Chapter 1: Analyzing Data to Make Accurate Clinical Judgments
The nurse is exhibiting critical thinking in which client care situation? Transcribing medication orders onto the nurse's medication administration record. Notifying the healthcare provider of a critical lab result. Answering the client's call bell alarm while the nursing assistant is at lunch. Performing a focused assessment on a client who is complaining of shortness of breath.
Performing a focused assessment on a client who is complaining of shortness of breath. Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 4
A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? To establish a database against which subsequent assessments can be measured To establish rapport with the client and family To gather information for specialists to whom the client might be referred To quantify the degree of pain a client may be experiencing
To establish a database against which subsequent assessments can be measured Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 3
An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n) ongoing or partial assessment. focused or problem-oriented assessment. emergency assessment. initial comprehensive assessment.
focused or problem-oriented assessment. Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 4
When assisting a client with health promotion, what must the nurse also nurture? A healthy environment Knowledge of the Healthy People 2020 indicators Family communication School/work attendance
A healthy environment Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 6
A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment? Assessment Diagnosis Implementation Evaluation
Evaluation Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 2
Revising the plan as needed occurs in what part of the nursing process? Assessment Diagnosis Planning Evaluation
Evaluation Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 2
Which of the following is the best example of assessment in everyday life? Taking the dog for a walk in the park to get exercise Listening to a favorite song to relax in the evening Texting a friend to let her know that you made it home safely Measuring the remaining tread on a car tire to determine whether it is time to replace it
Measuring the remaining tread on a car tire to determine whether it is time to replace it Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 2
The client has a murmur. This is what type of data? Subjective Objective Focused Comprehensive
Objective Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 6
A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client? Breathing Airway Circulation Disability
Airway Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 4
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. Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 5
When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what? Assessment Diagnosis Planning Evaluation
Diagnosis Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 2
The nurse prepared to complete a comprehensive health assessment on a client in the community. What should the nurse expect to complete when performing this assessment? Select all that apply. Health history Wellness teaching Physical examination Outcome identification Medication administration
Health history Physical examination Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 3
When doing an overall assessment of a client, the nurse is able to use findings for which primary purpose? Identify conditions that the health care provider may have missed. Identify in what areas the client can educate the family. Identify in what areas the client needs the most care. Identify the client's medical diagnosis.
Identify in what areas the client needs the most care. Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 3
An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of? Nursing intervention Nursing goal Nursing evaluation Nursing assessment
Nursing intervention Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 7
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 Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 3
Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next? assessment diagnosis planning evaluation
evaluation Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 2
The result of a nursing assessment is the prescription of treatment. documentation of the need for a referral. client's physiologic status. formulation of nursing diagnoses.
formulation of nursing diagnoses. Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 2
Which assessment finding should the nurse document as objective data? Biographical information Body functions Lifestyle practices Personal relationships
Body functions Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 6
A nurse is admitting a client, having completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data? Patient centered Subjective Unconfirmed Objective
Objective Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 3
A client who underwent abdominal surgery this morning reports feeling weak and dizzy. The nurse also observed a decrease in urine output in the last hour. What action should the nurse take first? Assess the client. Administer IV fluids. Evaluate the outcome. Reevaluate the nursing plan.
Assess the client. Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 3
After performing a comprehensive assessment on a client, the nurse notes the following. Which part of the nursing process is the nurse performing? Nursing Notes: ● Client reports pain in bilateral lower extremities when walking short distances, relieved with rest. ● Pulses are weak, barely palpable in bilateral lower extremities. ● Bilateral feet are cool to touch ● Total cholesterol > 200. ● Client smokes two packs of cigarettes daily for past 20 years. documentation of subjective assessment findings development of priority nursing diagnosis analysis of assessment findings implementation of interventions
analysis of assessment findings Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 7
A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility? Perform a musculoskeletal examination. Collect subjective and objective data related to overall function. Take anthropometric measurements. Obtain a 24-hour diet recall.
Collect subjective and objective data related to overall function. Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 6
After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time? Initial Focused Ongoing Emergency
Ongoing Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 3
A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing? Initial comprehensive Ongoing or partial Focused or problem-oriented Emergency
Ongoing or partial Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 3-4
A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take? Perform an emergency assessment. Develop a nursing diagnosis. Conduct a partial assessment. Review the client's chart.
Perform an emergency assessment. Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 4
During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client? physical environmental social well-being developmental level
environmental Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 2,3
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 Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 2,4
A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next? Cluster client cues. Evaluate outcome. Identify client concerns. Implement an intervention.
Evaluate outcome. Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 2
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment? To determine any changes from the baseline data To collect subjective data related to the client's overall health To perform a rapid assessment for prompt treatment To evaluate whether outcomes of treatment are met
To determine any changes from the baseline data Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 4
An 80-year-old bed-bound client is admitted with altered mental status. The comprehensive nursing assessment reveals the following: ● bruising at different stages of healing ● decreased Body Mass Index indicating malnutrition ● stage 3 pressure ulcer on the coccyx ● cloudy urine with large amounts of bacteria The nurse considers priorities based on the data. Which of the following should be a priority concern for this client? suspected abuse nutritional deficiency impaired skin integrity urinary tract infection
suspected abuse Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 9
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 Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 4
The nurse is assigned the following clients. Which client requires an emergency assessment? the client who underwent a hysterectomy yesterday and is now reporting shortness of breath and has decreased oxygen saturations the client admitted with small bowel obstruction who underwent surgery this morning and is now reporting incisional pain 7 out of 10 the client admitted with a fractured arm who reports some numbness and tingling in the fingers the client admitted with chest pain yesterday who now denies pain after nitroglycerin administration
the client who underwent a hysterectomy yesterday and is now reporting shortness of breath and has decreased oxygen saturations Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 4
A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides? Data on the client's prognosis for recovery Information on the effectiveness of interventions A baseline for comparison with future findings Information on the nurse's cultural competence
A baseline for comparison with future findings Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 3
A new order for an antibiotic is received for a client. The nurse reviews the client's electronic medical record. The record states the client has no known allergies. What action should the nurse take? Administer the medication. Ask the client if they have allergies. Double-check in the admission notes for allergies. Hold the medication.
Ask the client if they have allergies. Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 5
A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse? Assess the nasogastric tube for proper functioning. Intervene by pulling out the nasogastric tube. Evaluate output in an hour. Develop a plan of care.
Assess the nasogastric tube for proper functioning Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 9
A client has been admitted with new onset hypertension with a past medical history of asthma, type 2 diabetes, and hypercholesterolemia. After developing a nursing care plan, the nurse reports findings to the health care provider. After receiving medication orders from the health care provider, the nurse administers several medications for hypertension. What is the next best action of the nurse? Update the plan of care. Evaluate patient outcome. Develop a nursing diagnosis. Perform a comprehensive assessment.
Evaluate patient outcome. Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 2,3
A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment? "The client has been ordered a nutritional consult; I do the health assessment right after that is finished." "I'll do the health assessment when the client's family leaves so that distractions will be minimal." "I'm going to assess the client now so that I can begin formulating the care plan." "The health assessment will be more thorough if I wait until the client is pain free."
"I'm going to assess the client now so that I can begin formulating the care plan." Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 2
The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next? Leave the inhalers with the client to self-administer. Validate that the client understands how to use the inhalers. Ask the client if they need any assistance with the inhalers. Provide privacy for the client to administer the inhalers.
Validate that the client understands how to use the inhalers. Chapter 1: Analyzing Data to Make Accurate Clinical Judgments - Page 6
