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

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 performing a focused assessment, which involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the client's health. An emergency assessment is performed to identify life-threatening problems. A time-lapse assessment compares a client's current status to baseline data obtained earlier.

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?"

A helpful strategy in the termination phase of an interview is to ask the client: "Is there anything else you would like us to know that will help us plan your care?" This gives the client an opportunity to add data the nurse did not think to include. Expectations and previous practices should be addressed during the working phase of an interview.

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.'"

Subjective data should be recorded using the client's own words, using quotation marks as appropriate. Paraphrasing the client's words may lead to assumptions and misrepresentations.

When the nurse inspects a postoperative incision site for infection, which type of assessment is the nurse performing?

Focused

There are four types of assessment that a nurse may make, based on when the nurse is seeing the client. In focused assessments, the nurse determines whether the problem still exists; the status of the problem is also assessed as well as precise details in its improvement or worsening. A complete (general or initial) assessment would be done at the time of admission. A time-lapse assessment allows the nurse to reassess a client and condition that is already known to re-evaluate its status. The fourth type would encompass emergency assessment and may include a head-to-toe assessment.

When performing an assessment, the nurse should focus most on the developmental stage for which client?

Toddler

Nursing assessments vary according to the client's developmental needs. When assessing an infant, toddler, or child, the nurse should give special attention to physiologic and psychosocial aspects of growth and development to identify client problems. It is not as important to focus on developmental stage when assessing clients in the other age groups, because their developmental needs do not vary as much and do not affect the assessment as much.

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?

Objective

Objective data are data that are observable and measurable and can be seen, heard, felt, or measured by someone other than the client. Subjective data are information perceived only by the affected person. Physical and unreliable are not types of 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?"
"Here is my card with my phone number. Please call if you have concerns."

Some therapeutic ways to terminate an interview are to give a warning, ask the client to summarize the most importance concerns, ask "what else?", offer yourself as a resource, and explain all care routines. The nurse should not tell the client that the nurse is terminating an interview to check on someone else, as this gives the message that another client is more important. Asking a client whether the client wants to continue is not appropriate, as this implies that the information is not that important.

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is:

the initial comprehensive client assessment.

The initial comprehensive client assessment results in the baseline data that enables the nurse to make judgments, plan care, and refer clients to other health care workers if necessary.

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

able to prioritize.

It is essential to get the most important information first when doing an assessment. This is prioritizing. Being purposeful is when a nurse completes a task that has meaning for the client. Complete means that the information obtained is comprehensive. Factual is concerned with what is actually the case rather than interpretations of or reactions to a situation (for example, a diagnosis as opposed to a hunch).

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.

The nurse should make every effort to make the client comfortable prior to interviewing, including obtaining an prescription for and administering pain medication; if the pain persists, obtain only vital data and defer the remainder of the interview until the client is more comfortable. The information on the electronic health record is not inclusive of the subjective data from the client. The client is not refusing the interview, and the nurse can always come back later to complete it.

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

Gather data from sources

The nursing process includes: assessment, diagnosis, planning, implementation, and evaluation. The first phase, assessment, is the collection of data to identify actual or potential health problems for nursing interventions. Aside from evaluation, which is the final phase of the nursing process and involves assessing the client's progress toward meeting goals established in the plan of care, the remaining two options are not related to the specific activities in the nursing assessment process.

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

The four types of nursing assessment include complete, focused, time-lapse, and emergency. In time-lapse assessments, the nurse reassesses a client and condition that is already known to re-evaluate the client's status. In this case the nurse is revisiting the client's feelings and plans to change her life situation by leaving her abusive husband. In emergency assessments, the nurse assesses the client for life-threatening problems which are acutely present.. In focused assessments, the nurse focuses on assessing a specific problem that is already known to exist to further refine planning interventions. In complete (general or initial) assessments, the nurse does a thorough assessment of all aspects of a client's health status on the client's admission to a health care facility.

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?

Disturbed sleep pattern

The client has problems sleeping due to the unfamiliar environment. Although hospitalized, the client doesn't report isolation, powerlessness, or chronic pain.

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 Impaired Parenting

A 14-year-old parent with little family support is at risk for difficulties with the expanded role of parent. The client has not stated feeling loneliness or pain. The infant's feedings are not discussed in the scenario.

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."

