdomen is firm and distended with hypoactive bowel sounds. The client states, "I rarely sleep more than 6 hours."

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.

What is an advantage of using the functional health patterns model for assessment?

The nurse can identify client strengths and assets.

Following a client interview, the nurse is organizing data obtained according to Gordon's functional health patterns model. Which statements reflect the focus of this model? Select all that apply.

The nurse collects data regarding the client's health perception and health management The nurse explores the client's perception of the client's major roles and responsibilities in life The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality

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.

The nurse ensures that the interview environment is private and comfortable. The nurse arranges the seating in the interview room to facilitate an easy exchange of information. The nurse prepares to meet the client by reading current and past records and reports.

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further traning?

The nurse introduces oneself to the client by pointing to the nurse's name badge

Which action is taken during the maintenance phase of an interview? Select all that apply.

The nurse keeps focused on the task or goals to ensure that needed data are obtained and goals are achieved. The nurse observe the client's behavior and listens attentively. The nurse establishes a verbal contract with the client, incorporating the goals of the interview.

A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?

Time-lapse

The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?

To establish a database to identify problems and strengths

A nurse is assisting with feeding residents lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins cardiopulmonary resuscitation. Why did the nurse assess respiratory status?

To identify a life-threatening problem

What is the primary purpose of validation as a part of assessment?

To plan appropriate nursing care

When performing an assessment, the nurse should focus most on the developmental stage for which client?

Toddler

The nurse is interviewing a client who is newly admitted to the unit. Which techniques used by the nurse will facilitate communication during the interview? Select all that apply.

Use broad opening statements. Share observations. Use silence.

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?

Validate the data.

While doing an assessment, the nurse identifies questionable data. Which should the nurse do first?

Validate the questionable data.

A nurse is performing auscultation during the physical examination of a client. The nurse most likely would be assessing:

a bruit

The nurse is reviewing information about a client and notes the following documentation: "Client is confused." The nurse recognizes that this information is an example of:

an inference.

The nurse is interviewing a client who is reporting chills, fever, malaise, and cough. During the working phase of the client interview, the nurse:

asks the client to describe symptoms

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:

body systems.

A nurse is preparing to conduct an interview of a newly admitted client. Which actions would the nurse be taking? Select all that apply.

deciding what data are needed assessing own feelings about previous clients modifying the environment for the interview

A client visits the health care facility for a regular check-up. The nurse integrates the functional health pattern model when assessing the client. Which nursing action best describes how the nurse collects and organizes the data?

focuses on client's normal, altered, and risk for altered function

A nurse is assessing a client admitted to the health care facility with angina. Which method would be most appropriate for the nurse to use to collect subjective data?

interview

A nursing student is discussing assessment findings of an assigned client with the instructor. The instructor determines that the student needs additional assistance and review when the student identifies which as objective data?

nursing staff

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 nurse is conducting a nursing assessment with a client who is unwilling to participate in the interview process. If the nurse makes a diagnostic error it would most likely be because of:

omission of pertinent data.

A nurse is conducting an admission assessment of a client who has come to the primary care clinic. The nurse conducts this assessment for which reason?

to identify problematic functional health patterns

When documenting subjective data, the nurse should:

use the client's own words placed in quotation marks.

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.