HA - Chapter 1: Analyzing Data to Make Accurate Clinical Judgments
An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the first action of the nurse? Open the client's airway If the client is injured, protect the cervical spine Begin CPR Ensure that the client is safe
Open the client's airway All life-threatening problems identified during the initial assessment require the initiation of critical interventions. The nurse opens the client's airway; assists the client's breathing; provides assistance with circulation (CPR if needed); if the client is injured, protects the cervical spine; ensures that the disoriented or suicidal client is safe; and provides pain management and sedation. The client has assessments and critical interventions performed simultaneously as life-threatening problems are treated.
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed entry. exploratory. focused. comprehensive.
comprehensive. An initial comprehensive assessment involves collection of subjective data about the client's perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client's overall function) as well as objective data gathered during a step-by-step physical examination. Regardless of who collects the data, a total health assessment (subjective and objective data regarding functional health and body systems) is needed when the client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared.
A client who was alert and oriented at the start of the shift is now presenting with diaphoresis, confusion, and lethargy. The client received NPH 20 units insulin sliding scale (Lispro/ Humalog). Based on this information, what type of assessment should the nurse perform on the client? ongoing or partial comprehensive emergency focused
focused The client is exhibiting signs and symptoms of hypoglycemia, so a focused/problem-oriented assessment should be conducted. The nurse should first check the client's glucose level and treat it before it becomes dangerously low. Ongoing or partial assessments will be completed, but this is not the best answer. An initial comprehensive assessment would have already been completed on admission. Because this is not a life-threatening situation that requires a rapid response team, an emergency assessment is not required.
A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption? Review the client's medication administration record for analgesic use. Ask the client about the most recent experiences of pain. Meet with the client's spouse and daughter to discuss the client's pain. Collaborate with the physician who is treating the client.
Ask the client about the most recent experiences of pain. Data are best validated by the client. Other sources are valid and useful, but the client is the ultimate source, especially in the case of subjective data.
Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to arrive at conclusions about the client's health. document any physical symptoms the client may have. contribute to the medical diagnosis. validate the data collected.
arrive at conclusions about the client's health. The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment data.
How does a nurse best facilitate the nursing health assessment? Maintaining privacy Asking the appropriate questions Formulating a nursing diagnosis Creating a nursing care plan
Asking the appropriate questions Knowing how to facilitate the nursing health assessment by asking appropriate questions to obtain more information assists the nurse to solve the mystery or create a nursing care plan.
Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first? Perform a comprehensive head-to-toe assessment. Conduct a focused assessment. Notify the health care provider. Alert the critical assessment team.
Conduct a focused assessment. Because a comprehensive assessment had already been conducted, the nurse would perform a focused assessment based on the observed neurological changes. The nurse would need to obtain more information before alerting the critical assessment team or contacting the health care provider; some actions would include completing the physical neurological exam, checking blood glucose, checking for changes in medications that may have contributed to the change in mental status, and reviewing the a.m. labs for abnormal sodium level.
An assessment that concentrates on patterns of role performance that all humans share is called what? Head-to-toe Body systems Focused Functional
Functional A functional assessment focuses on the functional patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs.
A nurse analyzes the data obtained from an initial assessment of a new client: weight gain of 15 lbs in 3 months, intolerance to cold, constipation, and lethargy. The nurse determines the client may have hypothyroidism and develops several nursing diagnoses with interventions to address the client concerns. Which action should the nurse take next? Implement interventions. Reassess the client. Evaluate outcomes. Cluster cues.
Implement interventions. Because the nurse has already assessed the client, analyzed the data, clustered the client cues, identified client concerns, and developed a plan with interventions, the next step in the nursing process would be to implement the interventions. The nurse would reassess the client after the interventions were implemented and evaluate the outcomes.
A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas? Physiologic, psychological, sociocultural, developmental, and spiritual data Focuses primarily on the client's physiologic development status Involves the client's musculoskeletal system and activities of daily living Focuses only on the client's psychological, sociocultural, and spiritual well-being
Physiologic, psychological, sociocultural, developmental, and spiritual data A nursing health assessment includes physiologic, psychological, sociocultural, developmental, and spiritual data. Medical health assessment focuses primarily on the client's physiologic development status. The assessment by a physical therapist focuses mainly on the client's musculoskeletal system and activities of daily living.