The purpose for which the assessment is being performed offers the best guidance for what type and how much data to collect. The type of nursing assessment the nurse should conducted should not depend on (a) the nurse's preference, (b) how much time the nurse has, or (c) what the physician wants. It is important to take into account how the client is feeling when preparing to assess, but the client's feelsing should not dictate which assessments the nurse performs.

Which are models used in nursing to assist in clustering data? Select all that apply.

Human Needs
Functional Health Patterns
Human Response
Body Systems

Models used for organizing or clustering data when doing an assessment are the Human Needs, the Functional Health Patterns, the Human Response, and the Body Systems models. The Change Theory model is not related but instead explains how change takes place and how change can be instituted.

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?

Pain

Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief. Sleepiness would be be observed if the client did not respond in a timely manner. A client with low anxiety is relaxed and would answer the question with intention and thoughtfulness. A hungry client would be short-tempered and angry.

What should the nurse do prior to performing an initial assessment on a newly admitted client?

Review the records available on the client.

Records prepared by different members of the health care team provide information essential to comprehensive nursing care. The nurse should review records early when gathering data before the first contact with the client. This review helps to focus the nursing assessment and to confirm and amplify information obtained already. The other actions are not appropriate prior to performing an assessment. An assessment must be done whether it is convenient or not, for the appropriate care to be given.

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?

Both during the collection and at the end of the collection

Not all data need to be validated, but the nurse may validate data during the collection or at the end of the data-gathering process. When it is clear that the data are correct, the nurse may analyze the data and formulate nursing diagnoses.

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

In addition to information about medical diagnoses, treatment, and prognosis, a literature review of nursing and medical references offers nurses important information about nursing diagnoses, developmental norms, and psychosocial and spiritual practices that are helpful when assessing and caring for clients. Consulting with the client, physician, or client's chart would not give as comprehensive of a review.

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 primary source of information is the client. The client's spouse, friends, and test results would be secondary sources of data. There are no teritiary or quaternary sources of assessment data.

The purpose of obtaining a nursing history is to:

identify actual and potential health problems.

The purpose of the nursing health history is to identify the patient's strengths and weaknesses; health risks, such as hereditary and environmental factors; and potential and existing health problems. This interview does not typically include physical assessment of a client. As part of the nursing assessment and overall nursing process, its purpose is not to influence time within the process. The physician's medical work-up provides the data to develop the medical diagnoses.

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.

During the introductory phase, the nurse should inform the client how the information will be used and that confidentiality will be maintained. The alternate responses are not associated with the interview process and experience for the client.

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client?

Ineffective Breastfeeding

The frequency of breastfeeding is the likely cause of the infant's inability to gain weight. Feeding should be priority for a newborn. Although the infant does demonstrate an impaired sleep pattern and impaired comfort, these are not as important as the infant's inability to gain weight. There is no evidence that the mother is at risk for impaired parenting.

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
Caring

The nurse's interpersonal competence is critical beginning with the very first assessment. The client's initial impression is crucial. The nurse's competence, professionalism, and interpersonal qualities of caring and respect invite confidence and assure the client that help is available. The length of time as a nurse does not influence competence and professionalism.

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

The nursing health history captures and records the uniqueness of the client and should be obtained as soon as possible after a client presents to the health care facility for care. If the nurse waits until the client is ready, this may occur too late and the problem may become more problematic. Twenty-four hours is also too long. Waiting until the client is discharged is inappropriate because important medical as well as psychological information may be missed or not communicated.

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.

The nursing physical assessment that involves the examination of all body systems is called the review of systems. An assessment only on a specific problem area is a focused assessment. Nurses do not assess clients by focusing on the system that the client is most comfortable with. Examining a certain body system is not relevant in nursing.

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

A time-lapsed assessment is scheduled to compare a client's current status to the baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time are scheduled for this type of check. An emergency assessment is conducted if the client is having an emergency such as chest pain or hemorrhaging from the hand. Focused assessment is performed on clients focusing on the system or systems involved in the client's problem. Developmental stage assessment is the process of mapping a child's performance compared with children of similar age.

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.

If the client is in bed, the nurse sitting in a chair placed at a 45-degree angle to the bed ensures the nurse is sitting at eye-level with the client, which promotes communication. If the nurse is standing at the foot or at the side of the client's bed, an authoritative position is established, which does not promote good communication. If both the nurse and the client are seated, being 30 cm apart intrudes upon personal space; ideally the nurse and client should be about 1 m apart.

