prep-u chapter 14

The purpose of obtaining a nursing history is to:

identify actual and potential nursing diagnoses. Page 337

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

inform the client of the maintenance of confidentiality. p350

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

collection, validation, communication of client data p335

Nurses perform assessments on clients as part of their routine care. Which statements accurately describe the unique focus of these nursing assessments? Select all that apply.

1. An initial assessment establishes a complete database for problem solving and care planning. 2' The findings from a nursing assessment may contribute to the identification of a medical diagnosis. 3' Nursing assessments focus on the client's responses to health problems. p337

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview?

Administer prescribed pain medication prior to conducting the interview p350-351

During the nursing examination, the nurse notices that the client, an older adult female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation?

Ask the client if it is okay to interview her husband for the answers to the interview questions. p350

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 p353

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next?

Recheck the temperature paying close attention to technique p353

An assessment involves gathering pieces of information about a client's health status. Which piece of information is subjective?

Client has generalized myalgia or muscle pain. p346-347

A 50-year-old female client is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information?

Consult nursing and medical literature p348

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 p346

While performing the nursing history the nurse notes that the client states he is having very little pain, but is occasionally grimacing and rubbing his shoulder throughout the interview. The nurse acknowledges this behavior and questions the client, and then proceeds with other phases of the interview. This action takes place during which phase of the nursing interview?

Maintenance p350

Which quality does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply.

Professionalism Respect for client Competence Caring p338

The nurse working at a local community hospital understands the importance of having a client database for continuous data collection. What does the nurse identify as the the primary reason for collecting data continuously?

The client's health status can change quickly. p337

The nursing instructor is teaching the students how to do an interview on a client. Which statement made by a student indicates a need for further instruction?

The nurse should show the name badge to the client so they can identify the nurse. p351

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

Toddler p345

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 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 p355

Which of the following are examples of objective data? Select all that apply.

breath sounds laboratory results a client's temperature p346-347

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

focused assessment p339

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 p345