nursing fundamentals chapter 12

objectives are

(signs) also known as signs that are observable, perceptible, and measurable Examples: cues are a description of an incision site ("reddened, small amount bloody drainage on dressing") or a blood pressure measurement ("180/100")

Types of assessment vary depending on the

-clinical situation, -the patient's health status, -the time available, -the purpose of data collection.

the second of the two major sources of data exist for the collection of information about the patient, what are considered secondary sources

-family members, -significant others, -other members of the healthcare team, -laboratory tests, -and literature review,

An interview can be divided into four phases:

1) preparatory, 2) introductory, 3) maintenance, 4) concluding

These assessment parameters are examples of what functional health pattern Current stress level Coping ability Ability to endure life stressors Physiologic responses to stress (e.g., blood pressure, heart rate)

Coping and stress tolerance

These assessment parameters are examples of what functional health pattern General survey of the patient's health status Usual health behaviors

Health perception and health management

what are the function health patterns of nutrition

Metabolism, Coping-Stress Tolerance, and Sleep-Rest.

These assessment parameters are examples of what functional health pattern Patient's perceptions of key relationships Observations of interactions with others

Roles and relationships

These assessment parameters are examples of what functional health pattern Regular sleep habits and routine

Sleep and rest

provides a framework for collecting and organizing patient data, providing a foundation for the development of nursing diagnoses.

The functional health pattern assessment

one of the two major sources of data exist for the collection of information about the patient, what is the primary

The patient, because only he or she can give a firsthand description of the health problem and its effects on his or her lifestyle.

__________________is a systematic analysis in which inspection, palpation, percussion, and auscultation are used.

The physical examination

assists in verifying and clarifying cues and inferences, thus increasing the likelihood that cues and inferences are accurate, free from bias, and interpreted correctly

Validation (validate data)

The nurse has admitted a single mother with nausea and vomiting for the last 3 days and upper left quadrant abdominal pain. Which of the statements below indicate that the nurse is using the functional health patterns model of assessment? Select all that apply: a) "Please describe your appetite over the last week." b) "What kind of help have you had from your family since this started?" c) "Have you been able to sleep or rest lately as usual?" d) "Have you had symptoms like this in the past?" "Your blood pressure is 94/48; heart rate is 122."

a, b, c. These three statements assess the functional health patterns of Nutrition-Metabolism, Coping-Stress Tolerance, and Sleep-Rest. Statement D focuses on past symptoms in relation to the current admission adhering to a medical model or review of body systems. Vital signs are objective data collected in adherence to a head-to-toe model to first gauge the current state of health.

Which types of data would be collected during a physical assessment? a) Color, moisture, and temperature of the skin b) Type, amount, and duration of pain c) Foods eaten that cause nausea d) Specific allergies resulting in itching

a. Color, moisture, and temperature of the skin Physical assessment is the examination of the client for objective data that may better define the client's condition and help the nurse in planning care. Physical assessment includes the color, moisture, and temperature of the skin. The health history interview would elicit information (data) about pain, nausea, and allergies. Chapter 12: Nursing Assessment - Page 207-208

When performing an assessment, the nurse should focus most on the developmental stage for which client? a) Toddler b) Young adult c) Middle-age adult d) Adolescent

a. 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. Chapter 12: Nursing Assessment - Page 205

Observation helps the nurse anticipate

appropriate data to be collected during the nursing interview and physical examination.

First phase of the nursing process in which data are gathered to identify actual or potential health problems

assessment

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? a) Record the pulse rate on the appropriate vital signs sheet in the chart. b) Ask another nurse to take the pulse. c) Assess the client's blood oxygen saturation level. d) Wait 4 hours and take the client's pulse again.

b. Ask another nurse to take the pulse. Validation is the act of confirming or verifying. The purpose of validating is to keep data as free from error, bias, and misinterpretation as possible. Because verification of all data is neither possible nor necessary, nurses need to decide which items need to be verified. Data need to be verified when there are discrepancies; this will ensure that assessments and documentation are accurate. In this case, the nurse should confirm the suspicious pulse rate by having another nurse check the client's pulse. The nurse should not just record data whose accuracy is in question. Assessing the client's blood oxygen saturation level would not serve to validate the questionable pulse rate; the nurse needs to measure and record an accurate pulse rate. The nurse should not wait 4 hours to take the client's pulse again; there is no need to wait, and if the client's pulse rate actually were 20 beats/min, this situation would need to be addressed immediately. Chapter 12: Nursing Assessment - Page 211

