Chapter 14 Assessment THE POINT

A nurse is performing an assessment on a client. Which should the nurse record as subjective data? Select all that apply.

"My leg hurts when I move." "I am so afraid of what my diagnosis is." "I am always anxious." Explanation: Subjective data are information perceived by only the affected person, usually expressed as feelings or comments by the client. The client's thoughts or statements can be documented in the record using quotations. Objective data, such vital signs or height and weight, are those that are observable and measurable by the nurse.

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques?

"When did you first notice the rash on your leg?" Explanation: An example of appropriate communication is the statement, "When did you first notice the rash on your leg?" This is an example of a direct question that can be asked to validate information or clarify information. The other sentences demonstrate poor communication techniques. The nurse should avoid cliches, questions that require a "yes" or "no" answer, intimidating "why" and "how" questions, probing questions, and using judgmental comments.

Which assessment data cue does the nurse recognize as subjective data?

A pain rating of 7 Explanation: Subjective data are information perceived only by the affected person. Only the person experiencing pain can assign a rating to it. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Lung sounds, pupil size and reactivity to light, and the presence of edema are all examples of objective data.

What must the nurse do to identify actual or potential health problems?

Gather data from sources Explanation: The nursing process includes: assessment, diagnosis, planning, implementation, and evaluation. The first phase, assessment, is the collection of data to identify actual or potential health problems for nursing interventions. Aside from evaluation, which is the final phase of the nursing process and involves assessing the client's progress toward meeting goals established in the plan of care, the remaining two options are not related to the specific activities in the nursing assessment process.

The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

Inspection Explanation: When the nurse performs a physical assessment, four techniques: inspection, palpation, percussion, and auscultation will be used. In most cases the nurse will perform them in sequence. Because palpation and percussion can alter bowel sounds, the nurse will inspect, auscultate, percuss, then palpate an abdomen.

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?

functional assessment Explanation: The nurse is performing a functional assessment that focuses on areas that relate to the physical performance of activities, such as how the client is able to meet activities of daily living, demonstration of cognitive abilities, and social functioning. A comprehensive assessment encompasses all of the assessment data for the client. The focused assessment relies on one area of functioning such as the respiratory system if a client is having an asthma attack. The database assessment is performed during the initial history and physical portion of the client's illness and represents a comprehensive and all inclusive initial collection of data.

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client?

Risk for Impaired Parenting Explanation: A 14-year-old parent with little family support is at risk for difficulties with the expanded role of parent. The client has not stated feeling loneliness or pain. The infant's feedings are not discussed in the scenario.

At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

Objective Explanation: Measurable and observable urine output is an example of objective data. Objective data are also called signs or overt data. Subjective data are information perceived only by the affected person. Subjective data are also called symptoms or covert data.

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.'" Explanation: Subjective data should be recorded using the client's own words, using quotation marks as appropriate. Paraphrasing the client's words may lead to assumptions and misrepresentations.

A nurse manager identifies a need for further instruction when a new nurse makes which statement?

"The client is always the best source for collecting data." Explanation: "The client is always the best source for collecting data" is a statement that requires additional instruction by the charge nurse. Although the client is usually the best source for information when collecting data during an assessment, a family member, friend, or caregiver can be especially helpful sources of data when the client is a child or has a limited cognitive capacity.

The night shift nurse is caring for a hospitalized client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client?

Disturbed sleep pattern Explanation: The client has problems sleeping due to the unfamiliar environment. Although hospitalized, the client doesn't report isolation, powerlessness, or chronic pain.

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

Focused Explanation: The nurse conducts a focused assessment of the client with a specific identified problem. An initial assessment is conducted by the nurse to establish a baseline database and identify current health problems. The nurse performs an emergency assessment during a crisis to identify life-threatening problems. A time-lapse assessment is one in which the nurse reassesses a client to evaluate the client's progress since a previous assessment for the same condition.

Which statement by a nurse best indicates an accurate understanding of the different types of assessments?

