Fundamentals of Nursing Chapter 11: Assessing

How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his 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 of the following questions is the most appropriate conclusion to the interview?

"Is there anything else we should know in order to care for you better?"

A nurse is conducting an interview with a patient who complains of abdominal distress. What is an appropriate interview question for this patient?

"What is your problem as you see it?"

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?"

The nurse is conducting an assessment on a client and identifies a need for an interpreter. Which of the following is the best choice for an interpreter?"

A professional interpreter

During the nursing examination, the nurse notices that the patient, an elderly female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation?

Ask the patient if it is okay to interview her husband for the answers to the interview questions. Correct

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

A nursing student is learning about how to perform a thorough assessment in a health assessment class. Which of the following is the best source of information for the student to learn data collection for an assessment?

Client

A client reports to a health care facility with complaints of abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data?

Client himself

After performing an assessment on a client, the new graduate nurse labels the main problem as "ineffective airway clearance," and supports this nursing diagnosis by listing as evidenced by a nonproductive cough, crackles in lower lobes, and pulse ox reading of 94%. The nurse used which process?

Clustering

The nurse is planning to do a physical assessment on a newly admitted client.The assessment will be a review of systems (ROS). This means the nurse plans to do which of the following?

Complete an exam of all body systems

The nurse is conducting a nursing 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.

A client is a poor historian of his past medical history. Whom should the nurse consult about the client's past history?

Family

The nurse is conducting an interview on a newly admitted client. Which of the following is recommended when conducting a client/nurse interview?

Focus your full attention on the client

A nurse is interviewing a hospitalized patient. Which nurse-patient positioning facilitates an easy exchange of information?

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

When charting the assessment of a client, the nurse writes,"Client is depressed." This documentation is an example of which of the following?

Interpretation of data

The nursing student is learning how to do a complete assessment by organizing the data into the different body systems. This is an example of which of the following types of assessment?

Medical model

The nurse records the name, age, and race of the client. These data are components of which of the following?

Nursing or health history

A nurse has just taken vital signs on a newly admitted client. Vital signs would be entered on the client record as which of the following types of data?

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 count (WBC) lab value. The nurse is gathering which type of data when looking up the lab value?

Objective

While studying methods of data collection, a nursing student learns that there are many different skills involved. Which of the following is a key nursing skill that uses all five senses?

Observation

A nurse working on a medical unit is mentoring a new graduate. The new nurse asks why it is necessary to perform an assessment on the same client twice during a 12 hour shift. What would be the nurse's best response to the new graduate?

Ongoing data collection is critical to the deletion or modification of old problems and finding new ones

When performing an assessment on an older client the nurse discovers that the client needs a cane when walking and has problem seeing in the night. Under which of the following stages of Maslow's Human Needs Theory should the nurse cluster this data?

Safety and Security

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

Subjective

The nurse is conducting an admission assessment on a client who informs the nurse that dyspnea follows the exertion the client is experiencing. What would be the best way for the nurse to chart this data?

The client reports feeling dyspneic after exertion

While performing an assessment, the nurse recognizes that his own personal biases may be interfering with the collection of data. What step should the nurse take to assure the information is factual and accurate?

The nurse should consult with another nurse for that colleague's description of the assessment or observations

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 that afternoon to do some kind of check-up. Which type of check would be most appropriate for the nurse to perform on this client?

Time-lapsed assessment

While doing an assessment, the nurse identifies questionable data. Which of the following should the nurse do first?

Validate the questionable data

While admitting a teenage client who has a diagnosis of anorexia, the client 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

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.

The nurse is planning on doing a nursing/health history on a new client by performing an interview. Which of the following are considered phases of the nursing interview? Select all that apply.

• Preparatory phase • Introduction phase • Working phase • Termination phase

A nurse is preparing to interview a client who is newly admitted to the unit. Which strategies will help establish a relaxed and comfortable environment during the interview? Select all that apply.

• Proper seating arrangement • Proper distance from the client

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 which of the following?

A cue

A nurse is assessing an energetic 80-year-old, admitted to the hospital with complaints of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this patient?

A focused assessment of the specific problems identified

An unlicensed staff member asks the nurse what the difference is between a medical assessment and a nursing assessment. Which of the following is the nurse's best response?

