Health Assesment EAQ 1

The nurse in the family planning clinic reviews the health history of a sexually active 16-year-old whose chief concern is a thick, burning, vaginal discharge accompanied by low abdominal pain. After her examination, the girl is informed that she may have a STI that requires treatment. The adolescent is concerned that her parents will discover that she is sexually active. She asks the nurse whether her parents will be contacted. How would the nurse respond?

- "Your parents will not be contacted because treatment at the clinic is confidential." RATIONALE: To prevent disclosure, family planning clinics treat these adolescents as emancipated minors who can sign their own consent forms. Federal law allows family planning clinics to maintain minors' confidentiality, although individual states may have different regulations. There is a concern that teenagers will not seek or continue treatment if they fear disclosure. Most family clinics receive funding and charge on a sliding scale based on income, thereby encouraging adolescents to seek treatment.

Which approaches would the nurse use during a crisis intervention interview?

- Active - Goal directed RATIONALE: The nurse would assume an active role in assessing the situation and conduct the interview with authority. During crisis intervention, the nurse would be goal directed to help the client cope with the crisis. A passive approach is not appropriate, the client usually needs direction to move forward. A reflective approach might be more appropriate for long-term therapy. An interpretive (Analytical) approach is used during psychoanalysis.

A client reports being physically abused by his or her partner. Which interventions would the nurse include in the plan of care? Select that apply.

- Assess level of danger - Notify adult protective services RATIONALE: Guidelines for interviewing a victim of domestic violence include assessing the current level of danger and notifying adult protective services. The nurse would explain to the client the required process for notifying the agency of the abuse. The nurse would not press for information the client is not comfortable providing. The nurse would use a language the client understands and avoid medical terminology. The nurse would also interview the client in a private area without others around.

Which is the priority nursing action when admitting a child to the emergency department who was bitten by a stray dog and sustained a soft tissue injury on the inner aspect of the left forearm?

- Assessing the injury and the child's vital signs and health history. RATIONALE: For effective decisions to be made, baseline information on the child's condition, extent of injury, and significant health history are required first. Hyperimmune antirabies serum is not a preferred treatment. Inoculation for establishment of short-term, passive immunity to rabies follows initial care of injuries; the priority is assessment and treatment of the injury. Authorities should be notificed after the injured child has received care.

Which step in the nursing process involves the nurse interviewing a client about a current health problem and taking the client's vital signs?

- Assessment RATIONALE: Assessment involves the collection of comprehensive date pertinent to the client's health.

Which decribes the rationale for not discussing a client's condition with another individual not directly involved in the client's care?

- Breach of confidentiality. RATIONALE: The release of information to an unauthorized person or gossiping about a client's activities constitutes a breach of confidentiality and an invasion of privacy. Libel occurs when a person writes false statements about another that may injure the individual's reputation. Negligence is a careless act of omission or commission that results in injury to another. Defamation of character is the publication of false statements that injure a person's reputation.

The nurse is reviewing the CSF laboratory findings of four clients. Which client would the nurse suspect has had a previous meningeal hemorrhage?

- Brown RATIONALE: The brown color indicates meningeal hemorrhage. A yellow color of CSF is due to hemolysis of red blood cells leading to increased bilirubin. An unclear or hazy appereance of the CSF indicates an elevated WBC count. A pink-red to orange color indicates the presence of RBCs in the CSF.

Which statements demonstrate acting in an appropriate manner in a professional environment?

- Care that is consistent with my level of expertise would be provided. - It is important to remember and follow the policies and procedures of the institution. - I would use restraints on a client only after obtaining a written order from a primary health care provider. RATIONALE: The nurse would provide care that is consistent with his/her level of expertise. If any injury occurs to the client while performing a procedure on which the nurse is not trained, it may lead to legal complications. The nurse would always remember and follow the policies and procedures of the institution to avoid malpractice. To prevent any legal issues, the nurse would bring it to the attention of the nursing supervisor if she/he is assigned to care for more clients than reasonable. The nurse would NEVER disclose the client's confidential medical information without his/her consent.

While caring for four different clients, the nurse assesses their breathing pattern. Which client's assessment findings indicate Cheyne-Stokes respiration?

- Client 3: Irregular, alternating apnea and hyperventilation. 12 BPM. RATIONALE: In Cheyne-Stokes respiration, a client's breathing pattern is characterized by progressively deeper and faster breathing, that is, hyperventilation followed by apnea.