"The purpose for the assessment offers guidance for which type and how much data to collect." Explanation: The purpose for which the assessment is being performed offers the best guidance for what type and how much data to collect. The type of nursing assessment the nurse should conducted should not depend on (a) the nurse's preference, (b) how much time the nurse has, or (c) what the physician wants. It is important to take into account how the client is feeling when preparing to assess, but the client's feelings should not dictate which assessments the nurse performs.

A 57-year-old client presents to the clinic with a report of abdominal pain. The client underwent a sigmoid colostomy 3 months ago for colon cancer. The client's recovery had been uneventful until 1 week ago. Which sign(s) or symptom(s) should the nurse prioritize in the assessment? Select all that apply.

Absence of bowel sounds Tenderness around ostomy Redness at ostomy stie Explanation: The absence of bowel sounds, tenderness and redness around the ostomy site are all red flags that there is a problem related to the previous surgery which needs to be evaluated and treated. The nurse would conduct a focused assessment to determine what needs to be addressed first and provide the best care for the client. The semisoft fecal material in the bag is an expected finding. A negative reading on the fecal occult testing would indicate there is no bleeding in the colon.

Which is the purpose of a focused assessment?

Adds depth to existing information Explanation: A focused assessment adds depth to existing information or the initial database gathered by the nurse. A database assessment provides breadth for future comparisons. A focused assessment does not suggest possible problems facing the client but rather rules out or confirms the client's problems. A focused assessment is not voluminous and comprehensive, like a database assessment, but limited and to the point.

A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrointestinal symptoms or should be reported to the physician. Which action should the nurse perform next?

Explanation: A nurse who is unsure of the significance of a particular finding should consult with another nurse. In some instances, years of experience are needed to distinguish significant from insignificant findings. Calling the family is not appropriate at this point as there is no information to report to them. Charting the information is important after the consultation with another nurse. Waiting to see whether the pain subsides is not appropriate; a timely assessment is needed for this client.

A nurse is completing the assessment of an 85-year-old client who is being admitted to a memory care home for progressing dementia. The client is unable to answer some of the questions or provide some of essential information that the nurse needs to create the best nursing care plan for this client. Which source will be the best for the nurse to consult to gain this missing information?

Family member Explanation: The nurse should consult with family members or significant others to gain this information. The best contact will be the individual who has been caring for the client most recently. Past medical records, social media, and neighbors will be limited in information about the client and most likely will be unable to provide the most accurate information.

Which piece of client information is subjective?

Generalized myalgia or muscle pain Explanation: 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.

Which are assessment techniques the nurse uses when performing a physical examination? Select all that apply.

Inspection Palpation Percussion Auscultation Explanation: Four methods are used to collect data during the physical assessment: inspection, palpation, percussion, and auscultation. Documentation is done at the end, but it is not a method used for assessment.

When assessing the firmness of a client's abdomen, the nurse should use which assessment technique?

Palpation Explanation: Physical assessment skills of the nurse include auscultation, percussion, inspection, and palpation. Palpation is the use of touch to assess a client. It would be appropriate for assessing the firmness of the client's abdomen. None of the other assessment skills would allow the nurse to assess the firmness of the client's abdomen. Inspection is the use of visual observation to assess a client. Percussion is the use of striking with the fingers against the client's body to assess a client. Auscultation is the use of a stethoscope to assess body sounds within the client, such as heart and lung sounds.

The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source?

The client tells the nurse that there is a burning sensation when voiding. Explanation: Subjective data consist of information that only the client can describe, such as feelings, sensations, or experiences. An example of subjective data is a client's report of pain or fatigue. Objective data are those that can be measured and observed by others, a fever or a broken bone. The primary source is the client. Secondary sources include family members, reports, test results, and other health care providers.

Which is the primary reason for a nurse collecting data continuously on a client?

The client's health status can change quickly. Explanation: Data about the client is collected continuously because the client's health status can change quickly. It is not done as busy work nor is it to make the client feel good. Reimbursement is related to having certain assessments done, but is not based on continuous assessments of the client's condition.

Which traits of the nurse are most important for an assessment to be successful?

Trustworthy and confident Explanation: Successful assessments begin with the nurse gaining the client's trust and exhibiting confidence. Although enthusiasm can be helpful and competence is essential, being aggressive and forceful will turn the client off and will come off as too domineering. A low-key and timid nurse may not exemplify client advocacy characteristics, which are essential in the nurse-client relationship.

