Chapter 16 Nursing Assessment

Which of the following examples are steps of nursing assessment? (Select all that apply.) 1. Collection of information from patient's family members 2. Recognition that further observations are needed to clarify information 3. Comparison of data with another source to determine data accuracy 4. Complete documentation of observational information 5. Determining which medications to administer based on a patient's assessment data

1, 2, 3 Assessment includes collection of data from 2' sources like patient's family. Recognizing more observations are needed is an example of *validation of data.* Comparing data to determine accuracy is feature of interpretation. (4) is incorrect bc although complete documentation is important in assessment data, it is not an assessment step.

The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? (Select all that apply.) 1. Listen attentively to the patient's story. 2. Use gestures that reinforce your questions or comments. 3. Stand back away from the bedside. 4. Maintain direct eye contact. 5. Ask questions quickly to reduce the patient's fatigue.

1, 2, 4

When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.) 1. An observation of how a patient turns and moves in bed 2. The unit policy and procedure manual 3. The care recommendations of a physical therapist 4. The results of a diagnostic x-ray film 5. Your experiences in caring for other patients with similar problems

1, 3, 4

A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she conducts rounds on the patient? (Select all that apply.) 1. The nurse asks the patient to rate his pain on a scale of 0 to 10. 2. The nurse asks the patient what caused his fall. 3. The nurse asks the patient if he has had pain in his back in the past. 4. The nurse assesses the patient's lower-limb strength. 5. The nurse asks the patient what pain medication is most effective in managing his pain

1, 4 1. is validation of assessment data by asking pain rating scale again 4. assessing lower limb strength is validation via physical assessment 3. is not correct bc it is a new finding

A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? (Select all that apply.) 1. The skin around the wound is tender to touch. 2. Fluid intake for 8 hours is 800 mL. 3. Patient has a heart rate of 78 beats/min and regular. 4. Patient has drainage from surgical wound. 5. Body temperature is 38.3° C (101° F). 6. Patient states, "I'm worried that I won't be able to return to work when I planned."

1, 4, 5

A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: 1. Patient's level of function. 2. Patient's willingness to perform self-care. 3. Patient's level of consciousness. 4. Patient's health management values.

1. Patient's level of function

The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview? 1. Orientation 2. Working phase 3. Data validation 4. Termination

2

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the last month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. Thank you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?"

2, 4, 1, 5, 3

Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care? 1. Probing 2. Open-ended 3. Problem-oriented 4. Confirmation

2. Open-ended

A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? 1. "I can tell that your eating habits have led to your diabetes. Is that right?" 2. "It's been difficult for people to find jobs. Is that why you work part time?" 3. "You have four children; do you have any concerns about going home and caring for them?" 4. "I wish patients understood how overeating affects their health."

3

During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? 1. So you've had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct? 2. Have you taken anything for your headaches? 3. Tell me what makes your headaches begin. 4. Uh huh, tell me more.

3

The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: 1. Cue. 2. Reflection. 3. Clinical inference. 4. Probing.

3

A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? 1. Review of systems approach 2. Use of a structured database format 3. Back channeling 4. A problem-oriented approach

4

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also, I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? 1. Value-belief pattern 2. Cognitive-perceptual pattern 3. Coping-stress-tolerance pattern 4. Health perception-health management pattern

4

A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess? 1. Health perception-health management pattern 2. Value-belief pattern 3. Cognitive-perceptual pattern 4. Self-perception-self-concept pattern

4

*A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses the inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse assess?* A. Health perception-health management pattern B. Value-belief pattern C. Cognitive-perceptual pattern D. Coping-stress tolerance pattern

A Rationale: The nurse assesses the patient's understanding of his therapy and level of adherence. She also assesses his health practices.

*What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply.)* A. Active listening B. Back channeling C. Validating D. Use of open-ended questions E. Use of closed-ended questions

A, B, D Rationale: Active listening allows the patient to speak and shows the nurse's respect for what he or she has to say. Back channeling reinforces interest in what the patient has to say and shows the nurse's desire to hear the full story. Using open-ended questions encourages the patient to tell his or her story and actively describe his or her health status. Validation simply confirms accuracy of data collected. Closed-ended questions do not encourage storytelling.

*A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply.)* A. A problem-focused approach B. A structured comprehensive approach C. Using multiple visits to gather a complete database D. Focusing on the functional health pattern of role-relationship

A, C Rationale: The nurse should use a focused approach initially to determine the patient's respiratory status. However, to gather an admission assessment, multiple visits are needed because of the patient's age and level of physical distress. A structured comprehensive approach is not appropriate for this acute situation. *Eventually the nurse will want to assess the patient's role-relationship health pattern because of his wife's death.* But it is not appropriate at this time.