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? a) Subjective b) Objective c) Physical d)Unreliable

b. Objective Objective data are data that are observable and measurable and can be seen, heard, felt, or measured by someone other than the client. Subjective data are information perceived only by the affected person. Physical and unreliable are not types of data. Chapter 12: Nursing Assessment - Page 208

A nurse is conducting a focus assessment of a hospitalized patient who is a fall risk. Which of the following would be most appropriate? a) "Do you have many stairs that you need to navigate at home?" b) "Are you more unsteady on your feet when you are out of bed today?" c) "Are you feeling any pain in your abdomen?" d)"What is your usual or baseline diet at home?"

b. Statement B targets an existing problem that has already been identified and attempts to determine changes in the status of the problem. Statements A, C, and D do not address the current problem and are beyond the scope of the focus assessment.

While doing an assessment, the nurse identifies questionable data. Which should the nurse do first? a) Disregard the questionable data. b) Validate the questionable data. c) Inform the physician of the questionable data. d) Inform the client that the data are not correct.

b. Validate the questionable data. Questionable data are verified (validated) as part of the assessment step of the nursing process. It is not necessary to inform the physician or the client that the data are questionable as it is the nurse's responsibility to validate the data. The questionable data should not be disregarded. Chapter 12: Nursing Assessment - Page 210-211

Which piece of client information is subjective? a) A temperature of 102°F (38.9°C) b) Leukoplakia on the client's oral mucosa c) Generalized myalgia or muscle pain d) Alert and oriented to person and place but not time or situation e) Ptosis, a drooping of the eyelid, on the right side

c. 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. Chapter 12: Nursing Assessment - Page 208

In conducting an assessment of a patient with gastrointestinal bleeding, the nurse uses which of the following pieces of subjective data? Select all that apply: a) Hematocrit 20% b) Appearance of stool c) Spouse's statement of symptoms d) Health record description of signs

c. Subjective data contain symptoms that are supplied by the patient or family and are obtained via interview. Laboratory studies, direct observation, and descriptions in the health record of signs are examples of objective data.

Proficient interviewing skills are necessary for obtaining

comprehensive assessment data.

The patient is deemed unreliable if he or she is _____________or __________________or ______________, _____________ or ___________. In these situations, secondary sources help provide the necessary assessment information.

confused suffering from physical or mental conditions altering thinking judgement or memory

Pieces of data, subjective or objective, about a patient

cues

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficient data for planning care. Which action by the nurse would be most appropriate in this situation? a) Ask the client to wake up and try to answer the interview questions. b) Ask the client's spouse to come in and answer the interview questions. c) Wait until the next day to obtain the answers to the interview questions. d) Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

d. 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. Chapter 12: Nursing Assessment - Page 209

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. a) Leaving the door to the room open b) Leaving the television on c) Keeping the heat on high d) Providing a proper seating arrangement e) Maintaining a proper distance from the client

d. Providing a proper seating arrangement e. Maintaining a proper distance from the client In the interview of the client, both the seating arrangement and the distance from the client are important in establishing a relaxed and comfortable environment for data collection. Leaving the door opened, leaving the television on, and keeping the heat high will cause distractions for the client. Chapter 12: Nursing Assessment - Page 207

These are examples of Comparing cues to normal function. Referring to textbooks, journals, and research reports. Checking consistency of cues. Clarifying the patient's statements Seeking consensus with colleagues about inferences

data validation

Environmental factors can

facilitate or hinder collection of assessment data.

Systematic visual examination of the patient

inspection

Communication technique in which the nurse questions the patient in a goal-directed conversation

interviewing

Art of noticing patient cues

observation

Use of the techniques of inspection, palpation, percussion, and auscultation to obtain information about the structure and function of body parts

physical examination

Assessment is the

subjective and objective data from the patient and other sources for the purpose of describing health problems

1) the admission assessment, 2) focus assessment, 3) time-lapse reassessment, 4) and emergency assessment

types of assessment

subjective are

(symptoms) Examples: cue is the patient's statement, "I have a sharp pain in my shoulder." In the diagnosis phase, these cues are interpreted, clustered, and analyzed.