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse:

uses broad, open statements to communicate with the client. Explanation: The nurse should use broad, open statements to facilitate communication during an interview. Using close-ended questions, which prompt yes or no answers, should be avoided, as it does not provide the level of the detail the nurse is seeking. The nurse should pay full attention to the client; paying too much attention to note-taking or making computer entries will interfere with good communication. The nurse should avoid providing false reassurance and agreeing with every statement the client makes.

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?

Assess the client's blood pressure. Explanation: The priority intervention for the client with an unstable blood pressure is to first measure the blood pressure. Once the nurse is certain that this is within safe parameters, the nurse should assess the client's diet, activity level, and medication regimen.

Which client situation most likely warrants a time-lapse nursing assessment?

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. Explanation: A time-lapse assessment is often indicated in the care of a stable client whose current status is being compared to earlier baseline data. Shortness of breath and chest pain necessitate an emergency assessment, while a new admission to a unit or institution requires an initial assessment. Following up a known health problem most often requires a focused assessment.

Which are examples of subjective data? Select all that apply.

Anxiety Light-headedness Nausea Explanation: Subjective data are those that only the person experiencing them can perceive and report, such as anxiety, light-headedness, and nausea. Objective data are those that someone other than the person experiencing them can observe, such as edema and laceration.

The nurse delegates vital signs to be taken and recorded by the unlicensed assistive personnel (UAP). The UAP reports a blood pressure of 230/120 mm Hg on a client. Which is the nurse's priority action?

Assess the client and re-evaluate the vital signs. Explanation: The nurse is responsible for all delegated tasks. When the blood pressure is grossly elevated, the nurse should assess the client, re-evaluate the blood pressure, and notify the health care provider if findings are abnormal. The nurse should re-evaluate the blood pressure, not the UAP. The nurse should assess and re-evaluate the blood pressure before notifying the health care provider. The nurse's priority is to assess the client and provide interventions accordingly, not to notify the supervisor.

The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "No." What is the best thing for the nurse to do next?

Validate the data. Explanation: Data need to be validated when there are discrepancies (e.g., the client says there is no pain but the nonverbal behavior indicates that the client is experiencing pain). The nurse should not ignore the client's answer or the client's nonverbal behavior. The nurse should chart the assessment, but the priority is to validate the differences in the verbal communication and nonverbal behavior.

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being:

able to prioritize. Explanation: It is essential to get the most important information first when doing an assessment. This is prioritizing. Being purposeful is when a nurse completes a task that has meaning for the client. Complete means that the information obtained is comprehensive. Factual is concerned with what is actually the case rather than interpretations of or reactions to a situation (for example, a diagnosis as opposed to a hunch).

Which scenario is an example of a time-lapse reassessment?

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

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. Explanation: The nurse should make every effort to make the client comfortable prior to interviewing, including obtaining an prescription for and administering pain medication; if the pain persists, obtain only vital data and defer the remainder of the interview until the client is more comfortable. The information on the electronic health record is not inclusive of the subjective data from the client. The client is not refusing the interview, and the nurse can always come back later to complete it.

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?

Auscultate the chest for breath sounds. Explanation: Levels of responsibilities using the nursing process include assessing, diagnosing, planning, implementing and evaluating. The assessment phase of the nursing process includes gathering data by interviewing, observing, and performing a basic physical examination of people with common health problems with predictable outcomes. In this case, the nurse will gather data from the respiratory assessment by auscultating the lung sounds and observing the client's work of breathing. Identifying and documenting a client problem or diagnosis falls within the diagnosing phase of the nursing assessment. The nurse is in the planning phase of the nursing process when collaborating with the client to develop goals for care. For example, for this client, the nurse may establish the goal of improved oxygenation with decreased work of breathing. Applying oxygen is a nursing intervention and this falls within the implementation phase of the nursing process. This is the aspect of the process where the nurse actively carries out the actions that need to be taken to meet the client care goals.

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview?

