CUNY - NURSING SCR 110 CHAPTER 14 ASSESSING with complete solution,1. Read the following scenario and identify the adjective used to describe the characteristics of patient data that are numbered below. Place your answers on the lines provided.

CHAPTER 14 ASSESSING 1. Read the following scenario and identify the adjective used to describe the characteristics of patient data that are numbered below. Place your answers on the lines provided. The nurse is conduc ...

CHAPTER 14 ASSESSING 1. Read the following scenario and identify the adjective used to describe the characteristics of patient data that are numbered below. Place your answers on the lines provided. The nurse is conducting an initial assessment of a 79-year-old female patient admitted to the hospital with a diagnosis of dehydration. The nurse (1) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data. (2) First the nurse asks the patient about the most important details leading up to her diagnosis. Then the nurse (3) collects as much information as possible to understand the patient’s health problems; (4) collects the patient data in an organized manner; (5) verifies that the data obtained is pertinent to the patient care plan; and (6) records the data according to facility’s policy. (1) Purposeful ___________________ (2) Prioritized ___________________ (3) Complete ___________________ (4) Systematic ___________________ (5) Accurate and relevant ___________________ (6) Recorded in a standard format ___________________ 2. 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 3. 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.” 4. 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. 5. 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.” 6. 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 10. f. A patient vomits after eating supper. 7. 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. 8. 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 b 9. 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. 10. 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?” An older adult male with a history of benign prostatic hyperplasia (BPH) 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? While performing an assessment, the nurse recognizes that his own personal biases may be interfering with the collection of data. What step should the nurse take to assure the information is factual and accurate? A client reports to a health care facility with reporting abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data? What must the nurse do to identify actual or potential health problems? A nurse practitioner has a private practice in conjunction with a physician. She is providing psychiatric care to a woman who has a past history of being abused by her husband. During the last visit, the client stated that she was planning to leave her husband. On the next visit in two weeks, the nurse practitioner will assess her client's commitment to changing her life situation and her ability to feel empowered. What type of assessment is the nurse practitioner implementing? A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg? When assessing an infant, it is important to involve the: Which cultural group may interpret touch by another as an invasion of privacy? The purpose of obtaining a nursing history is to: A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority? The nurse is caring for a 14-year-old adolescent who has just delivered her first baby girl. The adolescent states that she lives with an aunt and has no other family around her. The delivery was uncomplicated, and the newborn is healthy. Which of the following would be the primary nursing diagnosis for this patient? The nurse is assessing a 3-week-old infant. Which of the following assessment findings would define the priority nursing diagnosis for this patient? The infant has not gained weight since birth. Bowel sounds are present in all quadrants. Breath sounds are clear to auscultation. Mom reports child cries much of the night but sleeps better in the daytime. Mom reports child only breastfeeds about four times in a 24-hour period and she doesn't seem to have much milk. The nursing instructor is teaching the students how to do an interview on a client. Which statement made by a student indicates a need for further instruction? "The nurse is conducting an interview with a newly admitted client. Which listening behavior guideline should the nurse implement in order to have a successful interview? When performing an assessment on an older client the nurse discovers that the client needs a cane when walking and has problem seeing in the night. Under which of the following stages of Maslow's Human Needs Theory should the nurse cluster this data? The nurse notices during an assessment interview that the client cannot stay on focus and jumps from one topic to another. The client also is speaking very rapidly and at time incoherently. What should the nurse suspect is the main cause of this behavior? 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? 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 nursing student has learned that when doing an assessment on any client, it is essential to get the most important information first. By doing so the nurse's action is an example of which of the following? The nursing instructor is teaching the students about the proper techniques for conducting a client interview. A student asks the instructor the reason for asking the client what he or she would like to be called. What explanation provided by the instructor is most appropriate? Which client situation most likely warrants a time-lapse nursing assessment? How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation? A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of a focus assessment? A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: Which would be considered examples of subjective data? Select all that apply. Which of the following are examples of objective data? 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: Which quality does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply. When performing an assessment, the nurse should focus on the developmental stage for which client? While studying methods of data collection, a nursing student learns that there are many different skills involved. Which of the following is a key nursing skill that uses all five senses? A nursing student is assisting with taking nursing, or health histories of all clients. The student identifies when is the best time to do a nursing/health history? The nurse is planning to do a physical assessment on a newly admitted client.The assessment will be a review of systems (ROS). This means the nurse plans to do which of the following? The nurse is conducting an admission assessment on a client who informs the nurse that dyspnea follows the exertion the client is experiencing. What would be the best way for the nurse to chart this data? The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? Select all that apply. 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 that afternoon to do some kind of check-up. Which type of check would be most appropriate for the nurse to perform on this client? The nurse working at a local community hospital understands the importance of having a client database for continuous data collection. What does the nurse identify as the the primary reason for collecting data continuously? 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 count (WBC) lab value. The nurse is gathering which type of data when looking up the lab value? Nurses collect objective and subjective data during the client interview. Which client data is subjective data? Select all that apply. An assessment involves gathering pieces of information about a client's health status. Which piece of information is subjective? Which of the following is an example of a time-lapse reassessment? During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should: During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should: During the interview component of the health assessment, how does the nurse convey to the client that the information is important? The nurse is reviewing information about a client and notes the following assessment data. Which data cue does the nurse recognize as subjective data? Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? The nurse is assessing a man in an outpatient setting. Which of the following assessment findings would lead to the priority nursing diagnosis for this client? 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 patient reports a 30-year heavy smoking habit and having a cough for about six months. Auscultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminished bowel sounds. His lips are slightly bluish in color. A woman has delivered a healthy newborn and is scheduled to go home today, her third post-partum day. Her vital signs are stable. How often would the nurse expect to take the vital signs of a stable in-patient? The nurse is assessing the blood pressure of a young adult patient. The reading seems low in comparison the trend of other measurements. What might the nurse suspect is the cause of the abnormally low reading? Select all that apply. A client who is bleeding profusely from a stab wound is brought to the emergency department. Which type of assessment is most appropriate for this client? While caring for a client who has a problem related to digestion, a nurse has been referred by the primary care provider to be seen by a gastroenterologist. Which of the following parts of the client record should the nurse look at to see the recommendations made by the gastrointestinal specialist? The nurse is reviewing the laboratory report section of a client's record. For what reason is this important for the nurse to review? Select all that apply. 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 client's temperature is 39.4 C. What should be the nurse's priority action? The nurse is conducting a client interview and notices that the client answers every questions with a "yes" or "no" response. What is mostly likely the cause of this action by the client? The nursing instructor is teaching the students about assessments. Which of the following does the instructor list as being most important in order for an assessment to be successful? The nurse is preparing to perform an assessment on a newly admitted client. What should the nurse do prior to performing this initial assessment? Nurses collect objective and subjective data when performing client assessments. What is an example of objective data? A nurse is assessing an energetic 80-year-old, admitted to the hospital with complaints of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this patient? The nurse is interviewing a client that is newly admitted to the unit. Which techniques used by the nurse will facilitate communication during the interview? Select all that apply. Which statement made by the nurse indicates data that would be documented as part of an objective assessment? At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented? 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? The nurse is assessing a male client with a diagnosis of vascular dementia. As a result of his cognitive deficit, the client is unable to provide many of the data that are required on the hospital's nursing admission history document. How should the nurse best proceed with this assessment? An unconscious client is brought to the emergency department. Which assessment should be implemented first? The nurse observes the client as he walks into the room. What information will this provide the nurse? Before conducting a health assessment on a client, what should the nurse do first? The night shift RN is caring for a hospitalized adult 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? 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: The nurse is conducting a health history on a newly admitted client. Which aspect of the client should the nurse include while doing the history? Select all that apply. A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client? A nursing student is learning about how to perform a thorough assessment in a health assessment class. Which of the following is the best source of information for the student to learn data collection for an assessment? A nursing instructor teaching about assessment data identifies a need for further instruction when a student makes which of the following statements? 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. The nurse is performing a physical assessment of a newly admitted client. During the assessment the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client is there is any pain the answer is, "No." What is the best thing for the nurse to do next? The nurse is conducting an interview on a newly admitted client. Which of the following is recommended when conducting a client/nurse interview? A client comes to the emergency department with a stab wound and is bleeding profusely. Which type of assessment should the nurse perform on this client immediately? A nurse is interviewing a hospitalized patient. Which nurse-patient positioning facilitates an easy exchange of information? During the nursing examination, the nurse notices that the client, an older adult female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation? A nurse is beginning the preparatory phase of the nursing interview for a client who fractured the left leg in a fall. Which nursing actions occur in this phase of the nursing interview? Select all that apply. During the initial assessment of a newly admitted client, the nurse has clustered the client's range of motion (ROM) with his gait, his bowel sounds with his usual elimination pattern, and his chest sounds with his respiratory rate. The nurse is most likely organizing assessment data according to: In order for a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment? 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? The nurse has identified a priority problem on her unit. Which statement is true regarding addressing a priority problem? The nurse is caring for a patient for the third day in a row on the hospital unit. At his evening vital sign assessment, the nurse notices the radial pulse is much slower than his apical pulse. This finding is new. Which of the following would the nurse do next? 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 which of the following? 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. The nursing instructor is teaching about collecting data for an assessment and informs the students about the importance of validation. Which of the following statements made by a nursing student indicates a need for further instruction? The nursing student demonstrates accurate application of the assessment phase of the nursing process by performing which action? 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? 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? The RN is interviewing an 80-year-old woman admitted to the hospital for evaluation of her diabetes. The client states she enjoys being in the hospital because she lives alone and does not have many friends. She states her husband died 1 year ago and she is no longer able to drive. She relies on her daughter who lives one hour away to shop for her once a week. The client states, "My daughter can never stay long, she is just in and out in no time." Which nursing diagnoses would be appropriate for this client? Select all that apply. The nurse records the name, age, and genetic background of the client after obtaining this data. This data are components of which action? The nurse is collecting data from a client during a complete assessment. What is the nurse demonstrating when the documentation of the assessment is performed in a timely precise manner?