Nurs 211 Chapter 14: Assessing Prep U
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? -Subjective -Objective -Physical -Unreliable
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? -Subjective -Objective -Primary -Secondary
Objective
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 -Interviewing friends to ascertain the client's exercise habits -Asking the client to discuss social functioning -Performing an abdominal assessment
Obtaining data regarding the amount and frequency of drinking
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 Loneliness -Acute Pain -Risk for Impaired Parenting -Ineffective Breastfeeding -Ineffective Infant Feeding Pattern
Risk for Impaired Parenting
The charge nurse identifies the need for further education when a new nurse makes which statement? -"Physical assessment is the examination of the client for objective data." -"Physical assessment is the examination of the client for subjective data." -"Physical assessment is ongoing to detect changes in the client's condition." -"Physical assessment should be documented in a timely manner."
"Physical assessment is the examination of the client for subjective data."
The nurse is terminating an interview with a client in the behavioral health unit. Which statements by the nurse would indicate an effective termination of the interview? Select all that apply. -"We have 5 minutes left. Do you have any questions?" -"What are some of your most important concerns?" -"I have to go and check on another client now." -"Here is my card with my phone number. Please call if you have concerns." -"Are you ready to finish the interview now?"
"Here is my card with my phone number. Please call if you have concerns." "What are some of your most important concerns?" "We have 5 minutes left. Do you have any questions?"
Which nursing skill uses all five senses? -Documentation -Observation -Listening -Caring
Observation
The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate? -"When I perform the nursing history, I will need to ask your family to leave the room." -"I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes." -"I will perform a physical assessment while I am obtaining the nursing history." -"I will leave a form with you to complete the nursing history information I need."
"I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes."
A nurse manager identifies a need for further instruction when a new nurse makes which statement? -"The client is always the best source for collecting data." -"The client is usually the best source for collecting data." -"Family members are a good source of data when the client is a young child." -"Caregivers can be a helpful source of data when the client has a limited capacity for information."
"The client is always the best source for collecting data."
Which statement made by the nurse indicates data that would be documented as part of an objective assessment? -"The client's sister reports that the client has unrelieved pain." -"The client's right leg is cold to the touch, from the knee to the foot." -"The client reports nausea following eating." -"The client reports having heartburn after breakfast."
"The client's right leg is cold to the touch, from the knee to the foot."
Which statement by a nurse best indicates an accurate understanding of the different types of assessments? -"It is up to the nurse to decide which assessment to perform." -"How much time the nurse has and how the client is feeling determine which type of assessment to perform." -"The purpose for the assessment offers guidance for which type and how much data to collect." -"The physician informs the nurse of which type of assessment to perform for each client."
"The purpose for the assessment offers guidance for which type and how much data to collect."
Which are examples of subjective data? Select all that apply. -A nurse observes a client wringing the hands before signing a consent for surgery. -A nurse observes redness and swelling at an intravenous site. -A client describes pain as an 8 on the pain assessment scale. -A client feels nauseated after eating breakfast. -A client's blood pressure is elevated following physical activity. -A client reports being cold and requests an extra blanket.
A client describes pain as an 8 on the pain assessment scale. A client feels nauseated after eating breakfast. A client reports being cold and requests an extra blanket.
Which are examples of subjective data? Select all that apply. -A nurse observes a client wringing the hands before signing a consent for surgery. -A nurse observes redness and swelling at an intravenous site. -A client describes pain as an 8 on the pain assessment scale. -A client feels nauseated after eating breakfast. -A client's blood pressure is elevated following physical activity. -A client reports being cold and requests an extra blanket.
A client feels nauseated after eating breakfast. A client reports being cold and requests an extra blanket. A client describes pain as an 8 on the pain assessment scale.
Which are examples of objective data? Select all that apply. -A client's report of pain -Laboratory test results -Breath sounds on auscultation -A client's report of being unable to breathe -A client's temperature
A client's temperature Breath sounds on auscultation Laboratory test results
A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client? -A full assessment of the urinary system -A focused assessment of the specific problems identified -Obtaining a detailed assessment of the client's sexual history -Conducting a thorough systems review to validate data on the client's record
A focused assessment of the specific problems identified
Which scenario is an example of a time-lapse reassessment? -Seeing a client down on the floor, the nurse assesses the client's airway, breathing, and circulation, calls for help, and begins a quick neurological exam. -A nurse just coming on shift performs a focused physical assessment on each client, based on the client's diagnosis. -A nurse in a long-term skilled nursing facility assesses a new resident's baseline health status. -A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.