Avoid the impulse to interrupt. Explanation: When doing an interview with a client, the nurse must listen actively for feelings, in addition to the verbal comments made by the client. The nurse should demonstrate patience if the client has a memory block and should avoid the impulse to fill in words or interrupt the client. Pauses in the conversation should be allowed, as silence gives both parties time to gather thoughts.

A parent arrives to the pediatric clinic with a 3-year-old child who is crying and tells the nurse the right ear hurts. Which assessment finding(s) should the nurse prioritize for further assessment? Select all that apply.

Child pulling at right ear Right external ear canal red Right ear tender to touch Explanation: A focused assessment will concentrate on the signs and symptoms of a possible ear infection, based on the initial presentation of the child. This will include the child pulling at the ear, red ear canal, and tenderness to touch the right ear. The temperature is slightly elevated but still within normal range. The child clinging to the parent is an indication the child may not be feeling well but does not specify what the specific problem is.

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

Collection, validation, communication of client data Explanation: 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.

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 Caring Explanation: The nurse's interpersonal competence is critical beginning with the very first assessment. The client's initial impression is crucial. The nurse's competence, professionalism, and interpersonal qualities of caring and respect invite confidence and assure the client that help is available. The length of time as a nurse does not influence competence and professionalism.

What should the nurse do prior to performing an initial assessment on a newly admitted client?

Review the records available on the client. Explanation: Records prepared by different members of the health care team provide information essential to comprehensive nursing care. The nurse should review records early when gathering data before the first contact with the client. This review helps to focus the nursing assessment and to confirm and amplify information obtained already. The other actions are not appropriate prior to performing an assessment. An assessment must be done whether it is convenient or not, for the appropriate care to be given.

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?

Time-lapsed assessment Explanation: A time-lapsed assessment is scheduled to compare a client's current status to the baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time are scheduled for this type of check. An emergency assessment is conducted if the client is having an emergency such as chest pain or hemorrhaging from the hand. Focused assessment is performed on clients focusing on the system or systems involved in the client's problem. Developmental stage assessment is the process of mapping a child's performance compared with children of similar age.

A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client?

A focused assessment of the specific problems identified Explanation: The priority assessment at this time is a focused assessment of the client's primary concern. A focused assessment may be performed during the initial assessment if the client's health problem is apparent. A full assessment of the urinary system may be appropriate but is not the priority. A detailed assessment of the client's sexual history is not warranted, and although a thorough systems review is conducted, it is not the priority at this time.

Which statement is true regarding addressing a priority problem?

A priority problem requires a nursing intervention before another problem is addressed. Explanation: A priority problem requires a nursing intervention before another problem is addressed, but addressing priority problems does not entail skipping any interventions. The priority of problems can change as a client's condition changes. There are no predetermined times or intervals at which to identify priority problems. This is why critical thinking plays a central role in nursing.

Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training?

All data collected need to be validated. Explanation: Validation is the act of confirming or verifying. The purpose of validation is to keep data as free from error as possible. It is an important part of assessment. However, it is neither possible nor necessary to validate all data; nurses should decide which items need verification.

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care Explanation: The nursing health history captures and records the uniqueness of the client and should be obtained as soon as possible after a client presents to the health care facility for care. If the nurse waits until the client is ready, this may occur too late and the problem may become more problematic. Twenty-four hours is also too long. Waiting until the client is discharged is inappropriate because important medical as well as psychological information may be missed or not communicated.

A nurse is interviewing a new client admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview?

The nurse assesses the client's comfort and ability to participate in the interview. Explanation: During the introductory phase of the interview, the nurse determines if the client is going to be able to participate in the interview. The highlighting of important points occurs in the termination phase of the interview. Ensuring the environment is comfortable and private occurs during the preparatory phase, and the gathering of information occurs during the working phase. Asking the client if any other information needs to be divulged occurs in the termination phase.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver?

The nurse uses open-ended questions when working with a crying client. Explanation: Any nurse who wishes to be an effective caregiver must first learn how to be an effective communicator. Good communication skills enable nurses to get to know their clients and, ultimately, to diagnose and to meet their needs for nursing care. By asking open-ended questions the nurse can gain more information as to why the client is crying. Without understanding the "why" behind the crying the nurse cannot determine if the hospital chaplain might be needed. Providing privacy for the client can be thoughtful but not a way to learn more.

