CHAPTER 12 – NURSING ASSESSMENT – Flashcards
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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? - Initial assessment - Time-lapse assessment - Emergency assessment - Focused assessment
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Focused assessment P. 204 Rationale: The nurse is performing a focused assessment that 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
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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? "Client states, 'I don't see the point in trying anymore.'" "Client states that his rehabilitation will be unsuccessful." "Client is demonstrating signs and symptoms of depression." "Client makes statements indicating a loss of hope."
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"Client states, 'I don't see the point in trying anymore.'" p. 208 Rationale: 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
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A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment? Comprehensive Focused Time-lapse Emergency
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Time-lapse p. 204 Rationale: The time-lapse assessment is scheduled to compare a client's current status to 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-lapse assessments to reassess health status and to make necessary revisions in the plan of care
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A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? "Unable to palpate femoral pulse in left leg." "Appears anxious and frightened." "I am so sick; I am about to throw up." "My leg hurts so bad. I can't stand it."
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"Unable to palpate femoral pulse in left leg." p. 208-209 Rationale: Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client. Objective data are also called signs or overt data. The nurse being unable to palpate a femoral pulse in the client's leg is objective data.
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Who or what is the primary source of information for a nursing history? Other health care personnel The client Previous medical records Family members
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The client p. 209 Rationale: The client is the primary (and usually the best) source of information. Unless specified otherwise, it is assumed that the data recorded in the nursing history were collected from the client.
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A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which statement by the nurse would recognize the client's value as an individual? - "Mr. Koeppe, tell me what you do to take care of yourself." - "Mr. Koeppe, I know you can't answer my questions, but it's okay." - "Can you tell me how long your father has been this way?" - "Sarah, I have to go and read your father's old charts before we talk."
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"Mr. Koeppe, tell me what you do to take care of yourself." p. 206, including table 12-3 Rationale: Clients such as older adults with dementia, and their children, cannot be relied on to report accurately. However, they should be encouraged to respond to interview questions as best as they can. Bypassing the client sends a message that the nurse does not have time or has doubts in the client's ability to communicate
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Of the following data, what type would be collected during a physical assessment? - Color, moisture, and temperature of the skin - Foods eaten that cause nausea - Specific allergies resulting in itching - Type, amount, and duration of pain
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Color, moisture, and temperature of the skin p. 207-208 Rationale: Physical assessment is the examination of the client for objective data that may better define the client's condition and help the nurse in planning care. Physical assessment includes the color, moisture, and temperature of the skin. The health history interview would elicit information (data) about pain, nausea, and allergies.
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A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond? "Everyone who ages has bowel problems." "Do you take anything to help your constipation?" "Do you have a family history of chest problems?" "Why don't you use a laxative every night?"
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"Do you take anything to help your constipation?" p. 210, Box 12-1. Rationale: A possible cause of omission of pertinent data is failing to follow up on cues during data collection. The nurse should ask about what the client uses to self-treat her constipation in order to identify further important information. It is not correct to ignore the statement, ask "why" questions, or make assumptions.
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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? Client's friends Client himself Test reports Client's wife
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Client himself p. 209 Rationale: As the client is in a conscious state, he himself is the primary source of information since he can give firsthand information. The client's wife, friends, and test results would be secondary sources of data.
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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. - attempts to write down everything the client says. - agrees with each of the client's statements. - reassures the client of good outcomes.
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uses broad, open statements to communicate with the client. p. 207 Rationale: The nurse should use broad, open statements to facilitate communication during an interview. Full attention should be paid to the client; paying too much attention to note-taking will interfere with good communication. False reassurance must be avoided and the nurse may not agree with every statement the client makes.
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The nurse is interviewing a client who is reporting chills, fever, malaise, and cough. During the working phase of the client interview, the nurse: - asks the client to describe symptoms. - summarizes the key points of the interview. - arranges for a private location. - introduces self to client.
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asks the client to describe symptoms p. 207 Rationale: During the working phase, the nurse collects assessment data from the client. In the preparatory phase, the nurse prepares the environment for the interview. Introductions initiate the interview during the introductory phase. The nurse highlights key points of the interview in preparation for terminating the interview in the termination phase.
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The nurse is summarizing the key points of the interview. This nursing activity occurs during which phase? - Preparatory phase - Working phase - Termination phase - Introductory phase
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Termination phase p. 207 Rationale: The nurse highlights the key points of the interview during the termination phase. During the preparatory phase the nurse prepares the setting for the interview and reviews any available information about the client. Introductions take place during the introductory phase, and the nurse outlines expectations for the interview. The nurse collects subjective data during the working phase.