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? -Addressing priority problems involves skipping interventions. -Priority problems are identified at predetermined intervals throughout the shift. -A priority problem requires a nursing intervention before another problem is addressed. -The priority of problems is established and continued according to the nursing plan of care.
A priority problem requires a nursing intervention before another problem is addressed.
Which action would the nurse perform in the assessment phase of the nursing process? -Developing a plan to manage the client's health problems -Coming up with a nursing diagnosis based on a potential health risk -Asking the client whether the client has cultural preferences -Determining whether the client's goals for wellness have been met
Asking the client whether the client has cultural preferences
Which is the purpose of a focused assessment? -Provides breadth for future comparisons -Suggests possible problems -Adds depth to existing information -Gives a comprehensive volume of data
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? -Inform the client that the interview must proceed before getting anything that will alter sensorium. -Administer prescribed pain medication prior to conducting the interview. -Document that the client refused the interview. -Use the information that is on the electronic health record and eliminate the need for the interview.
Administer prescribed pain medication prior to conducting the interview.
Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training? -Validation is an important part of assessment. -Validation helps to keep data as free from error as possible. -All data collected need to be validated. -Validation is the act of confirming or verifying.
All data collected need to be validated.
Which are examples of subjective data? Select all that apply. -Anxiety -Light-headedness -Nausea -Edema -Laceration
Anxiety Light-headedness Nausea
When is the best time for a nurse to take a client's health history? -After the client is settled and feels ready -As soon as possible after a client presents for care -Within 24 hours of admission -Anytime before the client is discharged
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 to wake up and try to answer the interview questions. -Ask the client's spouse to come in and answer the interview questions. -Wait until the next day to obtain the answers to the interview questions. -Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.
Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.
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? -During the collection of data only -At the end of the data-gathering process -In the middle of the data-gathering process -Both during the collection and at the end of the collection
Both during the collection and at the end of the collection
Nurses understand the problem that clients have when they are repeatedly asked the same questions. To best avoid this problem, which intervention should nurses perform when beginning to collect assessment data? -Organize all questions into categories. -Make the questions short. -Carefully review the client's record. -Tell the client the questions will be quick.
Carefully review the client's record.
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 -Number of years in profession -Caring
Caring Competence Respect for client Professionalism
Which is the best source of information for the nurse when collecting data for an assessment? -Primary physician -Client -Charge nurse -Medical record
Client
The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply. -Client states, "I feel so sad all of the time." -Clothes unkempt and hair greasy -Blood pressure 140/82 mm Hg -Client states, "I am in pain." -Ecchymosis on upper left arm
Client states, "I feel so sad all of the time." Client states, "I am in pain."
Which group of terms best defines assessing in the nursing process? -Problem-focused, time-lapsed, emergency-based -Designing a plan of care, implementing nursing interventions -Collection, validation, communication of client data -Nurse-focused, establishing nursing goals
Collection, validation, communication of client data
A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrintestinal symptoms or should be reported to the physician. Which action should the nurse perform next? -Call the family. -Consult with another nurse. -Chart the information. -Wait and see whether the pain subsides.
Consult with another nurse.
The nurse is caring for an older adult client admitted to the hospital for a respiratory condition. What type of data should the nurse review prior to caring for this client? Select all that apply. -Consultations -Lab reports -Medical history -Progress notes -Financial history -X-ray reports
Consultations Lab reports Medical history Progress notes X-ray reports
The nurse is conducting a health 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. -Consult with other members of the health care team about the conflicting client information. -Prioritize documentation of objective data collected in the examination while avoiding any mention of the discrepancy. -Ask significant family members about the client's usual breathing pattern at home.
Continue the health history with questions focusing on respiratory function.
Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? -Initial -Focused -Emergency -Time-lapse
Focused
A client has been discharged from an acute care facility with a referral for a home health nurse to make an assessment. What is the priority action by the home health nurse on the initial home visit? -Care for the client's physical pain. -Establish the client's database. -Evaluate the care previously provided. -Receive a report from the nursing staff.
Establish the client's database.