The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side." This statement is an example of:

a cue. Explanation: Cues and inferences describe the early analysis of data. "The client does not respond when I speak while standing on the client's right side," is a cue that something may be wrong. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. A nurse can observe a cue directly but not an inference. The information in this case is based on the nurse's direct observation, not interpretation or inference, and thus cannot be a misinterpretation. There is no evidence that the nurse's observation duplicates other data collected.

While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, "The client's hearing may be impaired on the right side." This statement is an example of:

an inference. Explanation: The judgment a nurse makes about a cue is known as an inference. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. The nurse can observe a cue directly, but not an inference. The key is the verb used —"hearing may be impaired." The statement is not erroneous or duplicate data.

During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to:

body systems. Explanation: The categorization of assessment findings according to systems (in this case, musculoskeletal, gastrointestinal, and respiratory) is characteristic of a body systems model for organizing data. Although systematic, this strategy tends to ignore spiritual and psychosocial considerations. Human needs are based on food, water, and shelter. Human response patterns involve the subjective awareness of information. The functional health patterns model is used to provide a more comprehensive nursing assessment of the patient focusing on sleep, roles, exercise, relationships, etc.

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

Laboratory test results Breath sounds on auscultation A client's temperature Explanation: Objective data are those that the nurse can gathered from observation (e.g., posture, skin color, behavior), health records (e.g., laboratory test results, reports from other health care team members), and physical assessment (e.g., breath sounds, strength of extremities, blood pressure, temperature). Subjective data are those that only the person experiencing them can perceive and report, such as pain and a feeling of being unable to breathe.

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview?

"Is there anything else we should know in order to care for you better?" Explanation: A helpful strategy in the termination phase of an interview is to ask the client: "Is there anything else you would like us to know that will help us plan your care?" This gives the client an opportunity to add data the nurse did not think to include. Expectations and previous practices should be addressed during the working phase of an interview.

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 do you protect yourself when having sex?" Explanation: An open-ended question is the best type to use to gather the most information. Asking how the client uses protection during sex will obtain information about safer sex practices. Asking how many sexual partners the client has had or if the client is in a committed relationship will not help to ascertain the information. Asking, "Do you use condoms" is a closed-ended, yes or no question that will not provide comprehensive information.

Which nursing skill uses all five senses?

Observation Explanation: Observation is the conscious and deliberate use of the five senses (sight, smell, hearing, taste, and touch) to gather data. Documentation uses sight (seeing the client's chart) and touch (typing on a keyboard or writing with a pen). Listening involves just hearing what the client is saying. Caring need not involve any of the senses but is displaying kindness and concern for others.

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

review as much information as possible. Explanation: The preparatory or preinteraction phase occurs when the nurse meets the client. The nurse should review as much information as possible about the client during this phase. It would be premature for the nurse to attempt to clarify the client's health status, identify nursing diagnoses, or develop a nursing care plan without having completed the client interview, nursing history, and nursing assessment, all of which happen later in the assessment process.

The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate?

"I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes." Explanation: Nurses are responsible for completing nursing histories, and it usually takes approximately 30 to 60 minutes to obtain data such as history of present illness, past medical history, support network, and other pertinent data. The physical assessment is performed separately. Family members can offer valuable information, as long as the client gives permission for them to remain present during the history taking.

Which is an example of objective data?

The skin of a client who has liver failure has a yellowish tint. Explanation: 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. Reports of nausea, feeling very anxious, and dizziness are subjective data. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person.

The nurse is conducting a health history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?

Continue the health history with questions focusing on respiratory function. Explanation: First, the nurse needs to validate the data with the client, who is the primary source. The nurse can validate data with the health care provider but consulting with the client is the best option. The client must give permission for family members to participate in the health history. Ultimately, the nurse documents all assessment data, both from the history and the physical exam. It is appropriate to note inconsistencies between objective and subjective data.

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is most likely the cause of this action by the client?

Explanation: Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief. Sleepiness would be observed if the client did not respond in a timely manner. A client with low anxiety is relaxed and would answer the question with intention and thoughtfulness. A hungry client would be short-tempered and angry.