*Which of the following are examples of data validation? (Select all that apply.)* A. The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record. B. The nurse asks the patient if he is having pain and then asks the patient to rate the severity. C. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content. D. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement. E. The nurse asks the patient to describe a symptom by saying, "Go on."

A, D Rationale: Validation involves comparing data with another source. By asking the patient about pain and then having it rated the nurse collects two assessment findings. The nurse asking an open-ended question about the patient's understanding of the booklet is not data validation. Telling the patient to "go on" is back channeling.

*A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply.)* A. The skin around the wound is tender to touch. B. Fluid intake for 8 hours is 800 mL. C. Patient has a heart rate of 78 and regular. D. Patient has drainage from surgical wound. E. Body temperature is 101° F (38.3° C). F. Patient asks, "I'm worried that I won't return to work when I planned."

A, D, E Rationale: These form a pattern of a problem with wound healing. Fluid intake of 800 mL in 8 hours and having a heart rate of 78 are normal findings. The patient indicating some worry about not returning to work when planned may suggest a problem, but more cues are needed to see a pattern that would allow the nurse to clearly identify the problem.

Which scenario best illustrates the use of data validation when making an independent nursing clinical decision? a. The nurse determines that she needs to remove a wound dressing when the patient reveals the time of the last dressing change, and she notices that the present dressing is saturated with fresh and old blood. b. The nurse administers pain medicine due at 1700 at 1600 because the patient complains of increased pain. c. The nurse removes a leg cast when the patient complains of decreased mobility. d. The nurse administers potassium when a patient complains of leg cramps.

ANS: A Changing the wound dressing is the only independent nursing action given. The nurse validates what the patient says with her own observation of the dressing. This option is the only assessment option as well that involves data validation. Administering pain medicine or potassium and removing a leg cast are examples of nursing interventions.

The nurse is assessing a patient with a hearing deficit. Where is the best place to conduct this interview? a. The patients room with the door closed b. The waiting area with the television turned off c. The patients room before administration of pain medication d. The patients room while the occupational therapist is working on leg exercises

ANS: A Distractions should be eliminated as much as possible when interviewing a patient with a hearing deficit. The best place to conduct this interview is in the patients room with the door closed. The waiting area does not provide privacy. Pain can sometimes inhibit someone's ability to concentrate, so before pain medication is administered is not advisable. It is best for the patient to be as comfortable as possible when conducting an interview. Assessing a patient while another member of the health care team is working would be distracting and is not the best time for assessment to take place.

Subjective data include a. A patients feelings, perceptions, and reported symptoms. b. A description of the patients behavior. c. Observations of a patients health status. d. Measurements of a patients health status.

ANS: A Subjective data include the patients feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition. Data sometimes reflect physiological changes, which you further explore through objective data collection. Describing the patients behavior, observations made, and measurements of a patients health status are all examples of objective data.

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse a. Completes a comprehensive database. b. Identifies pertinent nursing diagnoses. c. Intervenes based on patient goals and priorities of care. d. Determines whether outcomes have been achieved.

ANS: A The assessment phase of the nursing process involves data collection to complete a thorough patient database. Identifying nursing diagnoses occurs during the diagnosis phase. The nurse carries out interventions during the implementation phase, and determining whether outcomes have been achieved takes place during the evaluation phase of the nursing process.

Which of the following are examples of subjective data? (Select all that apply.) a. Patient describing excitement about discharge b. Patients wound appearance c. Patients expression of fear regarding upcoming surgery d. Patient pacing the floor while awaiting test results e. Patients temperature

ANS: A, C Subjective data include patients feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data.

After setting the agenda during a patient-centered interview, what will the nurse do? a. Begin by introducing himself. b. Conduct a nursing health history. c. Explain that the interview will be over in a few more minutes. d. Tell the patient that hell be back to administer medications in 1 hour.

ANS: B After setting the agenda, the nurse should conduct the actual interview and proceed with data collection. Setting the stage begins with introductions and takes place before an agenda is set. The termination phase includes telling the patient when the interview is nearing an end. Telling the patient medications will be given later when the nurse returns would typically take place during the termination phase of the interview.

While completing an admission database, the nurse is interviewing a patient who states that he is allergic to latex. The most appropriate nursing action is to first a. Leave the room and place the patient in isolation. b. Ask the patient to describe the type of reaction. c. Proceed to the termination phase of the interview. d. Document the latex allergy on the medication administration record.

ANS: B The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered.