These assessment parameters are examples of what functional health pattern Mobility Status Cardiovascular status Respiratory status Exercise routine Leisure activities

Activity and Exercise

admission assessment is called

An in-depth, comprehensive appraisal of a patient's health at the time of entry into a healthcare facility or at the time of the first home health visit or outpatient clinic visit

These assessment parameters are examples of what functional health pattern Changes in cognitive function Ability to hear, see, and speak Pain, numbness, or other sensations

Cognition and perception

What "activities" make up the assessment phase

Collection of data Validation of data Organization of data

Which group of terms best defines assessing in the nursing process? a) Designing a plan of care, implementing nursing interventions b) Nurse-focused, establishing nursing goals c) Collection, validation, communication of client data d) Problem-focused, time-lapsed, emergency-based

Collection, validation, communication of client data

These assessment parameters are examples of what functional health pattern Usual bowel and bladder elimination habits, last bowel movement Laxative use Excretory function of the skin (e.g., excessive perspiration)

Elimination—excretory function (bowel, bladder, and skin)

These assessment parameters are examples of what functional health pattern Eating habits Appraisal of appetite Weight loss or gain Changes in skin, hair, or nails

Nutrition and metabolism

These assessment parameters are examples of what functional health pattern Descriptions of self Physical appearance Effects of illness Major life accomplishments

Self-perception and self-concept

These assessment parameters are examples of what functional health pattern Patient's appraisal of his or her sexual role and sexual health

Sexuality and reproduction

the third phase of an interview, the nurse and patient work toward achieving the specific task or goal agreed on in the introductory phase

The maintenance phase or working phase

occurs before the nurse meets the patient

The preparatory or preinteraction phase

These assessment parameters are examples of what functional health pattern Identification of valued people and possessions Sources of support Religious practices

Values and beliefs

the sound of blood moving through a narrowed or twisted blood vessel is known as

a bruit

The nurse is performing an admission assessment on a young client admitted to the unit. Which are considered objective data? Select all that apply. a) 38-year-old man b) Height: 6 ft (1.82 m) c) Weight: 195 lb (89 kg) d) "My leg hurts." e) "I am afraid something serious is wrong."

a. 38-year-old man b. Height: 6 ft (1.82 m) c. Weight: 195 lb (89 kg) Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person being assessed. Age, vital signs, height, and weight are objective data. Subjective data are data that the client reports or feels and are usually documented in the record with quotations. The client statements "My leg hurts" and "I am afraid something serious is wrong" are subjective data. Chapter 12: Nursing Assessment - Page 208-209

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? a)Focused b)Initial c)Emergency d)Time-lapse

a. Focused The nurse is performing a focused assessment, which involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the client's health. An emergency assessment is performed to identify life-threatening problems. A time-lapse assessment compares a client's current status to baseline data obtained earlier. Chapter 12: Nursing Assessment - Page 204

Technique of listening to body sounds with a stethoscope

auscultation

Which of the following are true about the introductory phase of interviewing? Select all that apply: The introductory phase is the first phase of the interviewing process. Introduce yourself by name and position. Focus on goals and move to the next topic after data are collected. Observe behavior and patient's self-perceptions.

b, d. Introduction of self, including position, and observing behavior and self-perceptions are both elements of the introductory phase. The introductory phase is the second phase following the preparatory phase. Focus on goals and goal attainment are included in the maintenance phase.

Which statement made by the nurse indicates data that would be documented as part of an objective assessment? a) "The client's sister reports that the client has unrelieved pain." b) "The client's right leg is cold to the touch, from the knee to the foot." c) "The client reports nausea following eating." d) "The client reports having heartburn after her breakfast."

b. "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. Chapter 12: Nursing Assessment, p. 208.