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 Explanation: Maslow uses a hierarchy of five sets of human needs to organize data with basic physiological needs, such as the need for oxygen, being the most urgent. Gordon's (1994) framework identifies 11 functional health patterns and organizes client data into these patterns. The human response patterns organize data according to human responses to interventions. A medical model used to organize data collection, with which all nurses are familiar, is the body systems model. This method organizes data collection according to organ and tissue function in various body systems

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. Explanation: Tympanic membrane thermometers are noninvasive and fast to use, but studies show discrepancies between their readings and those of oral thermometers, resulting in both false-positive and false-negative readings. The nurse can minimize these discrepancies by using the same ear and device for measurement each time and by using proper technique. The other actions listed would be appropriate for the nurse to take after rechecking the infant's temperature and confirming that it actually is lower than normal.

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?

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 purpose of obtaining a nursing history is to:

identify actual and potential health problems. Explanation: The purpose of the nursing health history is to identify the patient's strengths and weaknesses; health risks, such as hereditary and environmental factors; and potential and existing health problems. This interview does not typically include physical assessment of a client. As part of the nursing assessment and overall nursing process, its purpose is not to influence time within the process. The physician's medical work-up provides the data to develop the medical diagnoses.

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

inform the client of the maintenance of confidentiality. Explanation: During the introductory phase, the nurse should inform the client how the information will be used and that confidentiality will be maintained. The alternate responses are not associated with the interview process and experience for the client.

For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

Initial Explanation: The Joint Commission has mandated that each client have a documented nursing admission (initial) assessment that follows institutional policies. An initial assessment is comprehensive and covers both a client's physical and psychosocial health. A focused assessment is one that addresses one specific problem that has already been identified; this type of assessment is not mandated by the Joint Commission.

Which is the best source of information for the nurse when collecting data for an assessment?

Client Explanation: The client is the primary, and usually best, source of information when doing an assessment. The medical record may also provide information, but only if the client has been at the health care facility before; even then, the client is likely to have more current information than the medical record. Although the charge nurse is responsible for the care of all clients on the unit, the charge nurse is not likely to know the details of any one client's information. The primary physician would provide medical care based on the medical assessment and would not have more information than the client about the client's current health status.

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply.

Client states, "I feel so sad all of the time." Client states, "I am in pain." Explanation: Subjective data are statements by the client. Objective data are observations made by the nurse when gathering data such as vital signs and physical signs.

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 sits in a chair placed at a 45-degree angle to the bed. Explanation: If the client is in bed, the nurse sitting in a chair placed at a 45-degree angle to the bed ensures the nurse is sitting at eye-level with the client, which promotes communication. If the nurse is standing at the foot or at the side of the client's bed, an authoritative position is established, which does not promote good communication. If both the nurse and the client are seated, being 30 cm apart intrudes upon personal space; ideally the nurse and client should be about 1 m apart.

The nurse is assessing a client in an outpatient setting. The client states, "I don't want to live anymore. My family hates me, and I am so tired of being sick. I have a gun, and I am seriously thinking of killing myself." The client reports a 30-year heavy smoking habit and having a cough for about 6 months. Auscultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminished bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing diagnosis for this client?

Risk for Suicide Explanation: The client who talks of suicide and has a plan to implement it should be taken seriously, making this the priority diagnosis. The other choices are important but could be addressed after making interventions for suicide prevention.

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 Explanation: When the client responds to a question, the nurse conveys interest by maintaining eye contact, occasionally nodding, or verbally responding to the client's remarks. This is best accomplished by selecting a seat at eye level to allow direct engagement with the client during the interview. Standing during the interview can limit the interaction between nurse and client. Questions should be open-ended to elicit the most information and engage the client. Yes or no (close-ended) questions do not encourage the client to provide the level of detail the nurse is attempting to collect.

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 nurse Explanation: The question focuses on independent actions that nurses can perform. Interventions for which the nurse may be legally responsible include increasing the frequency of assessments and initiating necessary changes in the treatment regimen. Nurses are responsible for alerting the appropriate professional (e.g., the physician) whenever assessment data differs significantly from the baseline. The nursing supervisor would be alerted if the professional does not evaluate the client. The case manager would be alerted when the client was ready for discharge.