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

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.

Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. A client's pain, nausea, and chills can only be felt by that person. Data collected about a client, such as the client wringing the hands, redness and swelling at an intravenous site, and a blood pressure measurement, are considered objective data. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client.

Which is the purpose of a focused assessment?

Adds depth to existing information

A focused assessment adds depth to existing information or the initial database gathered by the nurse. A database assessment provides breadth for future comparisons. A focused assessment does not suggest possible problems facing the client but rather rules out or confirms the client's problems. A focused assessment is not voluminous and comprehensive, like a database assessment, but limited and to the point.

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

Focused

The nurse conducts a focused assessment of the client with a specific identified problem. An initial assessment is conducted by the nurse to establish a baseline database and identify current health problems. The nurse performs an emergency assessment during a crisis to identify life-threatening problems. A time-lapse assessment is one in which the nurse reassesses a client to evaluate the client's progress since a previous assessment for the same condition.

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

Nausea
Anxiety
Light-headedness

Subjective data are those that only the person experiencing them can perceive and report, such as anxiety, light-headedness, and nausea. Objective data are those that someone other than the person experiecing them can observe, such as edema and laceration.

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

The question focuses on independent actions that nurses can perform. Interventions for which the nurse may be legally responsible include increasing the frequency of assessments and initiating necessary changes in the treatment regimen. Nurses are responsible for alerting the appropriate professional (e.g., the physician) whenever assessment data differs significantly from the baseline. The nursing supervisor would be alerted if the professional does not evaluate the client. The case manager would be alerted when the client was ready for discharge.

Which is an example of objective data?

The skin of a client who has liver failure has a yellowish tint.

What is an advantage of using the functional health patterns model for assessment?

The nurse can identify client strengths and assets.

In the functional health patterns model, the client's strengths, talents, and functional health patterns are an integral part of the assessment data. This framework identifies strengths as well as deficits. The body systems model starts with an assessment of the client's general state of health and then moves to a systematic assessment of each body system. By systematically assessing each organ system using the body systems model, the nurse may reveal information that the client did not consider important.

Which piece of client information is subjective?

Generalized myalgia or muscle pain

Symptoms such as muscle pain or myalgia are considered subjective cues in a client's health history, as only the client can determine its presence. Signs of illness, such as temperature, leukoplakia, and ptosis, are considered objective cues in a health history, as is a nurse observing that a client is not oriented to time or situation. Objective signs are observable, perceptible, and measurable.

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.

The four types of assessment a nurse may perform are initial, focused, time-lapse, and emergency. A time-lapse reassessment is performed to reevaluate any changes in the client's health from a previous assessment. It is used to monitor the status of an already identified problem for a client with whom the nurse is already familiar. In this question the only scenario that depicts these components is that of the client with mobility issues. The assessment of the client who is found down on the floor is an emergency assessment. The assessment of each client based on the client's specific diagnosis is a focused assessment. The baseline assessment of the new resident in the long-term care facility is an initial assessment.

The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment?

Time-lapsed assessment

A nurse is comparing a client's current status to the baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses, are scheduled for periodic time-lapsed assessments to reassess their health status and to make necessary revisions in the care plan. This assessment can be comprehensive or focused. An initial assessment would be performed on admission. An emergency assessment is generally focused on any life-threatening client issues. PCAM is a tool health care providers can use to assess client complexity using the social determinants of health. These determinants may explain why some clients engage and respond well in managing their health while others with the same or similar health conditions do not experience the same outcomes.

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.

The nurse should use broad, open statements to facilitate communication during an interview. Using close-ended questions, which prompt yes or no answers, should be avoided, as it does not provide the level of the detail the nurse is seeking. The nurse should pay full attention to the client; paying too much attention to note-taking or making computer entries will interfere with good communication. The nurse should avoid providing false reassurance and agreeing with every statement the client makes.

For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

Initial

The Joint Commission has mandated that each client have a documented nursing admission (initial) assessment that follows institutional policies. An initial assessment is comprehensive and covers both a client's physical and psychosocial health. A focused assessment is one that addresses one specific problem that has already been identified; this type of assessment is not mandated by the Joint Commision.