The nurse is attempting to prompt the patient to elaborate on her complaints of daytime fatigue. Which question should the nurse ask? a. Is there anything that you are stressed about right now? b. What reasons do you think are contributing to your fatigue? c. What are your normal work hours? d. Are you sleeping 8 hours a night?

ANS: B The question asking the patient what factors might be contributing to her fatigue will elicit the best open-ended response. Asking whether the patient is stressed and asking if the patient is sleeping 8 hours a night are closed-ended questions eliciting simple yes or no responses. Asking about normal works hours will elicit a matter-of-fact response and does not prompt the patient to elaborate on her complaints of daytime fatigue nor ask about the contributing reasons.

A nursing student is completing an assessment on an 80-year-old patient who is alert and oriented. The patients daughter is present in the room. Which of the following actions made by the nursing student requires the nursing professor to intervene? a. The nursing student is making eye contact with the patient. b. The nursing student is speaking only to the patients daughter. c. The nursing student nods periodically while the patient is speaking. d. The nursing student leans forward while talking with the patient.

ANS: B When assessing an older adult, nurses need to listen carefully and allow the patient to speak. Positive nonverbal communication, such as making eye contact, nodding, and leaning forward, shows interest in the patient. Gathering data from family members is acceptable, but when a patient is able to interact, nurses need to include information from the older adult to complete the assessment.

A nurse using the problem-oriented approach to data collection will first a. Complete an observational overview. b. Disregard cues and complete the database questions in chronological order. c. Focus on the patients presenting situation. d. Make accurate interpretations of the data.

ANS: C A problem-oriented approach focuses on the patients current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection.

To gather information about a patients home and work surroundings, the nurse will need to utilize which method of data collection? a. Carefully review lab results. b. Conduct the physical assessment before collecting subjective information. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview.

ANS: C A thorough nursing history includes information about the patients home and work surroundings. Neither lab results nor the physical assessment will reveal much about the home and work surroundings. Collecting data is part of the working phase of the interview.

A nurse comparing data validation and data interpretation correctly explains the difference with which statement? a. Validation involves looking for patterns in professional standards. b. Data interpretation involves discovering patterns in professional standards. c. Validation involves comparing data with other sources for accuracy. d. Data interpretation occurs before data validation.

ANS: C Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. The nurse should validate data before interpreting the data and making inferences. The nurse is interpreting and validating patient data, not professional standards.

Which of the following methods of data collection is utilized to establish a patient's nursing database? a. Reviewing the current literature to determine evidence-based nursing actions b. Orders for diagnostic and laboratory tests c. Physical examination d. Anticipated medications to be ordered

ANS: C A nursing database includes a physical examination. Orders are included in the order section of the patients chart. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. Medication orders are usually written after the database is completed.

A patient expresses fear of going home and being alone. Her vital signs are stable and her incision is nearly completely healed. The nurse can infer from the subjective data that a. The patient can now perform the dressing changes herself. b. The patient can begin retaking all her previous medications. c. The patient is apprehensive about discharge. d. Surgery was not successful.

ANS: C Subjective data include expressions of fear of going home and being alone. These data indicate that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistant. With this in mind, what clinical decision should the nurse make? a. Administer scheduled medications assuming she would have been informed if the vital signs were abnormal. b. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return. c. Ask the nursing assistant to record the patients vital signs before administering medications. d. Omit the vital signs because the patient is presently in no distress.

ANS: C The nurse should ask the nursing assistant to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action.

Components of a nursing health history include a. Current treatment orders. b. Nurses concerns. c. Nurses goals for the patient. d. Patient expectations.

ANS: D *Components of a nursing health history include physical examination findings, patient expectations, environmental history, and diagnostic data.* Current treatment orders are located under the Orders section in the patients chart and are not a part of the nursing health history. Patient concerns, not nurses concerns, are included in the database. Goals that are mutually established, not nurses goals, are part of the nursing care plan.

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). The nurse is performing what type of assessment approach in this situation? a. Comprehensive assessment using Gordons Functional Health Patterns b. General to specific assessment c. Activity-exercise pattern assessment d. Problem-oriented assessment

ANS: D The nurse is not doing a complete, general assessment and then focusing on specific problem areas. *Instead, the nurse focuses immediately on the problem at hand and performs a problem-oriented assessment.* Utilizing Gordons Functional Health Patterns is an example of a structured database-type assessment technique. The nurse in this question is performing a specific problem-oriented assessment approach. The nurse is not performing an activity-exercise pattern assessment in this question.