Consider the nurse's role in the health assessment of a client. What action will the nurse perform initially when admitting a client to a long-term care facility? collecting information regarding the client's health status stabilizing the client's physical condition developing an effective, respectful nurse-client relationship creating an environment that encourages client autonomy
collecting information regarding the client's health status Regardless of the care setting, the nurse's initial role in health assessment is to collect data. While all the remaining options are relevant to quality client care, they are not associated directly with the nurse's role concerning health assessment.
A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time? ongoing or partial comprehensive emergency focused
emergency Assessments pre- and post-procedure are essential to determine if there are deviations from the client's baseline. Because the airway is impaired, which is life-threatening, the nurse would conduct an emergency assessment on the client. Ongoing or partial, comprehensive, and focused assessments would not be appropriate in this situation. Priority assessments after a thyroidectomy include monitoring vital signs (decreased blood pressure and elevated heart rate may indicate internal or external bleeding); assessing reflexes (because some of the parathyroid gland is removed, the client is at risk for hypocalcemia, which will cause hyper-reflexes, tetany; calcium gluconate should be available on the unit); and monitoring airway and breathing (increased swelling/edema could cause narrowing of the airway; a tracheostomy set should be kept at the bedside of these clients).
The nurse is obtaining a health history from a client with a long history of type 2 diabetes. Which of the following subjective findings should the nurse further investigate? Select all that apply. "I have noticed changes in my vision." There is dimpling where the client has been injecting insulin. "I do not urinate as much as I used to and I have gained weight." Scale states that the client now weighs 10 lbs more than the last visit. "I do not have any allergies."
"I have noticed changes in my vision." "I do not urinate as much as I used to and I have gained weight." Subjective findings are what the client states, which in this situation includes a change in vision and urine output. Observing dimpling of skin where the client injects the insulin and obtaining the client's weight are examples of objective data. The fact that the client does not have allergies, though it is a subjective piece of data, does not warrant further investigation.
When the nurse is performing a physical examination on admission of a client to the medical unit, the client says the doctor already did an exam. The best response by the nurse would be "the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease." "the doctor's and nurse's assessments are totally unrelated and are necessary so all forms are completed appropriately." "each assessment is important and the nurse and doctor will get together to determine what orders need to be written." "I know it seems repetitive but the doctor is trying to treat the reason you were admitted and I will focus more on getting everything ready for you to go home."
"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease." The medical examination focus is on diagnosis and treatment of disease and the nursing examination focuses on the human response.
For which of the following clients should a nurse perform a focused assessment? Client with elevated blood pressure with no previous history of heart problems Client with 4-day history of sore throat and fever with enlarged lymph nodes Client with right upper abdominal pain that radiates into the groin area Diabetic with elevated blood sugars for the past 2 weeks
Client with 4-day history of sore throat and fever with enlarged lymph nodes A client with a sore throat and fever with enlarged lymph nodes requires only a focused assessment by the nurse. A focused assessment consists of a thorough assessment of a particular client problem. An elevated blood pressure with no previous history of heart problems requires an initial comprehensive assessment. Right upper abdominal pain that radiates into the groin area is an emergency situation and the nurse should collect only the data necessary to make a quick diagnosis for immediate treatment (emergency assessment). A client with diabetes has a chronic, ongoing health problem that needs reassessment and possibly a change in treatment (ongoing or partial assessment).
The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about? Functional Focused Head-to-toe Body system
Head-to-toe A head-to-toe or comprehensive assessment is the most organized system for gathering comprehensive physical data.
A client admitted with reports of nausea and vomiting has not reported any vomiting in the last 6 hours. What initial response should the nurse have regarding this assessment information and its effect on the client's nursing plan of care? Request that the health care team revise the plan of care. Notify the primary health care provider of the change in the client's health status. Recognize the need to reevaluate the client's plan of care. Monitor the client frequently for other changes in health status.
