NCLEX-Style Review Questions (PrepU)#2:
The nurse is completing a health assessment on a newly admitted client. Which of the following documented findings is classified as subjective data? Select all that apply.
A. The unlicensed assistive personnel (UAP) reports vital signs: temp 100 c; pulse, 88; resp, 24; blood pressure, 148/72.
B. The client states that the pain is worse at night
C. "I have not had a bowel movement for 3 days."
D. The client voided 120 ml of dark yellow urine.
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body systems.
Explanation:
The categorization of assessment findings according to systems (in this case, musculoskeletal, gastrointestinal, and respiratory) is characteristic of a body systems model for organizing data. Although systematic, this strategy tends to ignore spiritual and psychosocial considerations. Human needs are based on food, water, and shelter. Human response patterns involve the subjective awareness of information. The
functional health patterns model is used to provide a more comprehensive nursing assessment of the patient focusing on sleep, roles, exercise, relationships, etc.
Which of the following is an example of a time-lapse reassessment?
Bob is a nurse in a long-term skilled nursing facility. Noreen is a new client. Bob wants to gather information from Noreen, which includes her health status and any problematic health patterns, and to get a baseline for Noreen's overall functioning.
Daren is a nurse in a hospital who happens to walk by a room and notices a client down on the floor. Daren immediately assesses the client for airway, breathing, and circulation. Once the presence of these three is established, Daren calls for help and begins a quick neurological exam.
Natalia is a visiting nurse who has an appointment with Donald, an 85-year-old man with mobility issues. Natalia has worked with Donald in the past on the ways in which he can prevent falls. Today she wants to assess how he is doing with the fall prevention strategies they practiced before.
Joan is a nurse who is just coming on to her shift. She has received client reports from the nurse leaving the floor. To start off her day, she goes into each of her client's rooms and performs a focused physical assessment based on each individual's diagnosis.
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