The night shift nurse is caring for a hospitalized client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client? -Social isolation -Powerlessness -Chronic pain -Disturbed sleep pattern -Hyperthermia
Disturbed sleep pattern
A client comes to the emergency department with a stab wound and is bleeding profusely. Which type of assessment should the nurse perform on this client immediately? -Time-lapsed -Focused -Emergency -Head-to-toe
Emergency
A client is a poor historian of the client's past medical history. Whom should the nurse consult about the client's past history? -Physician -Old chart -Social worker -Family
Family
What must the nurse do to identify actual or potential health problems? -Evaluate care implemented -Meet with significant others -Call the physician -Gather data from sources
Gather data from sources
Which piece of client information is subjective? -A temperature of 102°F (38.9°C) -Leukoplakia on the client's oral mucosa -Generalized myalgia or muscle pain -Alert and oriented to person and place but not time or situation -Ptosis, a drooping of the eyelid, on the right side
Generalized myalgia or muscle pain
A nurse is performing an assessment on a client in which the nurse categorizes the data according to various categories of functions. Which assessment model is the nurse using? -Gordon's functional health patterns -Maslow's hierarchy -Medical -Prevention
Gordon's functional health patterns
The nurse notices during an assessment interview that the client cannot stay focused and jumps from one topic to another. The client also is speaking very rapidly and at times incoherently. What should the nurse suspect is the main cause of this behavior? -Pain -Hunger -High anxiety -Sleepiness
High anxiety
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 stands at the foot of the bed. -If both the nurse and client are seated, their chairs are at right angles to each other, 30 cm apart. -If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. -If the client is in bed, the nurse stands at the side of the bed.
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? -Focused -Psychosocial -Physical -Initial
Initial
Which are assessment techniques the nurse uses when performing a physical examination? Select all that apply. -Inspection -Palpation -Documentation -Percussion -Auscultation
Inspection Palpation Percussion Auscultation
The nurse must be familiar with the client record in order to provide care effectively. Which parts of the client record include only the findings of physicians? Select all that apply. -Medical history -Physical exam -Care plan -Progress notes -Laboratory values
Medical history Physical exam Progress notes
The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next? -Recheck the client's pulse in 2 hours. -Recheck the client's pulse at the next scheduled assessment time and document the findings on the chart. -Document the findings on the chart and recheck in 1 hour. -Notify the physician of the change and document the finding. -Notify the physician after the next scheduled assessment time if the pulse is unchanged.
Notify the physician of the change and document the finding.
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? -Hunger -Low anxiety -Pain -Sleepiness
Pain
What should the nurse do prior to performing an initial assessment on a newly admitted client? -Introduce the members of the health care team to the client. -Review the records available on the client. -Report to the charge nurse what needs to be done for the client. -Tell the client that the nurse will do an assessment only if it's convenient.
Review the records available on the client.
The nurse is assessing a client in an outpatient setting. The client states,"I don't want to live anymore. My family hates me, and I am so tired of being sick. I have a gun, and I am seriously thinking of killing myself." The client reports a 30-year heavy smoking habit and having a cough for about 6 months. Ascultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminshed bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing diagnosis for this client? -Risk-Prone Health Behavior -Ineffective Health Maintenance -Impaired Gas Exchange -Risk for Suicide -Stress Overload
Risk for Suicide
The nurse is assessing a client in an outpatient setting. The client states,"I don't want to live anymore. My family hates me, and I am so tired of being sick. I have a gun, and I am seriously thinking of killing myself." The client reports a 30-year heavy smoking habit and having a cough for about 6 months. Ascultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminshed bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing diagnosis for this client? -Risk-Prone Health Behavior -Ineffective Health Maintenance -Impaired Gas Exchange -Risk for Suicide -Stress Overload
Risk for suicide
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? -Physiologic -Safety and security -Love and belonging -Self-esteem -Self-actualization
Safety and security
The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment? -Supplement the client's information by speaking with family or friends. -Limit the assessment to objective data. -Obtain the client's records from admissions to other institutions. -Perform the assessment in several short episodes rather than at one sitting.
Supplement the client's information by speaking with family or friends.
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 client -The client's physician -The client's chart -The nursing and medical literature
The nursing and medical literature
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 physician -The nurse -The case manager -The nursing supervisor
The nurse
Which items reflect the assessment phase of the nursing process? Select all that apply. -The nurse asks the client, "How would you rate your pain?" -The nurse assists the client with coughing and deep breathing every hour. -The client's abdomen is firm and distended with hypoactive bowel sounds. -The client states, "I rarely sleep more than 6 hours." -The nurse and the client determine a tolerable pain level.
The nurse asks the client, "How would you rate your pain?" The client's abdomen is firm and distended with hypoactive bowel sounds. The client states, "I rarely sleep more than 6 hours."
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 recapitulates the interview, highlighting important points. -The nurse asks the client if there is anything else that needs to be divulged -The nurse gathers all the information needed to form the subjective database.
The nurse assesses the client's comfort and ability to participate in the interview.
Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training? -The nurse sits on eye level with the client. -The nurse verifies the client's name. -The nurse asks the client what name the client would like to be called. -The nurse introduces onself to the client by pointing to the nurse's name badge. -The nurse should sit on eye level with the client.