A nursing assessment focuses on the client's response to health problems.

While performing an assessment on a young client the nurse is using the Functional Health Pattern Model. When recording the facts that the client exercises daily, hikes weekly, and plays on a softball team regularly, under which heading should these data be clustered ?

Activity/Exercise

A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of focus assessment?

Adds depth to existing information

The nursing instructor is teaching about collecting data for an assessment and informs the students about the importance of validation. Which of the following statements made by a nursing student indicates a need for further instruction?

All data collected needs to be validated

Which of the following patient situations most likely warrants a time-lapsed nursing assessment?

An elderly resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

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 which of the following?

An inference

A nursing student is assisting with taking nursing, or health histories of all clients. The student identifies when is the best time to do a nursing/health history?

As soon as possible after a client presents for care

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

Avoid the impulse to interrupt

The nursing student has learned that when doing an assessment on any client, it is essential to get the most important information first. By doing so the nurse's action is an example of which of the following?

Being able to prioritize

During the initial assessment of a newly admitted client, the nurse has clustered the client's range of motion (ROM) with his gait, his bowel sounds with his usual elimination pattern, and his chest sounds with his respiratory rate. The nurse is most likely organizing assessment data according to which of the following?

Body systems

The nurse understands that collecting correct data is crucial in nursing care, but just as important is the correct timing and proper documentation of that data. The timing and documentation is also referred to as which of the following?

Communication of data

A 50-year-old female patient is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information?

Consult nursing and medical literature.

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

Focused

An older adult male with a history of benign prostatic hyperplasia presents to the emergency room with complaints of urinary retention. The nurse collects data related to the patient'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 assessment

Which type of assessment would the nurse be expected to perform on the client who is one day post-op following a cholecystectomy?

Focused assessment

The nurse notices during an assessment interview that the client cannot stay on focus and jumps from one topic to another. The client also is speaking very rapidly and at time incoherently. What should the nurse suspect is the main cause of this behavior?

High anxiety

A nursing student is conducting an interview with a client. Which of the following best demonstrates use of open-ended questions in an interview?

How are you feeling?

Before conducting a health assessment on a client, what should the nurse do first?

Introduce herself to the client.

The nursing instructor is teaching the students about the proper techniques for conducting a client interview. A student asks the instructor the reason for asking the client what he or she would like to be called. What explanation provided by the instructor is most appropriate?

It communicates respect for the client

The nurse working at a local community hospital understands the importance of having a client database for continuous data collection. What does the nurse identify as the the primary reason for collecting data continuously?

It is because the client's health status can change quickly

A client comes to the emergency department with flulike symptoms. The nurse records the vital signs and listens to the client's lung sounds. Vital signs and lung sounds are examples of which of the following types of data?

Objective

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

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

Pain

The nurse is reviewing information about a client and notes the following assessment data. Which of the following data cues does the nurse recognize as subjective data?

Pain rating is 7

The nursing instructor is teaching about physical assessment and the best methods used for performing such an assessment. The instructor identifies a need for further teaching when one of the students makes which of the following statements?

Physical assessment is the examination of the client for subjective data

The nurse is preparing to perform an assessment on a newly admitted client. What should the nurse do prior to performing this initial assessment?

Review the records available on the client

The nursing instructor is teaching the students how to do an interview on a client. Which of the following statements made by a student indicates a need for further instruction?

Show your name badge to the client so they can read who you are

The nurse is performing an assessment on a newly admitted client. The client states, "I feel really nervous." This is an example of which of the following types of data?

Subjective

The nurse is assessing a male client with a diagnosis of vascular dementia. As a result of his cognitive deficit, the client is unable to provide many of the data that are required on the hospital's nursing admission history document. How should the nurse best proceed with this assessment?

Supplement the client's information by speaking with family or friends

The nurse is summarizing the key points of the interview. This nursing activity occurs during what phase?

Termination phase

Who or what is the primary source of information for a nursing history?

The client

A nursing instructor teaching about assessment data identifies a need for further instruction when a student makes which of the following statements?

The client is always the best source for collecting 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 which of the following is the best place to get baseline data?

The initial comprehensive nursing assessment

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments?