During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

Sitting at eye level with the client

When the client responds to a question, the nurse conveys interest by maintaining eye contact, occasionally nodding, or verbally responding to the client's remarks. This is best accomplished by selecting a seat at eye level to allow direct engagement with the client during the interview. Standing during the interview can limit the interaction between nurse and client. Questions should be open-ended to elicit the most information and engage the client. Yes or no (close-ended) questions do not encourage the client to provide the level of detail the nurse is attempting to collect.

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training?

The nurse introduces onself to the client by pointing to the nurse's name badge.

When conducting an interview, the nurse should sit at eye level with the client, verbally introduce oneself, and state one's position. This sends the message that the nurse accepts responsibility and is willing to be accountable. The nurse should not simply point to the nurse's name badge in introducing oneself. The nurse should verify the client's name and ask what the client would like to be called.

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 whether it is okay to interview the client's spouse for the answers to the interview questions.

The nurse is responsible for collecting data in a timely manner. If the client is too fatigued, the nurse must ask for permission to obtain answers from the client's spouse prior to continuing to do so. Asking the client to wake up is disregarding the client's needs. Waiting until the following day is too long for the collection of important data.

The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source?

The client tells the nurse that there is a burning sensation when voiding.

Subjective data consist of information that only the client can describe, such as feelings, sensations, or experiences. An example of subjective data is a client's report of pain or fatigue. Objective data are those that can be measured and observed by others, a fever or a broken bone. The primary source is the client. Secondary sources include family members, reports, test results, and other health care providers.

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."

Objective data are information that is observable and measurable, such as observing that the client's right leg is cold to the touch. Subjective data relate to phenomena that only the client can experience, such as unrelieved pain, nausea, or heartburn.

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 priority intervention for the client with an unstable blood pressure is to first measure the blood pressure. Once the nurse is certain that this is within safe parameters, the the nurse should assess the client's diet, activity level, and medication regimen.

The nurse is assessing the spine of a 63-year-old woman who states, "I hope I don't end up with a big hump on my back like my mother did." The nurse knows the patient is referring to a condition known as:

kyphosis

The patient's posture should also be straight, without abnormal curving. In kyphosis, the shoulder and upper back tend to curve forward.

Which nursing skill uses all five senses?

Observation

Observation is the conscious and deliberate use of the five senses (sight, smell, hearing, taste, and touch) to gather data. Documentation uses sight (seeing the client's chart) and and touch (typing on a keyboard or writing with a pen). Listening involves just hearing what the client is saying. Caring need not involve any of the senses but is displaying kindness and concern for others.

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 should report any abnormal assessment findings or changes in the client's health status to the client's physician or the charge nurse immediately for prompt and appropriate treatment of the health alterations. The unlicensed assistive personnel should not document the findings as this is the nurse's responsibility. The nurse should not just reassess the client's temperature in 2 hours and chart that data; immediate reporting of the data to the physician or charge nurse is necessary.

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

When assessing, the primary source of client information is the client. Other sources the nurse should consider include the client's support people, the client record, family members accomapanying the client, and other health care professionals. It would not be appropriate to use other clients as a source, because this would violate confidentiality.

Which statement is true regarding addressing a priority problem?

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

A priority problem requires a nursing intervention before another problem is addressed, but addressing priority problems does not entail skipping any interventions. The priority of problems can change as a client's condition changes. There are no predetermined times or intervals at which to identify priority problems. This is why critical thinking plays a central role in nursing.

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

Client

The client is the primary, and usually best, source of information when doing an assessment. The medical record may also provide information, but only if the client has been at the health care facility before; even then, the client is likely to have more current information than the medical record. Although the charge nurse is responsible for the care of all clients on the unit, the charge nurse is not likely to know the details of any one client's information. The primary physician would provide medical care based on the medical assessment and would not have more information than the client about the client's current health status.

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.

Data need to be validated when there are discrepancies (e.g., the client says there is no pain but the nonverbal behavior indicates that the client is experiencing pain). The nurse should not ignore the client's answer or the client's nonverbal behavior. The nurse should chart the assessment, but the priority is to validate the differences in the verbal communication and nonverbal behavior.

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.

Validation is the act of confirming or verifying. The purpose of validation is to keep data as free from error as possible. It is an important part of assessment. However, it is neither possible nor necessary to validate all data; nurses should decide which items need verification.

