Week 1: Clinical Judgement in Health Assessment (Edapt)

A novice health examiner working in an urgent care center is preparing to assess a client when a more experienced colleague approaches and says, "Let me take this one. I know they want narcotics and it is not going to happen." What is the best response by the novice examiner to prevent bias in the client's health assessment?

"Thanks, but I can use the experience. Perhaps after I am done you can review my documentation and discuss with me how the client's health may have changed."

In which situation would it be most appropriate to perform a comprehensive health history assessment on a client?

A client is being seen for complaints of fatigue.

During the health assessment, the examiner observes that the individual avoids answering questions related to the cause of the rectal bleeding they are experiencing. Which actions will the examiner take to obtain a complete history of the bleeding? Select all that apply.

Acknowledge the intimate nature of the conversation and tell them to take their time. Ask the individual if the bleeding is a result of abuse or rape. Assure the person that any information shared will remain confidential except in cases of abuse.

When listening to a client's breath sounds, the examiner is unsure of a sound that is heard. Which action is of the highest priority for the examiner?

Ask a coworker to listen.

Which step of the nursing process includes data collection by health history, physical examination, and interview?

Assessment

During which steps of the nursing process are clinical judgment and critical thinking taking place? Select all that apply.

Assessment Diagnosis Planning Implementation Evaluation

The health examiner focuses the assessment on the client's urinary system after identifying which cluster of cues?

Burning with urination, foul smelling urine, frequent urination of small amounts

Which critical thinking skill helps the examiner see relationships among the data?

Clustering related cues

Identify sources of data the examiner incorporates into a complete health assessment by dragging them into the field below.

Information shared by the client's sister Information shared by the health care provider Laboratory results What the examiner sees Vital signs in the health record Client statements

Expert health examiners learn to attend to a pattern of assessment data and act without consciously labeling it. What is the term used to describe these responses?

Intuition

Indicate which body system may be affected by the listed cues. Each cue may fall into more than one category.

Neurologic System: Temperature 103.9 °F Oxygen saturation 81% (decreased) Confusion respiratory and cardiovascular - all of them

The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply.

Nonproductive cough. Rate of respirations 16 breaths per minute. Inspiratory wheezes noted in left lower lobes. Client reports dyspnea upon exertion.

Separate these observations into those that apply to the novice and those that apply to the expert by dragging the phrases to the correct location.

Novice: Appears hesitant Refers to notes frequently Follows a checklist Less likely to multitask Expert: Appears to "just know what to do" Collects subjective and objective data at the same time Allows client to take the lead

A client is brought by ambulance to the emergency department with multiple traumas received in an automobile crash. They are alert and cooperative, but their injuries are quite severe. How would the examiner proceed with data collection?

Simultaneously ask history questions while performing the examination and initiating treatment.

What is the best question for the examiner to ask first?

Tell me more about your pain. Where is it and when did it start?

Novice health examiners are most likely to collect clinical data by

a set of rules