CONCEPT 32: ASSESSMENT
About Assessment
1. A family member brings a client with type 1 diabetes mellitus to the emergency department.
The client is confused, has a heart rate of 100, respirations of 9, and a fruity sm
...
CONCEPT 32: ASSESSMENT
About Assessment
1. A family member brings a client with type 1 diabetes mellitus to the emergency department.
The client is confused, has a heart rate of 100, respirations of 9, and a fruity smell to the breath.
The initial action the nurse should take is to:
1. Notify the physician.
2. Call for the code team.
3. Assess the blood sugar.
4. Measure urine output.
Answer:
3. Assess the blood sugar.
Rationale:
The client is showing signs of the beginning of a diabetic coma. The first step by the nurse would
be to assess the client’s blood sugar. The nurse would then notify the physician of the results. A
code team is not necessary as the client is breathing and has a heart rate. Measuring urine output
would be a component of an ongoing assessment.
Nursing Process: Assessment
Client Need: Physiological Integrity
Cognitive Level: Creating
Learning Outcome: 1. Describe different types of assessments, indicating the proper use of
each.©2011 by Pearson Education, Inc.
North Carolina Concept-Based Learning Editorial Board, Test Bank for Nursing: A Concept-Based
Approach, Volume 2
2. The nurse in the clinic is assessing a 60-year-old client who has swollen ankles, rales, and
dyspnea. The nurse concludes that the client will need lifestyle-change teaching and asks:
1. If the client is married or divorced.
2. If the client smokes.
3. How many children the client has.
4. About the client’s family history.
Answer:
2. If the client smokes.
Rationale:
The nurse realizes the client may be experiencing heart failure and asks the client questions
aimed at obtaining the client’s lifestyle habits that can contribute to the heart failure, such as
smoking and dietary habits. Gathering psychosocial information such as marriage and children is
important, but in this case the nurse focuses on the client’s current problem and teaching needs.
Family history is also an important part of data gathering, but does not address the client’s
current lifestyle.
Nursing Process: Assessment
Client Need: Physiological Integrity
Cognitive Level: Evaluating
Learning Outcome: 2. Relate the purposes of conducting a physical examination.
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