The nurse is collecting data from a client during a complete assessment. Which skill is the nurse demonstrating when documenting the assessment data?

Communication

The client data collected are of no benefit to the client unless they are appropriately communicated. Appropriate communication involves correct timing and proper documentation. Clustering data is identifying data that are relevant to a specific system. Validation of data is having a sound basis in logic or fact, or the nurse making sure the information collected is correct. Collection of data occurs during the beginning of the client assessment.

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 client who talks of suicide and has a plan to implement it should be taken seriously, making this the priority diagnosis. The other choices are important but could be addressed after making interventions for suicide prevention.

A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method?

Presence of peristalsis

Physical assessment skills include auscultation, percussion, inspection, and palpation. The nurse may assess for peristalsis, which manifests as bowel sounds, by performing auscultation with a stethoscope. The size of the liver is determined with percussion, inspection yields pupil reaction, and skin temperature is assessed through physical palpation.

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.

Cues and inferences describe the early analysis of data. "The client does not respond when I speak while standing on the client's right side," is a cue that something may be wrong. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. A nurse can observe a cue directly but not an inference. The information in this case is based on the nurse's direct observation, not intepretation or inference, and thus cannot be a misinterpretation. There is no evidence that the nurse's obvservation duplicates other data collected.

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

Asking the client whether the client has cultural preferences

Assessing the client involves gathering information about the client's physical and emotional health; cognition; spiritual, cultural, or religious preferences; and sociodemographics. Developing a plan to manage the client's health problems falls within the planning phase of the nursing process. Coming up with the nursing diagnosis falls within the diagnosing phase of the nursing process. Determining whether the client's goals for wellness have been met occurs in the evaluation phase of the nursing process.

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 client's abdomen is firm and distended with hypoactive bowel sounds.
The client states, "I rarely sleep more than 6 hours."

Assessment data would include the client statement regarding sleep, the nurse's question about a pain rating, and physical assessment data of the abdomen. Seeking input from the data in setting goals would occur during the outcome identification and planning phase. Assisting the client with coughing and deep breathing would occur during the implementation phase.

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.

When a pulse deficit is present, the radial pulse rate is always lower than the apical pulse rate. The nurse should document and report to the physician any new finding of a pulse deficit immediately so that evaluation and follow-up can occur. The nurse should not wait until after rechecking the pulse to document the finding or report it to the physician.

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

Consultation

The client's physician may invite a specialist to assess and treat the client. The focus of this part of the record is additional findings related to the client's medical diagnosis and treatment; it is found in the section called "Consultation." Laboratory reports are related to the laboratory values of the client. Progress notes are the part of a medical record where health care professionals describe details to document a client's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. The medical history or case history of a client is information gained by a physician by asking specific questions, either of the client or of other people who know the person and can give suitable information.

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

Inspection
Palpation
Percussion
Auscultation

Four methods are used to collect data during the physical assessment: inspection, palpation, percussion, and auscultation. Documentation is done at the end, but it is not a method used for assessment.

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

The priority assessment at this time is a focused assessment of the client's primary concern. A focused assessment may be performed during the initial assessment if the client's health problem is apparent. A full assessment of the urinary system may be appropriate but is not the priority. A detailed assessment of the client's sexual history is not warranted, and although a thorough systems review is conducted, it is not the priority at this time.

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.

Family and friends can be an invaluable source of assessment data, especially in the care of clients who have cognitive deficits. It would be inappropriate to limit an assessment to solely objective data. Using previous medical records and breaking up the assessment are appropriate measures, but they do not supersede the importance of using family and friends as data sources.

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

Family members or significant others, if available, can provide information for a client who is confused or incapacitated. They can also be of assistance should there be gaps or conflicts within available medical records. Should these persons not be available, the only remaining option for medical history would be medical records or the client's primary physician if available. A social worker would not likely know a client's past medical history, aside from that already avaialble in the client's medical records.

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 preparatory or preinteraction phase occurs when the nurse meets the client. The nurse should review as much information as possible about the client during this phase. It would be premature for the nurse to attempt to clarify the client's health status, identify nursing diagnoses, or develop a nursing care plan without having completed the client interview, nursing history, and nursing assessment, all of which happen later in the assessment process.

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.