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While examining a client, the nurse assesses the temperature of the client's skin. The nurse most likely would be using which technique? - Inspection - Auscultation - Palpation - Percussion
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Palpation p. 208 Rationale: Palpation is used to assess the temperature of the skin. Inspection would reveal color, shape, movement, pulsations, and texture of an involved body part. Percussion determines a structure's denseness or hollowness and aids in discovering the location and level of organs, consistency of body structures, the presence of tenderness, and identification of masses or tumors. Auscultation identifies normal and abnormal sounds (such as in the bowel, lungs, heart) as well as the sound of blood moving through a narrowed or twisted vessel.
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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. - Number of years in profession - Respect for client - Caring - Professionalism - Competence
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- Respect for client - Caring - Professionalism - Competence p. 206 Rationale: 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. How long the nurse has practiced does not influence this.
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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? - Time-lapse - Initial - Emergency - Focused
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Emergency p. 204 Rationale: An emergency assessment is used to identify life-threatening problems and done when a physiologic or psychological crisis presents. It is different from a focused assessment, which is used to gather information about a particular problem. A time-lapse reassessment takes place after the initial assessment to evaluate any changes in the client's health.
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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. - "I am afraid something serious is wrong". - Height: 6' (1.82 m) - Weight: 195 lb (89 kg) - 38-year-old man - "My leg hurts."
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- Height: 6' (1.82 m) - Weight: 195 lb (89 kg) - 38-year-old man p. 208-209, including Table 12-4 Rationale: Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing it
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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? - Unreliable - Objective - Physical - Subjective
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Objective p. 208 Rationale: Objective data is data that is 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. The others are not types of data
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Nurses collect objective and subjective data during the client interview. Which client data is subjective data? Select all that apply. - A nurse observes redness and swelling at an IV site. - A client feels nauseated after eating his breakfast. - A client's blood pressure is elevated following physical activity. - A nurse observes a client wringing her hands before signing a consent for surgery. - A client describes his pain as an 8 on the pain assessment scale. - A client reports being cold and requests an extra blanket.
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- A client feels nauseated after eating his breakfast. - A client describes his pain as an 8 on the pain assessment scale. - A client reports being cold and requests an extra blanket. p. 208 Rationale: 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 her hands, redness and swelling at an IV 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
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An assessment involves gathering pieces of information about a client's health status. Which piece of information is subjective? - Client has leukoplakia on her oral mucosa. - Client is alert and oriented to person and place but not time or situation. - Client has ptosis, a drooping of the eyelid, on his right side. - Client has generalized myalgia or muscle pain. - Client has a temperature of 102°F.
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Client has generalized myalgia or muscle pain p. 208 Rationale: Symptoms such as muscle pain or myalgia are considered subjective cues in a client's health history. 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
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Which of the following is an example of a time-lapse reassessment? - 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. - 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. - 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. - 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.
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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 p. 203 Rationale: A time-lapse reassessment is performed in ordered 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
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The nurse is performing a physical assessment of a client admitted with emphysema. How will the nursing physical assessment differ from a medical physical assessment? - The nurse's physical assessment will focus on the client's functional abilities. - The physician's physical assessment will focus on pathologic conditions and their causes. - The physician's physical assessment will focus on the client's functional abilities. - The nurse's physical assessment will focus on pathologic conditions and their causes
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- The nurse's physical assessment will focus on the client's functional abilities. p. 203 Rationale: Unlike the physical assessment performed by the physician to identify pathologic conditions and their causes, the nursing physical assessment focuses primarily on the client's functional abilities
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Which client situation most likely warrants a time-lapse nursing assessment? - A client is being admitted to a general medicine unit after spending several days in the intensive care unit. - A nurse is auscultating the lungs and measuring the oxygen saturation of a client who has pulmonary edema. - The nurse has responded to the call light of a hospital client who is reporting shortness of breath and chest pain. - An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.
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- An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. p. 204 Rationale: A time-lapse assessment is often indicated in the care of a stable client whose current status is being compared to earlier baseline data. Shortness of breath and chest pain necessitate an emergency assessment, while a new admission to a unit or institution requires an initial assessment. Following up a known health problem most often requires a focused assessment
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Which group of terms best defines assessing in the nursing process? - Design a plan of care, implement nursing interventions - Problem-focused, time-lapsed, emergency-based - Nurse-focused, establishing nursing goals - Collection, validation, communication of client data
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Collection, validation, communication of client data p. 203 Rationale: Assessing is the systematic and continuous collection, validation, and communication of client data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem-focused, time-lapsed, and emergency-based describe types of assessments. Assessments are nurse focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are
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A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. Which type of assessment would the nurse perform? - Initial assessment - Focused assessment - Emergency assessment - Time-lapse assessment
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Focused assessment p. 204 Rationale: A focused assessment is completed by the nurse to gather data about a specific problem that has already been identified. It is also used to identify new or overlooked problems.