The nurse

The nurse is performing a physical assessment of a client admitted with emphysema. How will the nursing physical assessment differ from a medical physical assessment?

The nurse's physical assessment will focus on the client's functional abilities.

Nurses collect objective and subjective data when performing patient assessments. What is an example of objective data?

The skin of a patient who has liver failure has a yellowish tint.

A nurse practitioner has a private practice in conjunction with a physician. She is providing psychiatric care to a woman who has a past history of being abused by her husband. During the last visit, the client stated that she was planning to leave her husband. On the next visit in two weeks, the nurse practitioner will assess her client's commitment to changing her life situation and her ability to feel empowered. What type of assessment is the nurse practitioner implementing?

Time-lapsed

When performing an assessment, the nurse should focus on the developmental stage for which of the following clients?

Toddler

The nursing instructor is teaching the students about assessments. Which of the following does the instructor list as being most important in order for an assessment to be successful?

Trust and confidence

The nurse is performing a physical assessment of a newly admitted client. During the assessment the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client is there is any pain the answer is "no." What is the best thing for the nurse to do next?

Validate the data

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 client's temperature is 102. 9 F. What should be the nurse's priority action?

Verbally report the finding immediately to the client's physician

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 nursing student is performing an assessment on a client. Which of the following would the student record as subjective data? Select all that apply.

• "I am always anxious." • "I am so afraid of what my diagnosis is." • "My leg hurts when I move."

The nursing student is learning about the different types of assessments, when each type is used, and exactly how much information should be collected each time. Which of the following statements made by the nursing student indicates an understanding of the different types of assessments?

• "The purpose for the assessment offers guidance for which type and how much data to collect."

The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? Select all that apply.

• 38 year-old man • Height: 6' • Weight 195 pounds

Nurses collect objective and subjective data during the patient interview. Which patient data is subjective data? (Select all that apply.)

• A patient describes his pain as an 8 on the pain assessment scale. • A patient feels nauseated after eating his breakfast. • A patient complains of being cold and requests an extra blanket.

The nurse is caring for an older adult client admitted to the hospital for a respiratory condition. Types of data that the nurse should review before caring for this client include which of the following? Select all that apply

• Consultations • Lab reports • Medical history • Progress notes • X-Ray reports

Following a patient interview, the nurse is organizing data obtained according to Gordon's functional health pattern model. Which statements reflect the focus of this model? (Select all that apply.)

• Data are collected regarding the health perception/ health management of the patient. • The perception of the major roles and responsibilities in the patient's life is explored. • Elimination, activity, sleep, and sexuality are components of the assessment and data collection.

The nurse understands that conducting a physical examination on a client should always include which of the following? Select all that apply.

• Establishment of a database for interventions • Appraisal of health status • Identification of health problems

The nurse understands that how you begin and end an interview with a client are equally important. What are some ways that are helpful to terminate an interview? Select all that apply.

• Give a warning such as "We have 5minutes left". • Ask the client to summarize their most important concerns • Offer yourself as a resource

The nursing instructor is teaching about the different models used in nursing to assist in clustering data. Which of the following models should the instructor include during the teaching session? Select all that apply.

• Human Needs Model • Functional Health Patterns Model • Human Response Model • Body System Model

The nursing instructor is demonstrating to the class how to perform a physical assessment. Which of the following assessment techniques should be demonstrated by the nursing instructor? Select all that apply.

• Inspection • Palpation • Percussion • Ausculation

The nurse must be familiar with the client record in order to care for a client effectively. Which of the following are parts of the client record that include only the findings of physicians? Select all that apply.

• Medical history • Physical exam • Progress notes

Nurses perform nursing assessments on patients as part of their routine care. Which statements accurately describe the unique focus of these nursing assessments? (Select all that apply.)

• Nursing assessments focus on the patient's responses to health problems. • The findings from a nursing assessment may contribute to the identification of a medical diagnosis. • An initial assessment establishes a complete database for problem solving and care planning.

Which of the following qualities does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply.

• Professionalism • Respect for client • Caring • Competence

When reviewing the laboratory report section of a client's record, a nurse knows that this information is used for which of the following reasons? Select all that apply.

• To confirm previous collected data • To conflict with previous collected data • To help to establish a diagnosis • To monitor clients' responses to treatment