The nurse introduces onself to the client by pointing to the nurse's name badge.
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? -Developmental stage assessment -Time-lapsed assessment -Emergency assessment -Focused assessment
Time-lapsed assessment
When performing an assessment, the nurse should focus most on the developmental stage for which client? -Toddler -Young adult -Middle-age adult -Adolescent
Toddler
When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind? -Validate inferences with the client. -Do not share inferences with the client. -Document all inferences. -Avoid making any inferences.
Validate inferences with the client.
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? -Chart the data. -Validate the data. -Ignore the client's answer. -Ignore the client's nonverbal behavior.
Validate the data.
While doing an assessment, the nurse identifies questionable data. Which should the nurse do first? -Disregard the questionable data. -Validate the questionable data. -Inform the physician of the questionable data. -Inform the client that the data are not correct.
Validate the questionable data.
During admission, a teenage client who has a diagnosis of anorexia informs the nurse of a 5-pound weight loss within the last 6 months. What should the nurse do with this data? -Record it in the client's record. -Validate the weight loss with the client. -Inform the client that this cannot be correct. -Ignore this information completely and continue collecting data.
Validate the weight loss with the client.
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 to the charge nurse at the change of shift. -Inform the unlicensed assistive personnel to document the finding. -Verbally report the finding immediately to the client's physician. -Reassess the client's temperature in 2 hours and chart this data.
Verbally report the finding immediately to the client's physician.
Which statement made by the nurse indicates data that would be documented as part of an objective assessment? -"The client's sister reports that the client has unrelieved pain." -"The client's right leg is cold to the touch, from the knee to the foot." -"The client reports nausea following eating." -"The client reports having heartburn after breakfast."
Which statement made by the nurse indicates data that would be documented as part of an objective assessment? "The client's sister reports that the client has unrelieved pain." "The client's right leg is cold to the touch, from the knee to the foot." "The client reports nausea following eating." "The client reports having heartburn after breakfast."
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: -a cue. -an inference. -a misinterpretation. -duplicate data.
a cue
When collecting subjective and objective data for a database in a client's home, it is important to: -ask the client to turn off the television. -ask the social worker to verify the collected data. -collect a 24-hour diet recall. -evaluate the care provided by the physician.
ask the client to turn off the television.
A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being: -purposeful. -factual. -complete. -able to prioritize.
able to prioritize
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: -a cue. -an inference. -duplicate data. -erroneous data.
an inference
During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to: -body systems. -functional health patterns. -human response patterns. -human needs.
body systems.
The nurse is collecting data from a client during a complete assessment. Which skill is the nurse demonstrating when documenting the assessment data? -Clustering -Communication -Validation -Collection
communication
The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to: -examine certain body systems. -complete an exam of all body systems. -perform a review of the problem areas. -focus on only the systems that the client is comfortable with.
complete an exam of all body systems
The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to: -examine certain body systems. -complete an exam of all body systems. -perform a review of the problem areas. -focus on only the systems that the client is comfortable with.
complete an exam of all body systems.
Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist? -Medical history -Progress notes -Consultation -Laboratory reports
consultation
A client has just given birth to the client's first baby. The client reports to the nurse not knowing very much about newborns because of limited exposure to them. Which is the priority nursing diagnosis for the nurse to address prior to discharge of this client? -Fear -Deficient Knowledge -Alteration in Family Processes -Stress Overload -Ineffective Coping Mechanisms
deficient knowledge
A nurse has just taken vital signs on a newly admitted client. Vital signs would be entered on the client record as which type of data? -Subjective -Objective -Intuitive -Hunches
objective
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? -Head-to-toe -Focused -Emergency -Time-lapse
focused
The purpose of obtaining a nursing history is to: -assist the physician to establish a medical diagnosis. -minimize the time required to establish a nursing diagnosis. -focus on objective physical data specific to the client. -identify actual and potential health problems.
identify actual and potential health problems.
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 type of data? -Subjective -Objective -Intuitive -Hunches
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? -Subjective -Objective -Primary -Secondary
objective
During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should: -clarify the client's health status. -review as much information as possible. -identify existing and potential health problems. -develop the nursing plan of care.
review as much information as possible.
The nurse identifies which types of data when performing an assessment? Select all that apply. -Subjective -Intuition -Objective -Critical thinking -Hunches
subjective and objective
The nurse is summarizing the key points of the interview. This nursing activity occurs during which phase? -Preparatory phase -Introductory phase -Working phase -Termination phase
termination phase