While examining a client, the nurse assesses the temperature of the client's skin. The nurse most likely would be using which technique? a) Inspection b) Palpation c) Percussion d) Auscultation

b. Palpation Nursing physical assessment skills include inspection, palpation, percussion, and auscultation. Inspection would reveal color, shape, movement, pulsations, and texture of an involved body part. The correct answer in this scenario is palpation, which is used to assess the temperature of the skin. Percussion determines a structure's denseness or hollowness and aids in discovering the location and level of organs, consistency of body structures, the presence of tenderness, and identification of masses or tumors. Auscultation identifies normal and abnormal sounds (such as in the bowel, lungs, heart) as well as the sound of blood moving through a narrowed or twisted vessel. Chapter 12: Nursing Assessment - Page 208

A nurse is admitting a patient with congestive heart failure. Which of the following describe appropriate aspects of assessment? a) Define patient goals for increasing ability for self-care. b) Evaluate current therapeutic regimen at home. c) Identify activities that exacerbate symptoms. d) Apply oxygen therapy via nasal cannula.

c. "Identifying activities that exacerbate symptoms" is an example of data collection or assessment. Defining patient goals is an example of outcome identification. Evaluation of current home regimen is an evaluation rather than an assessment. Applying oxygen is an example of Implementation.

Which are examples of subjective data? a) A nurse observes a client wringing the hands before signing a consent for surgery. b) A nurse observes redness and swelling at an intravenous site. c)A client describes pain as an 8 on the pain assessment scale. d) A client feels nauseated after eating breakfast. e)A client's blood pressure is elevated following physical activity. f)A client reports being cold and requests an extra blanket.

c. A client describes pain as an 8 on the pain assessment scale. d. A client feels nauseated after eating breakfast. f. A client reports being cold and requests an extra blanket. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. A client's pain, nausea, and chills can only be felt by that person. Data collected about a client, such as the client wringing the hands, redness and swelling at an intravenous site, and a blood pressure measurement, are considered objective data. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client. Chapter 12: Nursing Assessment - Page 208

Which group of terms best defines assessing in the nursing process? a) Problem-focused, time-lapsed, emergency-based b) Designing a plan of care, implementing nursing interventions c) Collection, validation, communication of client data d)Nurse-focused, establishing nursing goals

c. 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. Chapter 12: Nursing Assessment - Page 203

Which statements accurately describe the unique focus of nursing assessments? a) Nursing assessments duplicate medical assessments. b) Nursing assessments target data pointing to pathologic conditions. c) Nursing assessments focus on the client's responses to health problems. d) The findings from a nursing assessment may contribute to the identification of a medical diagnosis. e) The focus of a nursing assessment is on actual, not potential, health problems. f) An initial assessment establishes a complete database for problem solving and care planning.

c. Nursing assessments focus on the client's responses to health problems. d. The findings from a nursing assessment may contribute to the identification of a medical diagnosis. f. An initial assessment establishes a complete database for problem solving and care planning. The nursing physical assessment focuses primarily on the client's functional abilities, which provides the nurse with an appraisal of the client's health status, the identification of health problems, and the establishment of a database for nursing interventions. In addition, the nurse's findings from the assessment should be conveyed to the physician, as these findings may aid the physician with medically diagnosing the client. The nursing assessment focuses on the whole client, including identification of potential health problems. The purpose of the physician's physical assessment is to identify pathologic conditions and their causes; therefore, the nursing assessment does not duplicate the physician's assessment. Chapter 12: Nursing Assessment - Page 203

The nurse is interviewing a client who is reporting chills, fever, malaise, and cough. During the working phase of the client interview, the nurse: a) arranges for a private location. b) summarizes the key points of the interview. c) asks the client to describe symptoms. d) introduces self to client.

c. asks the client to describe symptoms. During the working phase, the nurse collects assessment data from the client. In the preparatory phase, the nurse prepares the environment for the interview. Introductions initiate the interview during the introductory phase. The nurse highlights key points of the interview in preparation for terminating the interview in the termination phase. Chapter 12: Nursing Assessment - Page 207

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? a) "My leg hurts so bad. I can't stand it." b) "I feel anxious and frightened." c) "I am so sick; I am about to throw up." d) "Unable to palpate femoral pulse in left leg."

d. "Unable to palpate femoral pulse in left leg." Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client. Objective data are also called signs or overt data. The nurse being unable to palpate a femoral pulse in the client's leg is an example of objective data. The other statements, in which the client expresses feelings of pain, anxiety, fear, and nausea, are examples of subjective data, which only the client can experience. Chapter 12: Nursing Assessment - Page 208-209

