Chapter 14: assessing

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? Subjective Objective Primary Secondary

objective

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply. Respect for client Competence Professionalism Number of years in profession Caring

-Respect for client -competence -professionalism -caring

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.'" "Client makes statements indicating a loss of hope." "Client states that rehabilitation will be unsuccessful." "Client is demonstrating signs and symptoms of depression."

"Client states, 'I don't see the point in trying anymore.'"

A nurse is asking questions about a client's sexual history. Which is the best question for the nurse to ask to determine the client's use of safer sexual practices? "How many sexual partners have you had in the past 6 months?" "Do you use condoms?" "How do you protect yourself when having sex?" "Are you in a committed relationship?"

"How do you protect yourself when having sex?" Explanation: open-ended question

The nurse auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding? "We need to validate the information obtained in this assessment." "Crackles indicate that your child may have an allergy." "We will share this assessment finding with the physical therapist." "This is a normal finding and nothing of concern."

"We need to validate the information obtained in this assessment." explanation: The assessment of a toddler should involve the parents, as they are the primary caretakers and most knowledgeable about their toddler's normal behavior and development, as well as the history of any presenting symptoms.

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

-A client describes pain as an 8 on the pain assessment scale. -A client feels nauseated after eating breakfast. -A client reports being cold and requests an extra blanket.

Which scenario is an example of a time-lapse reassessment? -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. -A nurse just coming on shift performs a focused physical assessment on each client, based on the client's diagnosis. -A nurse in a long-term skilled nursing facility assesses a new resident's baseline health status. -A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.

-A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before. Explanation: 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

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 stands at the foot of the bed. -If both the nurse and client are seated, their chairs are at right angles to each other, 30 cm apart. -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 stands at the side of the bed.

-If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

When is the best time for a nurse to take a client's health history? After the client is settled and feels ready As soon as possible after a client presents for care Within 24 hours of admission Anytime before the client is discharged

As soon as possible after a client presents for care Explanation: waiting till a client feels ready may be too late. 24 hours is also too long.

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

Collection, validation, communication of client data

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview? Focus mainly on verbal comments. Fill in the words for the client. Avoid the impulse to interrupt. Fill in quiet spaces and pauses.

Avoid the impulse to interrupt

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? During the collection of data only At the end of the data-gathering process In the middle of the data-gathering process Both during the collection and at the end of the collection

Both during the collection and at the end of the collection

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client? -Explain the nurse will need to touch the client during the assessment -Ask if the client would like the door opened or closed when finished -Point out potential nursing care plan goals while assessing -Concentrate on a focused assessment of the abdomen and leave the rest of the assessment for a later time

Explain the nurse will need to touch the client during the assessment.

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 Functional Health Patterns Human Response Patterns Body Systems Model

Hierarchy of human needs

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? Subjective Objective Physical Unreliable

Objective

Which nursing skill uses all five senses? Documentation Observation Listening Caring

Observation

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case? Obtaining data regarding the amount and frequency of drinking Interviewing friends to ascertain the client's exercise habits Asking the client to discuss social functioning Performing an abdominal assessment

Obtaining data regarding the amount and frequency of drinking

What is an advantage of using the functional health patterns model for assessment? The nurse can identify client strengths and assets. The nurse can systematically examine every part of the body. The nurse can focus on the client's major anatomic systems. The nurse can collect data about the past and present condition of each organ or body system.

The nurse can identify client strengths and weaknesses. explanation: In the functional health patterns model, the client's strengths, talents, and functional health patterns are an integral part of the assessment data. This framework identifies strengths as well as deficits.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver? The nurse leaves the room when a client is crying to provide privacy. The nurse uses open-ended questions when working with a crying client. The nurse documents the client was crying at the end of the shift. The nurse calls the hospital chaplain to talk with the client.

The nurse uses open-ended questions when working with a crying client. Explanation: By asking open-ended questions the nurse can gain more information as to why the client is crying

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being: purposeful. factual. complete. able to prioritize.

able to prioritize

The nurse is caring for a 14-year-old client who has just gave birth. The client reports living with an aunt and having no other family around. The birth was uncomplicated, and the newborn is healthy. Which is the primary nursing concern the nurse will identify for this client's care planning? loneliness risk acute pain altered parenting risk ineffective breastfeeding ineffective feeding pattern in the newborn

altered parenting risk Explanation: A 14-year-old parent with little family support is at risk for difficulties with the expanded role of parent

The nurse on the night shift is caring for a hospitalized client who reports being unable to sleep. The client states, "I just cannot sleep here. I miss my home. There are too many lights and it is too hot." Which nursing concern does the nurse identify? social isolation powerlessness chronic pain altered sleep pattern hyperthermia

altered sleep pattern *If they don't say it, then don't focus on it

The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to: examine certain body systems. complete an exam of all body systems. perform a review of the problem areas. focus on only the systems that the client is comfortable with.

complete an exam of all body systems

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should: review literature pertinent to the client's attributes. assess personal feelings regarding similar clinical situations. inform the client of the maintenance of confidentiality. implement supportive nursing interventions.

inform the client of the maintenance of confidentiality.

What should the nurse do prior to performing an initial assessment on a newly admitted client? Introduce the members of the health care team to the client. Review the records available on the client. Report to the charge nurse what needs to be done for the client. Tell the client that the nurse will do an assessment only if it's convenient.

review the records available on the client

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? Physiologic Safety and security Love and belonging Self-esteem Self-actualization

safety and security

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? Primary Secondary Tertiary Quaternary

secondary explanation: 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 tertiary or quaternary sources of assessment data.

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is: the focus assessment done when admitted to the ER. the initial comprehensive client assessment. the health record from a previous admission. the client record from the health care provider's office.

the initial comprehensive client assessment

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 health care provider The nurse The case manager The nursing supervisor

the nurse

A nurse practitioner in private practice with a health care provider 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? Complete Focused Time-lapse Emergency

time-lapse

The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment? Emergency assessment Patient centered assessment method (PCAM) Time-lapsed assessment Initial assessment

time-lapsed assessment

What is the purpose of obtaining a nursing history? -to assist the health care provider to establish a medical diagnosis -to minimize the time required to establish a nursing concern for care planning -to focus on objective physical data specific to the client -to identify actual and potential health problems

to identify actual and potential problems Explanation: The purpose of the nursing health history is to identify the client's strengths and weaknesses; health risks, such as hereditary and environmental factors; and potential and existing health problems

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

toddler

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: agrees with each of the client's statements. attempts to write down everything the client says. uses broad, open statements to communicate with the client. reassures the client of good outcomes.

uses broad, open statements to communicate with the client