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?

The nursing and medical literature Explanation: 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.

The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next?

Notify the physician of the change and document the finding. Explanation: When a pulse deficit is present, the radial pulse rate is always lower than the apical pulse rate. The nurse should document and report to the physician any new finding of a pulse deficit immediately so that evaluation and follow-up can occur. The nurse should not wait until after rechecking the pulse to document the finding or report it to the physician.

Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist?

Consultation Explanation: The client's physician may invite a specialist to assess and treat the client. The focus of this part of the record is additional findings related to the client's medical diagnosis and treatment; it is found in the section called "Consultation." Laboratory reports are related to the laboratory values of the client. Progress notes are the part of a medical record where health care professionals describe details to document a client's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. The medical history or case history of a client is information gained by a physician by asking specific questions, either of the client or of other people who know the person and can give suitable information.

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?

Objective Explanation: 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.

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?

Objective Explanation: Reports of laboratory studies and other diagnostic tests are considered objective data, which can either confirm or refute other data collected during the nursing exam and history. Subjective data are about a client's feeling or what the client states. Primary data are collected by an investigator conducting research. Common sources of secondary data for social science include censuses, information collected by government departments, organizational records, and data that were originally collected for other research purposes.

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?

Focused Explanation: 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.

A 33-year-old client is brought to the urgent care center, doubled over in pain and crying. Upon assessment, the client admits to nausea and vomiting ×3 during the morning. Which action should the nurse prioritize after noting right lower quadrant (RLQ) rebound tenderness, blood pressure of 130/92 mm Hg, and pulse 100 beats/min and weak?

Notify the health care provider immediately Explanation: The client needs immediate attention and care due to the possibility of having appendicitis. The nurse would complete an emergency assessment and follow the policies of the facility to ensure proper care. It would be inappropriate to have the client wait 30 minutes to see if there is any improvement in the signs or symptoms. It would be improper to start an IV without the health care provider's prescription. The health care provider would need to evaluate the client and make the diagnosis because this action is outside the scope of practice for the nurse.

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 Explanation: A focused assessment is information that provides more details about specific problems and expands the original database. Obtaining data regarding the amount and frequency of drinking qualifies as a focused assessment. The other actions do not relate to the client's drinking habits or potential for alcohol overuse and thus would not be included in a focused assessment of these issues.

A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client?

Focused Explanation: In a focused assessment, the nurse gathers information about a specific problem that has already been identified. A head-to-toe assessment is an initial, complete assessment, typically to assess for any problems that have not been identified yet. An emergency assessment is used to identify a life-threatening problem. A time-lapse reassessment is scheduled to compare current status with the baseline obtained earlier.

A family presents to the emergency room with a 4-year-old child who is crying and reporting that the skin on the legs are itching and hurting. The parent explains that they were out walking in the woods when the child went running off the path and into some tall weeds. Which finding(s)s should the nurse prioritize in this assessment? Select all that apply.

Stating "My legs feel like they are burning" Redness and blisters forming on both legs Crying and trying to scratch legs due to itching Explanation: This client needs an emergency assessment to ensure the child did not encounter any poisonous vegetation such as poison ivy. Reports of burning, redness, blisters, and itching all indicate a possible reaction to poisonous foliage and require immediate attention and care. The other findings will be assessed after the emergent situation is stabilized.

The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment?

Supplement the client's information by speaking with family or friends. Explanation: Family and friends can be an invaluable source of assessment data, especially in the care of clients who have cognitive deficits. It would be inappropriate to limit an assessment to solely objective data. Using previous medical records and breaking up the assessment are appropriate measures, but they do not supersede the importance of using family and friends as data sources

A nurse practitioner in private practice with a physician 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?

