Chapter 14 PrepUWhich group of terms best defines assessing in the nursing process?
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 are examples of subjective data? Select all that apply.
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?
A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.
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.
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.
Which group of terms best defines assessing in the nursing process?
Collection, validation, communication of client data Assessing is the systematic and continuous collection, validation, and communication of client data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem-focused, time-lapsed, and emergency-based describe types of assessments. Assessments are nurse-focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are.
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.
The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client?
Ineffective Breastfeeding
The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client?
Pain
What should the nurse do prior to performing an initial assessment on a newly admitted client?
Review the records available on the client.
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.
Which items reflect the assessment phase of the nursing process? Select all that apply.
The nurse asks the client, "How would you rate your pain?" The client's abdomen is firm and distended with hypoactive bowel sounds. The client states, "I rarely sleep more than 6 hours."
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.
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.
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:
complete an exam of all body systems.
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 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 statement made by the nurse indicates data that would be documented as part of an objective assessment?
"The client's right leg is cold to the touch, from the knee to the foot."
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. 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 preparing to interview several clients during clinic hours. What language difficulty might a nurse encounter while performing various interviews in a diverse population of clients?
Clients not being fluent in the same language as the nurse Clients having a limited education Clients fearing saying the wrong thing Explanation: In regards to language difficulty, some examples that might interfere with a interview include the following: the client not speaking the same language as the nurse; the client having a limited education; and the client fearing saying the wrong thing. If a client speaks the same language there should not be a problem. Although being anxious might cause a problem during the interview, it is not associated with a language problem.
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
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
Which items reflect the assessment phase of the nursing process? Select all that apply.
The nurse asks the client, "How would you rate your pain?" The client's abdomen is firm and distended with hypoactive bowel sounds. The client states, "I rarely sleep more than 6 hours." Explanation: Assessment data would include the client statement regarding sleep, the nurse's question about a pain rating, and physical assessment data of the abdomen. Seeking input from the data in setting goals would occur during the outcome identification and planning phase. Assisting the client with coughing and deep breathing would occur during the implementation phase.
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.
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.
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.
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.
Which are examples of subjective data? Select all that apply.
Anxiety Light-headedness Nausea
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.
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.
The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data?
Both during the collection and at the end of the collection Explanation: Not all data need to be validated, but the nurse may validate data during the collection or at the end of the data-gathering process. When it is clear that the data are correct, the nurse may analyze the data and formulate nursing diagnoses.
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.
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.
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 are examples of objective data? Select all that apply.
Laboratory test results Breath sounds on auscultation A client's temperature 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.
While performing the nursing history, the nurse notes that the client reports having very little pain but is occasionally grimacing and rubbing one shoulder throughout the interview. The nurse acknowledges this behavior, questions the client, and then proceeds with other phases of the interview. This action takes place during which phase of the nursing interview?
Maintenance Explanation: Watching the client to determine whether nonverbal cues match the verbal communication typically occurs during the maintenance, or working, phase of the interview. Initial observations are noted during the introductory phase, when the nurse introduces oneself to the client, but they are further addressed in the maintenance phase. The preparatory phase is the time before the nurse actually meets with the client, during which the nurse gathers as much information about the client's health status as possible and plans for the interview and assessment. The concluding phase is when the nurse signals to the client that the interview is coming to a close and asks whether the client has any remaining questions.
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
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?
Safety and security Explanation: Physiologic needs are the physical requirements for human survival. Physiologic needs include breathing, water, food, sleep, clothing, shelter, and sex. Once a person's physiologic needs are relatively satisfied, the person's safety needs take precedence and dominate behavior. Safety and security needs include personal security, emotional security, financial security, health and well-being, and safety against accidents or illness and their adverse impacts. After physiologic and safety needs are fulfilled, the third level of human needs is interpersonal and involves feelings of love and belonging. These include relationships with friends, intimacy, and family. Self-esteem needs are ego needs or status needs, such as for getting recognition, status, importance, and respect from others. All humans have a need to feel respected; this includes the need to have self-esteem and self-respect. Self-actualization is what a person's full potential is and the realization of that potential.
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?
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.
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
Which scenario is an example of a time-lapse reassessment?
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.
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
The nurse watches a 43-year-old client walk into the room and notes the client is slightly limping on the left foot when walking. The nurse also notes the client has difficulty sitting in the chair and sits down carefully with the left leg slightly held forward. The client notes having had difficulty walking for the past year and it is getting worse. A previous ultrasound of the foot revealed a Morton neuroma. The client reports continued pain in the left foot when walking or standing for long periods of time. A physical examination reveals pain and tenderness on palpation of the upper left foot, skin is cool to touch with no redness noted, pedal pulse is 78 beats/min and regular. Which action by the nurse demonstrates the observation phase of an assessment?
Watching client walk into room Observation is the first step of a physical examination. This is when the nurse watches the client to observe any subtle indications of a problem, watches body language to see how it corresponds to the verbal communication, and determines possible areas which will need a focused assessment as the initial assessment develops. Review of past records should occur before the physical assessment is conducted. Assessing the area for pain, temperature and pulse are methods used during palpation.
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 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 initial comprehensive client assessment. Explanation: The initial comprehensive client assessment results in the baseline data that enables the nurse to make judgments, plan care, and refer clients to other health care workers if necessary.
