Fundamentals- Ch. 14
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
A client is a poor historian of the client's past medical history. Whom should the nurse consult about the client's past history?
Family
Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?
Focused
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.'"
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?"
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.
Which is the purpose of a focused assessment?
Adds depth to existing information
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.
conducting
Avoid the impulse to interrupt.
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.
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
During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficent 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.
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.
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.
A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?
Assess the client's blood pressure.
Which is the best source of information for the nurse when collecting data for an assessment?
Client
Which group of terms best defines assessing in the nursing process?
Collection, validation, communication of client data
The nurse is collecting data from a client during a complete assessment. Which skill is the nurse demonstrating when documenting the assessment data?
Communication
Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist?
Consultation
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.
For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?
Initial
The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?
Inspection
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 quandrant (RLQ) rebound tenderness, blood pressure of 130/92 mm Hg, and pulse 100 beats/min and weak?
Notify the health care provider immediately
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
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
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
Which nursing skill uses all five senses?
Observation
The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case?
Obtaining data regarding the amount and frequency of drinking
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?
Pain
When assessing the firmness of a client's abdomen, the nurse should use which assessment technique?
Palpation
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
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
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
A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which source?
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
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.
The nurse is reviewing the laboratory report section of a client's record. For what reason is this important for the nurse to review? Select all that apply.
To confirm previously collected data To reveal changes from previously collected data To monitor clients' responses to treatment To help establish a diagnosis
When performing an assessment, the nurse should focus most on the developmental stage for which client?
Toddler
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.
The nurse is performing an admission assessment on a young client admitted to the unit. Which are considered objective data? Select all that apply.
Weight: 195 lb (89 kg) 38-year-old man Height: 6 ft (1.82 m)
The purpose of obtaining a nursing history is to:
identify actual and potential health problems.
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.
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?"
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 auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding?
"We need to validate the information obtained in this assessment."
What must the nurse do to identify actual or potential health problems?
Gather data from sources
Which piece of client information is subjective?
Generalized myalgia or muscle pain
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
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
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
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
The nurse is about to record the fluid intake for a client with congestive heart failure. Which documentation is most appropriate?
The client consumed 780 mL of fluid for the 8-hour shift.
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.
Which is the primary reason for a nurse collecting data continuously on a client?
The client's health status can change quickly.
Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further traning?
The nurse introduces onself to the client by pointing to the nurse's name badge.
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
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
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 is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment?
Time-lapsed assessment
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.
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 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.
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.