Which interview technique is the nurse using when asking a client to score his or her pain on a scale from 0 to 10?

- Closed-ended questioning RATIONALE: Asking a client to score pain on a scale of 0 to 10 is a type of close-ended question. These types of questions specify the cause of the problem or the client's experience of the illness. Asking whether anything else is bothering the client is PROBING. When a client says something, a response by the nurse such as 'all right' or 'go on' is called back channeling. This encourages a client to provide more details.

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse would include which question when completing the initial assessment?

- Does walking for long periods of time increase your pain? RATIONALE: Clients with a medical history of heart disease, htn, phlebitis, diabetes, or varicose veins often experience vascular-related complications. The nurse would recognize that the relationship of symptoms to exercise will clarify the presenting problem is vascular or musculoskeletal. Pain caused by a vascular condition tends to increase with activity. Musculoskeletal pain is not usually relieved when exercise ends. Low potassium levels can cause cramping in the lower extremities; however, given the client's health history, vascular insufficiency should be suspected. Previously healed broken bones do not cause cramping and pain.

The nurse is performing a mental health depression screen to determine an adolescent's risk of suicide. Which statement by the adolescent would most concern the nurse?

- I have a plan for taking my life. RATIONALE: The nurse is most concerned if a client reports having a plan for committing suicide. In this situation, the nurse seeks immediate intervention. When obtaining a health history, the nurse will assess a client for reports of feeling down, having no close friends, and family history of depression. These factors will be further assessed to determine a client's risk for committing suicide, but do not represent immediate danger.

The nurse manager asks the nurse, 'How would you implement clinical decision-making in a group of clients?' Which answer(s) provided by the nurse show(s) effective critical thinking?

- I will discuss complex cases with other members of the health care team - I will identify the nursing diagnoses and collaborative problems of each client. - I will consider the time it takes to care for clients whose problems have higher priority. RATIONALE: The nurse would discuss complex cases with the other members of the health care team. It ensures a smooth transition in the care requirements. As a part of effective critical thinking, the nurse would diagnose the collaborative problems of each client. The nurse would consider the care time for the clients having problems that require high priority. Effective critical thinking requires the nurse to involve clients as decision-makers or participants in care. The nurse would decide on combining activities to resolve more than one client problem at a time.

Which step in the nursing process would involve promoting a safe environment for the client?

- Implementation RATIONALE: The nurse promotes a safe environment during the implementation stage. During planning, the nurse develops a care plan. During diagnosis, the nurse analyzes the assessment date to determine health care issue. The nurse collects data in assessment.

Which action would the nurse take when discovering a client admitted in premature labor has been using heroin throughout the pregnancy?

- Inform the client's primary health care provider. RATIONALE: The fetus of a heroin-addicted mother is at risk for serious complications such as hypoxia and meconium aspiration. It is important to notify the primary health care provider of the client's heroin use, because this information will influence the care of the client and the newborn. This information is used only in relation to the client's care. With the client's consent, it may be shared with other social service or health agencies that become involved with the client's long-term care. The nurse manager of the unit may be notified because it relates to the care of the client and her newborn. Client info is confidential, and only necessary staff should know such info. Hospital security would only be notified if actual illicit substances were discovered on hospital premises.

Which nursing action is priority when a client with severe chest pain and diaphoresis is brought to the emergency department?

- Initiate electrocardiogram (ECG) monitoring. RATIONALE: Because fatal dysrhytmias are the most common cause of death with acute coronary syndrome, the nurses, first action would be to start ECG monitoring. Obtaining a health history is important, but can be done after cardiac monitoring is established.

Which nursing action(s) reflect(s) the evaluation phase of the critical thinking process?

- Looking at all the situations objectively - using several criteria to determine the effectiveness of a nursing intervention RATIONALE: During evaluation, the nurse would look at the situations objectively to identify the client's response to interventions.

Which is the priority nursing intervention during the admission of a primigravida (first time) in labor?

- Monitoring the fetal heart rate. RATIONALE: Determining the fetal well-being supersedes all other measures; if the fetal heart rate is absent or persistently decelerating, immediate intervention is required. The health history, including the client's last meal and whether the membranes have ruptured may be taken once fetal well-being has been established.

The nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective?

- Observe the mother feeding the infant. RATIONALE: A return demonstration can confirm that the desired learning from earlier has taken place.

