Funds Chapter 14: Assessing

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.'" 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 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 time-lapse assessment is often indicated in the care of a stable client whose current status is being compared to earlier baseline data. Shortness of breath and chest pain necessitate an emergency assessment, while a new admission to a unit or institution requires an initial assessment. Following up a known health problem most often requires a focused assessment.

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 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.

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. 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.

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?

Risk for Impaired Parenting A 14-year-old parent with little family support is at risk for difficulties with the expanded role of parent. The client has not stated feeling loneliness or pain. The infant's feedings are not discussed in the scenario.

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

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. 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.

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 The four types of nursing assessment include complete, focused, time-lapse, and emergency. In time-lapse assessments, the nurse reassesses a client and condition that is already known to re-evaluate the client's status. In this case the nurse is revisiting the client's feelings and plans to change her life situation by leaving her abusive husband. In emergency assessments, the nurse assesses the client for life-threatening problems which are acutely present.. In focused assessments, the nurse focuses on assessing a specific problem that is already known to exist to further refine planning interventions. In complete (general or initial) assessments, the nurse does a thorough assessment of all aspects of a client's health status on the client's admission to a health care facility.

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?

Verbally report the finding immediately to the client's physician. The nurse should report any abnormal assessment findings or changes in the client's health status to the client's physician or the charge nurse immediately for prompt and appropriate treatment of the health alterations. The unlicensed assistive personnel should not document the findings as this is the nurse's responsibility. The nurse should not just reassess the client's temperature in 2 hours and chart that data; immediate reporting of the data to the physician or charge nurse is necessary.

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 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.

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." Objective data are information that is observable and measurable, such as observing that the client's right leg is cold to the touch. Subjective data relate to phenomena that only the client can experience, such as unrelieved pain, nausea, or heartburn.

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." Some therapeutic ways to terminate an interview are to give a warning, ask the client to summarize the most importance concerns, ask "what else?", offer yourself as a resource, and explain all care routines. The nurse should not tell the client that the nurse is terminating an interview to check on someone else, as this gives the message that another client is more important. Asking a client whether the client wants to continue is not appropriate, as this implies that the information is not that important.

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 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 is the purpose of a focused assessment?

Adds depth to existing information A focused assessment adds depth to existing information or the initial database gathered by the nurse. A database assessment provides breadth for future comparisons. A focused assessment does not suggest possible problems facing the client but rather rules out or confirms the client's problems. A focused assessment is not voluminous and comprehensive, like a database assessment, but limited and to the point.

Which are examples of subjective data? Select all that apply.

Anxiety Light-headedness Nausea Subjective data are those that only the person experiencing them can perceive and report, such as anxiety, light-headedness, and nausea. Objective data are those that someone other than the person experiecing them can observe, such as edema and laceration.

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

As soon as possible after a client presents for care The nursing health history captures and records the uniqueness of the client and should be obtained as soon as possible after a client presents to the health care facility for care. If the nurse waits until the client is ready, this may occur too late and the problem may become more problematic. Twenty-four hours is also too long. Waiting until the client is discharged is inappropriate because important medical as well as psychological information may be missed or not communicated.

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. The nurse is responsible for collecting data in a timely manner. If the client is too fatigued, the nurse must ask for permission to obtain answers from the client's spouse prior to continuing to do so. Asking the client to wake up is disregarding the client's needs. Waiting until the following day is too long for the collection of important data.

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

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.

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?

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.

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?

Assess the client's blood pressure. The priority intervention for the client with an unstable blood pressure is to first measure the blood pressure. Once the nurse is certain that this is within safe parameters, the the nurse should assess the client's diet, activity level, and medication regimen.

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data?

Both during the collection and at the end of the collection 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.

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

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.

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply.

Client states, "I am in pain." Client states, "I feel so sad all of the time." Subjective data are statements by the client. Objective data are observations made by the nurse when gathering data such as vital signs and physical signs.

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

Collection, validation, communication of client data Assessing is the systematic and continuous collection, validation, and communication of client data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem-focused, time-lapsed, and emergency-based describe types of assessments. Assessments are nurse-focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are.

Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist?

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.

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

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.

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

Gather data from sources The nursing process includes: assessment, diagnosis, planning, implementation, and evaluation. The first phase, assessment, is the collection of data to identify actual or potential health problems for nursing interventions. Aside from evaluation, which is the final phase of the nursing process and involves assessing the client's progress toward meeting goals established in the plan of care, the remaining two options are not related to the specific activities in the nursing assessment process.

Which piece of client information is subjective?

Generalized myalgia or muscle pain Symptoms such as muscle pain or myalgia are considered subjective cues in a client's health history, as only the client can determine its presence. Signs of illness, such as temperature, leukoplakia, and ptosis, are considered objective cues in a health history, as is a nurse observing that a client is not oriented to time or situation. Objective signs are observable, perceptible, and measurable.

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 Maslow uses a hierarchy of five sets of human needs to organize data with basic physiological needs, such as the need for oxygen, being the most urgent. Gordon's (1994) framework identifies 11 functional health patterns and organizes client data into these patterns. The human response patterns organize data according to human responses to interventions. A medical model used to organize data collection, with which all nurses are familiar, is the body systems model. This method organizes data collection according to organ and tissue function in various body systems.

For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

Initial The Joint Commission has mandated that each client have a documented nursing admission (initial) assessment that follows institutional policies. An initial assessment is comprehensive and covers both a client's physical and psychosocial health. A focused assessment is one that addresses one specific problem that has already been identified; this type of assessment is not mandated by the Joint Commision.

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 Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other that the person experiencing them. They include vital signs, moist skin, and refusal to eat or drink. Subjective data are data that the client feels or states. Usually subjective data are documented in the client's record as quotations. A hunch is a feeling or guess based on intuition rather than known facts. Intution is the ability to understand something immediately, without the need for conscious reasoning.

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 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.

A nurse working on a medicine unit is mentoring a new graduate. The new nurse asks why it is necessary to perform an assessment on the same client twice during a 12-hour shift. What would be the nurse's best response to the new graduate?

Ongoing data collection is critical to the deletion or modification of old problems and finding new ones. It is impossible to give quality care without knowledge of changes in the client's status. Ongoing data collection is critical to the deletion or modification of old problems and identification of new problems. Even though it will give the new graduate experience, this is not why the assessment is done twice during a 12-hour shift. A policy is developed to maintain agency consistency. Nurses have professional accountability and should not blindly follow agency policy.

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is most likely the cause of this action by the client?

Pain Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief. Sleepiness would be 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 nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply.

Respect for client Professionalism Competence Caring 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.

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

Review the records available on the client. Records prepared by different members of the health care team provide information essential to comprehensive nursing care. The nurse should review records early when gathering data before the first contact with the client. This review helps to focus the nursing assessment and to confirm and amplify information obtained already. The other actions are not appropriate prior to performing an assessment. An assessment must be done whether it is convenient or not, for the appropriate care to be given.

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 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.

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 The client's health record Family members accompanying the client Other health care professionals When assessing, the primary source of client information is the client. Other sources the nurse should consider include the client's support people, the client record, family members accomapanying the client, and other health care professionals. It would not be appropriate to use other clients as a source, because this would violate confidentiality.

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments?

The nurse The 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.

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 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.

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 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.

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

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.

When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind?

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 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. 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.

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 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 intepretation or inference, and thus cannot be a misinterpretation. There is no evidence that the nurse's obvservation duplicates other data collected.

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

able to prioritize. 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).

While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, "The client's hearing may be impaired on the right side." This statement is an example of:

an inference. The judgment a nurse makes about a cue is known as an inference. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. The nurse can observe a cue directly, but not an inference. The key is the verb used —"hearing may be impaired." The statement is not erroneous or duplicate data.

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

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.

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. The nurse should use broad, open statements to facilitate communication during an interview. Using close-ended questions, which prompt yes or no answers, should be avoided, as it does not provide the level of the detail the nurse is seeking. The nurse should pay full attention to the client; paying too much attention to note-taking or making computer entries will interfere with good communication. The nurse should avoid providing false reassurance and agreeing with every statement the client makes.