PREPU CH 14
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 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:
complete an exam of all body systems.
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.
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 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.
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.'"
An 80-year-old client presents to the clinic, reporting a headache that has continued for the past 4 days. Which question(s) should the nurse prioritize in the assessment? Select all that apply.
"Have you experienced any falls and hit your head?" "Are you having any dizziness?" "Is the headache affecting your vision?"
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.
"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?"
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?"
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."
The nurse reports for duty in the emergency department and notes the following clients for which the nurse will be assuming care. After receiving the hand-off report, which client should the nurse prioritize for care?
12-year-old female with asthma attack
The nurse is performing an admission assessment. Which are considered objective data? Select all that apply.
38-year-old man Weight: 195 lb (89 kg) Height: 6 ft (1.82 m)
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 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.
TEXTBOOK PRACTICE QUESTION: A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? A. "You made an inference that she is fine because she has no complaints. How did you validate this?" B. "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." C. "Sometimes everyone gets lucky. Why don't you try to help another patient?" D. "Maybe you should reassess the patient. She has to have a problem—why else would she be here?"
ANS: A Rationale: The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving.
TEXTBOOK PRACTICE QUESTION: The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all that apply. A. A patient tells the nurse that she is feeling nauseous. B. A patient's ankles are swollen. C. A patient tells the nurse that she is nervous about her test results. D. A patient complains that the skin on her arms is tingling. E. A patient rates his pain as a 7 on a scale of 1 to
ANS: A, C, D, E Rationale: Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting.
TEXTBOOK PRACTICE QUESTION: The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. A. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." B. "It's hospital policy. I know it must be tiresome, but I will try to make this quick!" C. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." D. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." E. "We need to check your health status and see what kind of nursing care you may need." F. "We need to see if you require a referral to a physician or other health care professional."
ANS: A, E, F Rationale: Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.
POWERPOINT PRACTICE QUESTION: True or False. Most health care institutions establish a minimum data set that specifies the information that must be collected from every patient and used as a structured assesment form to organize or cluster the data. A. True B. False
ANS: A. True Rationale: Most health care institutions establish a minimum data set that specifies the information that must be collected from every patient and uses a structured assesment form to organize and cluster the data.
TEXTBOOK PRACTICE QUESTION: A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? A. Maslow's human needs B. Gordon's functional health patterns C. Human response patterns D. Body system model
ANS: B Rationale: Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.
TEXTBOOK PRACTICE QUESTION: A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? A. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" B. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." C. "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." D. "Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."
ANS: B Rationale: Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking.
POWERPOINT PRACTICE QUESTION: Which one of the following assessments would be performed on a patient to gather data about his previously diagnosed liver cancer? A. Initial comprehensive assesment B. Focused assesment C. Emergency assesment D. Time-lapsed assesment
ANS: B. Rationale: In a focused assesment, the nurse gathers data about a condition that has already been diagnosed. An initial comprehensive assessment is performed shortly after the patient is admitted to a health care agency or service. When a physiologic or psychological crisis presents, the nurse performs an emergency assesment. A time-lapsed assesment compares a patient's current status to baseline data obtained earlier.
POWERPOINT PRACTICE QUESTION: True or False: A nursing assessment duplicates a medical assessment by focusing on the patient's responses to the health problem. A. True B. False.
ANS: B. False Rationale: A nursing assesment does not duplicate a medical assessment, rather it focuses on the patient's responses to the health problem.
POWERPOINT PRACTICE QUESTION: True or False. A patient rates his pain as a "7" on a pain rating scale. This rating is considered to be objective data. A. True B. False
ANS: B. False Rationale: A patient rating his pain on a pain rating scale is considered to be subjective data.
TEXTBOOK PRACTICE QUESTION: The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? A. Inform the charge nurse. B. Inform the surgeon. C. Validate the finding. D. Document the finding.
ANS: C Rationale: The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy.
TEXTBOOK PRACTICE QUESTION: A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? A. Correct the initial assessment form. B. Redo the initial assessment and document current findings. C. Conduct and document an emergency assessment. D. Perform and document a focused assessment of skin integrity.
ANS: D Rationale: Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.
TEXTBOOK PRACTICE QUESTION: The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? A. Comprehensive B. Initial C. Time-lapsed D. Quick priority
ANS: D Rationale: Quick priority assessments (QPAs) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care facility or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.
TEXTBOOK PRACTICE QUESTION: A patient vomits after eating supper. When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? A. Thank the wife for being present. B. Ask the wife if she wants to remain. C. Ask the wife to leave. D. Ask the patient if he would like the wife to stay
ANS: D Rationale: The patient has the right to indicate whom he would like to be present for the nursing history and exam. The nurse should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife.
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.
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.
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 Establishment of a database for interventions Identification of health problems
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
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.
A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?
Assess the client's blood pressure.
The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?
Auscultate the chest for breath sounds.
The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview?
Avoid the impulse to interrupt.
Which is the best source of information for the nurse when collecting data for an assessment?
Client
The nurse is preparing to interview several clients during clinic hours. What language difficulty might a nurse encounter while performing various interviews in a diverse population of clients?
Clients having a limited education Clients not being fluent in the same language as the nurse Clients fearing saying the wrong thing
Which group of terms best defines assessing in the nursing process?
Collection, validation, communication of client data
While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate?
Consult with another nurse for that colleague's description of the assessment or observations.
Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist?
Consultation
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 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
The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?
Functional assessment
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.
The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?
Inspection
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
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. Which 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
A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?
Secondary
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.
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 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
Which traits of the nurse are most important for an assessment to be successful?
Trustworthy and confident
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 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 assessing a client in an outpatient setting. The client states, "I do not 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. Auscultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminished bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing concern for this client?
suicide attempt risk