When an older adult is brought to the emergency department after being found in the street without a coat during a snowstorm, which actions would the nurse implement?

- Obtain a rectal temperature - Assess the fingers for areas of frostbite - Determine the client's level of consciousness - Ask for client identification RATIONALE: A rectal temp provides the most accurate temp. The extremities are more distal sites of circulation and are at increased risk for frostbite. Hypothermia decreases cerebral perfusion, which will result in confusion and a decreased LOC. Getting client identification will help in learning more about the client's previous health history and aid in contacting family members. Massage is contraindicates because it may injure tissues that have sustained frostbite.

Which response would the nurse make during the last interview before discharge, when the client who has follow-up therapy session says, "there are a few things that bother me that i've told no one." ?

- One purpose of continuing counseling is to allow you to discuss things that bother you. RATIONALE: Clients may introduce new topics during the last session to prevent termination; the nurse would encourage them to discuss these problems as outpatients in the follow-up therapy sessions. Two purposes of the last interview are to summarize and terminate, not to begin discussion of new problems. The last minutes of the last interview are not the appropriate time to introduce new problems.

Which client would benefit from reality orientation?

- Patient D: Uses analgesics and sedatives RATIONALE: Patients using analgesics and sedatives may develop disorientation and confusion.

Which action of the nurse would be incorrect in the contest of critical thinking skills for making clinical decisions in nursing practice?

- Rely on knowledge and experience for client care.

Which nurse is using complex critical thinking skills when caring for a client?

- Talks to the client to identify reasons for their behavior RATIONALE: The nurse practicing complex critical thinking skills begins to analyze and examine choices more independently. Talking to a client to identify reasons for a particular behavior, such as refusal to take pain medication or use of alternative therapy for pain, involves the use of complex critical thinking skills. An example of basic critical thinking skills is the nurse who depends on manuals or experts and the nurse who seeks the assistance of a senior nurse to set up an insulin pump. The nurse who acts without involving others and accepts accountability applies commitment, or the third level of critical thinking.

Which scenarios would the nursing student consider as the input component?

- The nurse checks the client's health history for allergy to iodine before inserting a urinary catheter. - The nurse checks if the client has a history of substance abuse before administering nasal medications. - The nurse checks the medical records of the client to know if he or she has had a rectal surgery in the past year before placing and internal fecal catheter. RATIONALE: The data or info. that comes from a patient's assessment is known as the input component.

Which measure would the nurse adopt while performing the health assessment of an adolescent?

- Treating adolescents as adults - maintaining an adolescent's right of confidentiality - performing the examination in a non-threatening area RATIONALE: while performing a health assessment of adolescents, the nurse would treat all adolescents as adults and maintain the adolescent's right of confidentiality. The nurse would also conduct the examination in a nonthreatening area. While performing the assessment of an adolescent, a nurse would call him or her by their first name. The nurse would gather all the history of infants and small children from their parents or guardians.

A 16-year-old high school student comes to a community health center because of the fear of having contracted herpes. The teenager is upset and shares this info with the community health center nurse. Which response would the nurse provide?

- You sound worried. Let me make arrangements to have you examined. RATIONALE: Telling the client that she sounds worried and offering to arrange an examination immediately identifies the client's fear as real and offers a service to meet the need for info about the client's physical status.

Which client who survived an earthquake would the nurse assess first to prevent an emergency threat?

- active hemorrhage RATIONALE: An active hemorrhage is a condition that is included in the emergent triage category. The emergent or life-threatening tier level indicates that the existing condition poses an immediate threat to life and should be assessed first.

Which intellectual factor would the nurse consider as a dimension when gathering data for a client's health history?

- attention span RATIONALE: Attention span is an intellectual dimension used to gather data for health history. The social dimension for gathering the health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.

The registered nurse is caring for a client in the medical unit. The registered nurse wants to transfer the responsibilities and accountability to another individual. Whom would the registered nurse use to accomplish this task?

- charge nurse

Which employee should be competent in critical thinking, leadership, communication, and time management skills?

- charge nurse - registered nurse RATIONALE: The charge nurse and RN would have a sophisticated level of competency in critical thinking, leadership, communication, time management, clinical practice, and organizational skills. These skills are helpful for the charge nurse or the RN when serving as the delegator. The student nurse, unlicensed personnel, and LPN do not delegate because they are less skilled than the charge nurse is.

During an admission interview, a client is expansive and distractible and demonstrates a fragmented, pressured, nonsequential pattern of speech. Which communication technique would the nurse use?