While the patients lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this complaint, thinking that no correlation has been noted between having a leg cast and developing restless sleep. A more theoretically sound approach would be to first a. Document the sleep patterns and complaint in the patients chart. b. Tell the patient you are just focused on the leg right now. c. Explain that a more thorough assessment will be needed next shift. d. Ask the patient about his usual sleep patterns and the onset of having difficulty resting.

ANS: D The nurse must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the patient about usual sleep patterns and the onset of having difficulty resting. The nurse should assess before documenting and should not ignore the patients complaints.

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurses best action in response to her observation? a. Proceed to the next patients room while making rounds. b. Offer a massage because the patient does not want any more pain medicine. c. Administer the pain medication ordered for moderate to severe pain. d. Ask the patient about the facial grimacing with movement.

ANS: D The nurse needs to clarify what she observes with what the patient states. Proceeding to the next room is ignoring this visual cue. The nurse cannot assume the patient does not want pain medicine just because he rates his pain level at 2 out of 10. The nurse should not administer medication for moderate to severe pain if it is not necessary.

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. This nurse should a. Notify the physician to recommend a psychological evaluation. b. Consider cultural differences during this assessment. c. Ask the patient to make eye contact to determine her affect. d. Continue with the interview and document that the patient is depressed.

B

*A nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of what type of assessment?* A. Agenda settling B. Problem-focused C. Objective D. Use of a structured database format

B Rationale: The nurse saw the inflammation and gathered additional information to determine if a problem existed with the IV site. The data were not all objective; the patient's report of tenderness is subjective. Setting an agenda is an interview technique. The nurse was not using a structured format for her assessment.

*A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply.)* A. Maintain a neutral facial expression B. Lean forward when interacting with the patient C. Acknowledge the patient's answers through head nodding D. Limit direct eye contact

B, C Rationale: Leaning forward shows that the nurse is aware and attending to what the patient is saying. The use of head nodding regulates the interaction and makes it easier for the patient to know the nurse's responses to his comments. A neutral expression does not express warmth or immediacy, which is needed to establish a positive relationship. Good eye contact communicates the nurse's interest in what the patient has to say.

*A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing?* A. So you've had an upset stomach and began vomiting—correct? B. Have you taken anything for your stomach? C. Is anything else bothering you? D. Have you taken any medication for your vomiting?

C Rationale: A probing question encourages a full description without trying to control the direction of the patient's story. It requires further open-ended statements. Confirming an upset stomach and vomiting is an example of summarizing findings. The questions about medications taken are examples of closed-ended questions that control the patient's response and do not ensure a full objective view from the patient.

*The nurse makes the following statement during a change of shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest?* A. The nurse is making an accurate clinical inference. B. The nurse has gathered cues to identify a potential problem area. C. The nurse has allowed stereotyping to influence her assessment. D. The nurse wants to validate her information with the other nurse.

C Rationale: The nurse is applying a stereotype about patients with back pain. An accurate clinical inference would not include the nurse's opinion. The cues suggest that the patient has acute pain, which the nurse is rejecting. Validation would involve having another nurse also assess the patient for pain.

*The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview?* A. Setting the stage B. Gathering information about the patient's chief concerns C. Collecting the assessment D. Termination

C Rationale: The nurse is focusing on the patient's nutritional status and asking specific questions to assess his diet history.

*During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem?(Select all that apply.)* A. Family report B. Chest x-ray film C. Physical examination with auscultation of the lungs D. Medical record summary of x-ray film findings

C, D Rationale: The family cannot provide information to reveal that the cough is a lung problem. A chest x-ray film is not a nursing assessment; if a previous chest x-ray film had been performed, the nurse could review that report to confirm a lung problem.

*What type of interview techniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?"(Select all that apply.)* A. Active listening B. Open-ended questioning C. Closed-ended questioning D. Problem-oriented questioning

C, D Rationale: The nurse's technique is to ask a closed-ended question using a problem oriented approach. The patient gives a specific answer to broaden the nurse's knowledge about the character of his pain.

*The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case the finding of nausea is which of the following?* A. An objective finding B. A clinical inference C. A validation D. A concomitant symptom

D Rationale: A concomitant symptom is a symptom that occurs along with a primary symptom. The finding is subjective based on patient self-report. There is no clinical inference since the nurse is not trying to find the meaning of the findings. The patient is reporting nausea, but there is no validation or confirmation with another source.

*A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns?* A. Value-belief pattern B. Cognitive-perceptual pattern C. Coping-stress-tolerance patterns D. Health perception-health management pattern

D Rationale: The nurse is attempting to learn about the patient's self-report of health practices, clinic appointments, and exercise plan designed to improve his health.