Recognize the need to reevaluate the client's plan of care. The health assessment allows data to be collected that is specific to the client and his or her nursing care needs. Initially, the nurse must be aware that any change to the client's health status may require an change to this plan of care. If changes are required, the health care team will be asked to consider and recommend them. Monitoring the client for changes is always considered a nursing responsibility. Notifying the primary health care provider is not directly related to the nursing plan of care.
The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following? The client's motivation for change The client's medical comorbidities The client's learning style The client's prognosis for recovery
The client's motivation for change The Health Belief Model is based on three concepts: the existence of sufficient motivation, the belief that one is susceptible or vulnerable to a serious problem, and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. As a result, implementation of this model should begin with an appraisal of the client's motivation to change. This consideration would precede the other listed variables, although each may affect care.
What is the primary function of the health care team? To work together to obtain maximum coverage To decide the best overall care To guide the client's care throughout times of crisis To develop an individual focus for each member
To decide the best overall care The health care team meets to collaborate on clients and decide the best overall care. This occurs throughout the lifespan, from the inception of life until death. The health care team is a partnership. The group includes the nurse, physician, nutritionist, social worker, physical therapist, occupational therapist, speech therapist, and/or dentist. They all work together on the same team for the benefit of the client.
The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions? Follows the ABC approach Uses evidence-based techniques Asks unlicensed staff to measure vital signs Focuses on the system that caused the hospitalization
Uses evidence-based techniques To accomplish pertinent and comprehensive data collection the nurse uses appropriate evidence-based assessment techniques and instruments when collecting data. The ABC approach may not be necessary. Although measure vital signs can be delegated to unlicensed staff, this does not ensure that the data will guide the identification of appropriate interventions. Focusing on one system may be appropriate in specific situations however the admission assessment should include all body systems
The nurse working in the emergency room has been assigned the following clients. Which client requires an ongoing assessment? a client admitted with acute atrial fibrillation who has a heart rate of 150 bpm and irregular heart rhythm a client admitted with a leg fracture who is reporting sudden shortness of breath and a rash a newly admitted client who was involved in a motor vehicle incident with a head injury and reports a headache of 3 on a scale of 1-10 a client admitted 2 days ago with exacerbation of chronic obstructive pulmonary disease with an oxygen saturation of 90% on 2L nasal cannula who reports ease of breathing
a client admitted 2 days ago with exacerbation of chronic obstructive pulmonary disease with an oxygen saturation of 90% on 2L nasal cannula who reports ease of breathing A client with improvement of symptoms would need ongoing assessments. Because it can be life-threatening for the client to have an irregular, fast heart rate (atrial fibrillation) of 150 BPM, an emergency assessment should be conducted for that client. The client with large bone fractures with sudden shortness of breath would require an emergency assessment; this client is at high risk for fat emboli, which could cause pulmonary embolism or stroke, and fat embolism syndrome, which can cause multi-organ failure if not treated in a timely manner. A newly admitted client would require a comprehensive assessment.
The nurse is conducting a health assessment on a client presenting to the emergency room with a critical condition. The nurse should initially ask questions regarding which topic(s) during the initial assessment? Select all that apply. medications allergies adverse reactions lifestyle changes stress at work
medications allergies adverse reactions The nurse should ask a client in critical condition brought into the emergency department about topics concerning the event, including medications, allergies, and adverse reactions. When a client has a professional relationship with the nurse and has had a thorough health assessment at the initial meeting, the nurse may explore other assessment topics such as lifestyle changes and stress at work. The thorough health history would be completed when the client was stable and able to answer further questions.
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's physiologic status. holistic wellness status. developmental history. level of functioning.
physiologic status. The physician performing a medical assessment focuses primarily on the client's physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.
The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority? lives alone significantly impaired hearing widowed 2 years ago greatly concerned about cost of services
significantly impaired hearing As a nurse, it is vital to sift through all the client information and make decisions on what information will impact client safety and quality of care. The ability to identify what is important on a daily basis for each individual client is paramount for nursing care. Of the data provided, the client's impaired hearing poses the greatest safety risk and has the greatest impact on the client's quality of life and so has priority. While the other options could be potential factors related to quality of life and safety, the nurse will need to assess them further.