- closed questions RATIONALE: The client demonstrates flight of ideas and other behaviors seen in the manic phase of bipolar disorder. The nurse must use highly structured closed questions to help the client focus on a single topic. Active listening, paraphrasing, and open-ended questions are excellent techniques that encourage the client to express feelings, explore options, and problem-solve; however, when the goal is to obtain specific information (e.g. admission interview), these techniques are not a good choice for the clients in the manic phase.

The emergency department is preparing for an influx of victims who may have been exposed to ionizing radiation after a disaster at a nuclear power plant. Which action is the priority for the nurse to perform as victims begin to arrive?

- decontaminate all clients. RATIONALE: The nurse's initial action will be to immediately begin decontamination procedures for all victims who present to the ER. Health histories will be obtained after clients are stabilized. Hospital administration must be notified before victims' arrival. Droplet precautions are used for airborne diseases, not radiation exposure.

Which nursing intervention is the priority action during the health history portion of the secondary survey in an emergency assessment?

- determining medication allergies RATIONALE: The priority nursing action during the health history portion of the assessment is to determine medication allergies. Noting the general appearance, examining the neck for stiffness, and auscultating for heart and lung sounds are actions that occur during the head-to-toe physical assessment, not the health history.

Which type of interview is correct when the nurse admits a client to a clinic?

- directive RATIONALE: The first step in problem-solving is data collection so that client needs can be identifies. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad, bc in a nondirective interview the client controls the subject matter. Problem-solving and information giving are premature at the initial visit.

Which nursing actions best promote communication when obtaining a nursing history?

- establishing eye contact - paraphrasing the client's message - using broad, open-ended statements RATIONALE: Eye contact indicates to the client that the nurse is listening and interested. Paraphrasing is an effective interviewing technique; it indicates to the client that the message was heart and invites the client to elaborate further. Open-ended statement provide a milieu in which people can verbalize their problems rather than be placed in a situation of providing a forced response. Asking 'why' and 'how' questions can be threatening to the client, who may not have the answer to these questions. False reassurance is detrimental to the nurse-client relationship and does not promote communication.

Which therapeutic communication technique would be useful for a client with major depressive disorder?

- reflecting, observing self, using silence, paraphrasing, asking open ended questions, encouraging comparison

Which definition is correct to explain the nursing process?

- sequence of steps used to meet the client's needs. RATIONALE: The nursing process is a step-by-step method that scientifically provides for a client's nursing needs.

Which questions would the nurse ask the client when obtaining the health history?

- tell me about your food habits - do you use alcohol or tobacco? - have you ever experienced any allergic reactions? The health history of a client includes the client's food habits so that the nurse can obtain an assessment of the client's nutrition status. The nurse also assess the clients habits and lifestyle patterns. Asking about the use of alcohol or tobacco helps determine the risk factors for certain diseases. The health history includes descriptions of allergies, reactions to food, latex, drugs, or contact agents such as soap.

The nurse is explaining the nursing process to a student nurse. Which step of the nursing process would include interpretation of data collected about the client?

An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client's assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned. Diagnosis is the formulation of a problem based on the gathering and interpretation of data collected about the client.

The nurse is assessing a client who arrived at the health care facility for an appointment. Which action by the nurse will be beneficial during the interview?

Asking about the client's current concerns

The nurse's coworker approaches the nurse to inquire about the test results of a friend who is being cared for by the nurse. Which response by the nurse would be correct?

Decline to discuss the friend's medical condition.

Which client is at a high risk for a rise in blood pressure based on the given data?

The blood pressure rises when the heart rate is decreased and the stroke volume is increased. In adults, the pulse should be 60 - 100 bpm. Client's C's heart rate is 40 beat/min, which is less than normal, and the stroke volume is increase. Thus client C has has a high risk of high bp.

A young woman tells the nurse, "my partner prevents me from taking my medications." Which should the nurse do to deal with the situation?

The statement indicates that the individual may be a victim of abuse, so the nurse would interview the client alone when the client has privacy and the individual suspected of being the abuser is not present. Discussing the problems with the primary health care provider may cause fear of retribution in the abused client. When dealing with people with mental illness, the nurse would collaborate with multiple community resources to obtain adequate healthcare. When dealing with vulnerable populations, the nurse would evaluate their cultural beliefs, values, and practices to determine their specific needs.