nurs 222 exam #2 chapter 14

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

Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training?

All data collected need to be validated.

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

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?

"I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes."

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 subjective data."

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.

Which statement by a nurse best indicates an accurate understanding of the different types of assessments?

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

Which statement is true regarding addressing a priority problem?

A priority problem requires a nursing intervention before another problem is addressed.

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 focused assessment of the specific problems identified

Which is the purpose of a focused assessment?

Adds depth to existing information

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.

Which are examples of subjective data? Select all that apply.

Anxiety Light-headedness Nausea

A physical examination on a client should always include which components? Select all that apply.

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

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

Which action would the nurse perform in the assessment phase of the nursing process?

Asking the client whether the client has cultural preferences

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.

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?

Carefully review the client's record.

A nurse is assessing a client admitted to the hospital with reporting left-sided weakness and difficulty speaking. Which documented statement best represents the data that should be collected in a nursing assessment?

Client is unable to communicate basic needs and cannot perform hygiene measures with left hand.

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?

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 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.

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?

Establish the client's database.

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

Focused

What must the nurse do to identify actual or potential health problems?

Gather data from sources

The nurse records the name, age, and genetic background of the client. The data are components of which tool?

Health history

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

Which are assessment techniques the nurse uses when performing a physical examination? Select all that apply.

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 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?

Notify the physician of the change and document the finding.

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next?

Recheck the temperature, paying close attention to technique.

During data collection the nurse may validate data by which method? Select all that apply.

Referring to textbooks, journals, and research reports Checking the consistency of cues Clarifying the client's statements Seeking consensus among colleagues about inferences

The nurse is interviewing an 80-year-old client admitted to the hospital for evaluation of diabetes. The client reports enjoying being in the hospital because the client lives alone and does not have many friends. The client reports having a spouse die 1 year ago and no longer being able to drive. The client relies on a daughter, who lives one hour away, to shop for the client once a week. The client states, "My daughter can never stay long and is just in and out in no time." Which nursing diagnoses would be appropriate for this client? Select all that apply.

Risk for Loneliness Powerlessness

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 for Suicide

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.

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

The client

Other than the client, what sources of client information should the nurse consider when assessing a client? Select all that apply.

The client's support people The client's health record Family members accompanying the client Other health care professionals

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.

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

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.

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?

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 immediately to the client's physician.

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

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being:

able to prioitize

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:

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.

Which is the best source of information for the nurse when collecting data for an assessment?

client

Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist?

consultation

During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:

review as much information as possible.

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

termination phase

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.