The judgment a nurse makes about a cue is known as an inference. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. The nurse can observe a cue directly, but not an inference. The key is the verb used —"hearing may be impaired." The statement is not erroneous or duplicate 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?

Consult with another nurse.

A nurse who is unsure of the significance of a particular finding should consult with another nurse. In some instances, years of experience are needed to distinguish significant from insignificant findings. Calling the family is not appropriate at this point as there is no information to report to them. Charting the information is important after the consultation with another nurse. Waiting to see whether the pain subsides is not appropriate; a timely assessment is needed for this client.

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.

During the introductory phase of the interview, the nurse determines if the client is going to be able to participate in the interview. The highlighting of important points occurs in the termination phase of the interview. Ensuring the environment is comfortable and private occurs during the preparatory phase, and the gathering of information occurs during the working phase. Asking the client if any other information needs to be divulged occurs in the termination phase.

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

A focused assessment is information that provides more details about specific problems and expands the original database. Obtaining data regarding the amount and frequency of drinking qualifies as a focused assessment. The other actions do not relate to the client's drinking habits or potential for alcohol overuse and thus would not be included in a focussed assessment of these issues.

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques?

"When did you first notice the rash on your leg?"

An example of appropriate communication is the statement, "When did you first notice the rash on your leg?" This is an example of a direct question that can be asked to validate information or clarify information. The other sentences demonstrate poor communication techniques. The nurse should avoid cliches, questions that require a "yes" or "no" answer, intimidating "why" and "how" questions, probing questions, and using judgmental comments.

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.

When assessing an obese client, a larger blood pressure cuff will likely be needed to prevent false high readings. It is not in the nurse's scope of practice to determine when and if cholesterol levels and an electrocardiogram are ordered. Diet education may or may not be warranted depending on the cause of the obesity.

The nurse is assessing the client's abdominal wound and notes yellow-green purulent wound drainage. The nurse recognizes that the drainage is an example of:

objective data.

Yellow-green purulent wound drainage is an example of objective data. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Subjective data are information perceived only by the affected person. Only the person experiencing pain can assign a rating to it. Making a judgment derived from data cues is an inference. An inference must be validated with subjective and/or objective data cues.

The nurse is caring for a patient with an IV infusion and notes an elevated BP, increased pulse and respirations, dyspnea, crackles, and neck vein distention. Based on the assessment, the nurse suspects:

fluid overload

Elevated BP, increased pulse and respirations, dyspnea, crackles, and neck vein distention are symptoms of fluid overload.

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."

Nurses are responsible for completing nursing histories, and it usually takes approximately 30 to 60 minutes to obtain data such as history of present illness, past medical history, support network, and other pertinent data. The physical assessment is performed separately. Family members can offer valuable information, as long as the client gives permission for them to remain present during the history taking.

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.

The nurse should validate inferences made from assessment data to ensure accuracy. Incorrect cues and inferences lead to the development of inappropriate nursing diagnoses and client plans of care. Making inferences can be helpful as long as the nurse validates them. It is not necessary to document inferences. Often, the nurse must share inferences with the client to validate them.

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.

Before beginning to collect data on a client, the nurse should review the client's record for data. Then the nurse can identify lower-priority data that are not important for the client's assessment. The nurse should avoid telling the client the questions will be quick or making the questions shorter, as proper assessment may not be quick and may necessitate longer questions. A nurse could organize the questions into categories, but reviewing the client's record would be more effetive for avoiding duplication of information and ensuring that the assessment is efficient and comprehensive.

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 always the best source for collecting data" is a statement that requires additional instruction by the charge nurse. Although the client is usually the best source for information when collecting data during an assessment, a family member, friend, or caregiver can be especially helpful sources of data when the client is a child or has a limited cognitive capacity.

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

Asking the client whether the client has cultural preferences

Assessing the client involves gathering information about the client's physical and emotional health; cognition; spiritual, cultural, or religious preferences; and sociodemographics. Developing a plan to manage the client's health problems falls within the planning phase of the nursing process. Coming up with the nursing diagnosis falls within the diagnosing phase of the nursing process. Determining whether the client's goals for wellness have been met occurs in the evaluation phase of the nursing process.

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

Which best describes assessment in the nursing process?

Which statement is true about a nursing diagnosis quizlet?

What are the types of nursing assessments quizlet?