Time-lapse Explanation: The four types of nursing assessment include complete, focused, time-lapse, and emergency. In time-lapse assessments, the nurse reassesses a client and condition that is already known to re-evaluate the client's status. In this case the nurse is revisiting the client's feelings and plans to change her life situation by leaving her abusive husband. In emergency assessments, the nurse assesses the client for life-threatening problems which are acutely present.. In focused assessments, the nurse focuses on assessing a specific problem that is already known to exist to further refine planning interventions. In complete (general or initial) assessments, the nurse does a thorough assessment of all aspects of a client's health status on the client's admission to a health care facility.

When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind?

Validate inferences with the client. Explanation: The nurse should validate inferences made from assessment data to ensure accuracy. Incorrect cues and inferences lead to the development of inappropriate nursing diagnoses and client plans of care. Making inferences can be helpful as long as the nurse validates them. It is not necessary to document inferences. Often, the nurse must share inferences with the client to validate them.

What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall?

Assess blood pressure with a large cuff. Explanation: When assessing an obese client, a larger blood pressure cuff will likely be needed to prevent false high readings. It is not in the nurse's scope of practice to determine when and if cholesterol levels and an electrocardiogram are ordered. Diet education may or may not be warranted depending on the cause of the obesity.

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?

Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions. Explanation: 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.

Which action would the nurse perform in the assessment phase of the nursing process?

Asking the client whether the client has cultural preferences Explanation: Assessing the client involves gathering information about the client's physical and emotional health; cognition; spiritual, cultural, or religious preferences; and sociodemographics. Developing a plan to manage the client's health problems falls within the planning phase of the nursing process. Coming up with the nursing diagnosis falls within the diagnosing phase of the nursing process. Determining whether the client's goals for wellness have been met occurs in the evaluation phase of the nursing process.

The nurse is collecting data from a client during a complete assessment. Which skill is the nurse demonstrating when documenting the assessment data?

Communication Explanation: The client data collected are of no benefit to the client unless they are appropriately communicated. Appropriate communication involves correct timing and proper documentation. Clustering data is identifying data that are relevant to a specific system. Validation of data is having a sound basis in logic or fact, or the nurse making sure the information collected is correct. Collection of data occurs during the beginning of the client assessment.

During admission, a teenage client who has a diagnosis of anorexia informs the nurse of a 5-pound weight loss within the last 6 months. What should the nurse do with this data?

Validate the weight loss with the client. Explanation: When a client reports data that appear to be distorted, either intentionally or unintentionally, the nurse—to ensure accuracy—needs to continually verify and validate all data. It would not be appropriate to tell the client the data are not correct or to ignore the data, as doing either could undermine the client's trust in the nurse and/or cause conflict with the client. The nurse should not just document this information, as it needs to be validated.

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 nurse finds that 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. Explanation: The nurse should report any abnormal assessment findings or changes in the client's health status to the client's physician or the charge nurse immediately for prompt and appropriate treatment of the health alterations. The unlicensed assistive personnel should not document the findings as this is the nurse's responsibility. The nurse should not just reassess the client's temperature in 2 hours and chart that data; immediate reporting of the data to the physician or charge nurse is necessary.

A 24-year-old client presents to the emergency department with signs and symptoms of a sickle cell crisis. The nurse quickly obtains the necessary laboratory tests to assist with the assessment, as well as conducts an assessment of the client to determine the proper nursing care the client will require. Which type of assessment did the nurse perform in this situation?

Emergency Explanation: The nurse should complete an emergency assessment which will focus on the sickle cell crisis so that immediate care can be started to best treat the client. A focused assessment is conducted when more data are needed about a specific situation or health concern. The initial, comprehensive assessment is conducted to establish the client's medical and health condition. It will identify potential concerns as well as identify what the client is doing to ensure a healthy life.

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 Explanation: Some people of Chinese descent are modest about having their bodies touched and may see touching as an invasion into their personal space. The nurse should explain what will be done as the assessment progresses and strive to help the client feel as comfortable as possible. However, asking if the client would like the door left closed or opened, is not a priority before starting the assessment. It would be inappropriate to discuss various goals before the assessment is complete. All the information is needed to determine which goals will be most appropriate for each client. It may also be inappropriate to only conduct a focused assessment at this time, depending on the situation and the client. If there are other issues, they should also be evaluated, so that appropriate nursing goals can be determined and the client can receive the best care possible.