Which scenario is an example of a time-lapse reassessment? a) Seeing a client down on the floor, the nurse assesses the client's airway, breathing, and circulation, calls for help, and begins a quick neurological exam. b) A nurse just coming on shift performs a focused physical assessment on each client, based on the client's diagnosis. c) A nurse in a long-term skilled nursing facility assesses a new resident's baseline health status. d)A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.

d. A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before. The four types of assessment a nurse may perform are initial, focused, time-lapse, and emergency. A time-lapse reassessment is performed to reevaluate any changes in the client's health from a previous assessment. It is used to monitor the status of an already identified problem for a client with whom the nurse is already familiar. In this question the only scenario that depicts these components is that of the client with mobility issues. The assessment of the client who is found down on the floor is an emergency assessment. The assessment of each client based on the client's specific diagnosis is a focused assessment. The baseline assessment of the new resident in the long-term care facility is an initial assessment. Chapter 12: Nursing Assessment - Page 203

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training? a) The nurse sits on eye level with the client. b) The nurse verifies the client's name. c) The nurse asks the client what name the client would like to be called. d)The nurse introduces oneself to the client by pointing to the nurse's name badge. e)The nurse should sit on eye level with the client.

d. The nurse introduces oneself to the client by pointing to the nurse's name badge When conducting an interview, the nurse should sit at eye level with the client, verbally introduce oneself, and state one's position. This sends the message that the nurse accepts responsibility and is willing to be accountable. The nurse should not simply point to the nurse's name badge in introducing oneself. The nurse should verify the client's name and ask what the client would like to be called. Chapter 12: Nursing Assessment - Page 207

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? a) The client b) The client's physician c) The client's chart d) The nursing and medical literature

d. 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. Chapter 12: Nursing Assessment, p. 209, 210.

The purpose of nursing assessment is to

gather data about the patient (individual, family, or community) that can be used in diagnosing, identifying outcomes, planning, and implementing care.

The "second phase" of an interview is referred to as the ________________ or the _________________It begins when the nurse and patient meet. Actions in this phase assist in establishing rapport, clarifying roles, and alleviating anxiety

introductory phase or orientation phase

Observable, measurable information that can be validated or verified

objective data

Use of the sense of touch to ascertain the size, shape, and configuration of underlying body structures

palpation

the term field of study

pathology

Examination by tapping the body surface with the fingertips and evaluating the sounds obtained

percussion

Comparing cues to normal function. For example, Mr. Jones is a professional athlete and has a resting pulse of 50 beats per minute; the nurse knows that ...

physiologic heart changes in physically fit people can result in a slower pulse rate (bradycardia).

benign growth of cells within the prostate gland

prostatic hyperplasia

examples of cues and inferences: Possible Inferences: pt may be dehydrated. pt has hypothyroidism. pt has some type of dermatitis what would the cue be

pt has dry, flaky skin.

examples of cues and inferences: Cue pts blood sugar is 55 mg/dL.

pt is having a hypoglycemic reaction.

Assessment data are

recorded and become a permanent part of the health record

hardening of the skin

scleroderma

The patient, family and significant others, health team members, and health records are

sources of assessment data.

Symptoms or covert cues that include the patient's feelings and statements about his or her health problems

subjective data

above the pubic bone

suprapubic

In this phase the interview is completed this is known as (reviewing and summarizing)

the concluding or termination phase

These are all part of which phase "one" - Review as much information as possible about the patient. - Decide what data are needed and what type of data collection form will be used. - Review the literature pertinent to the patient's developmental age, psychosocial aspects, and pathophysiologic considerations, if needed. - Assess your own feelings or reactions to previous patients that might interfere with the nurse-patient relationship. - Seek assistance from more experienced nurses, mentors, or supervisors if concerned about how to carry out the interview. - Plan for a private, quiet setting for the interview; schedule a mutually convenient time of day; and determine the length of time needed for data collection. - Modify the environment to facilitate the interview

the preparatory phase

Reexamining information to check its accuracy

validation

These are all part of which phase of the interview process? Observe the nonverbal behavior that accompanies verbal responses (e.g., a patient may say she is not nervous, worried, or anxious while biting her fingernails or moving constantly). Assess the patient's ability to continue the interview (e.g., grimace of pain, shortness of breath, fatigue).

working phase