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A nurse is assessing a client admitted to the health care facility with angina. Which method would be most appropriate for the nurse to use to collect subjective data? - Laboratory studies - Scale - Interview - Stethoscope
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Interview p. 208 Rationale: The nurse should interview the client to collect subjective data, which include the client's feelings and statements about his health problems. Objective data are collected through measuring devices and equipment, such as a stethoscope and scale, as well as laboratory studies. Objective data are known as signs and are observable, perceptible, and measurable.
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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 should verify the client's name. - The nurse should show her name badge to the client so he can identify the nurse. - The nurse should ask the client what name he would like to be called. - The nurse should introduce herself and give name and position. - The nurse should sit on eye level with the client.
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- The nurse should show her name badge to the client so he can identify the nurse. p. 207 Rationale: When conducting an interview the nurse should sit at eye level, introduce herself, and state her position. This sends the message that the nurse accepts responsibility and is willing to be accountable. Verify the client's name and ask what he would like to be called. Some clients cannot read and they should not be expected to know a nurse's name and position by reading a name badge.
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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? - Ask the client's husband to come in and answer the interview questions. - Wait until the next day to obtain the answers to the interview questions. - Ask the client to wake up and try to answer the interview questions. - Ask the client if it is okay to interview her husband for the answers to the interview questions.
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Ask the client if it is okay to interview her husband for the answers to the interview questions p. 209 Rationale: 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 husband 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.
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A 50-year-old female client is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information? - Consult nursing and medical literature. - Read the client's chart. - Consult with the client. - Consult with the client's doctor
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Consult nursing and medical literature. p. 209, 210 Rationale: 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, doctor, or client's chart would not give as comprehensive of a review
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A client comes to the acute care facility for diagnostic testing and elective surgery. Which type of assessment would the nurse most likely complete? - Admission assessment - Time-lapse reassessment - Emergency assessment - Focus assessment
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Admission assessment p. 203-204 Rationale: An admission assessment, also referred to as an initial assessment, is performed when the client enters a health care facility, receives care from a home health agency, or is seen for the first time in an outpatient clinic. A focus assessment collects data about a problem that has already been identified. This type of assessment has a narrower scope and a shorter time frame than the admission assessment. The nurse applies methods relevant to assessing the previously targeted problem. Time-lapse reassessment, another type of assessment, takes place after the initial assessment to evaluate any changes in the client's health. Nurses perform time-lapse reassessments when substantial periods of time have elapsed between assessments (e.g., periodic outpatient clinic visits, home health visits, health and developmental screenings). Emergency assessment takes place in life-threatening situations in which the preservation of life is the top priority. Time is of the essence for rapid identification of, and intervention for, the client's health problems.
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A nurse is engaged in the assessment phase of the nursing process. Which activity would the nurse most likely perform? Select all that apply. - Organize data. - Collect data. - Identify data patterns. - Analyze data. - Validate data.
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- Organize data. - Collect data. - Validate data. p. 210-211 Rationale: During assessment, the nurse collects, validates and organizes data. Identifying patterns and analyzing data occur during the next phase
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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? - Adds depth to existing information - Suggests possible problems - Provides breadth for future comparisons - Gives a comprehensive volume of data
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Adds depth to existing information p. 204 Rationale: A focus assessment adds depth to existing information or the initial database gathered by the nurse. A database assessment provides breadth for future comparisons. A focus assessment does not suggest possible problems facing the client but rather rules out or confirms the client's problems. A focus assessment is not voluminous and comprehensive, like a database assessment, but limited and to the point.
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A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment? - Initial assessment - Time-lapse reassessment - Emergency assessment - Focused assessment
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Focused assessment p. 204 Rationale: The nurse is performing a focused assessment to determine whether the problem still exists, and whether the status of the problem has changed. An initial or admission assessment is the initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction. Time-lapse reassessment is performed after the initial assessment, when substantial periods of time have elapsed between assessments. An emergency assessment is performed any time a physiologic, psychological, or emotional crisis occurs.
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Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? - Emergency assessment - Focused assessment - Initial assessment - Time-lapse assessment
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Focused assessment p. 204 Rationale: The nurse conducts a focused assessment of the client with a specific identified problem. An initial assessment is conducted by the nurse to establish baseline database and identify current health problems. The nurse performs an emergency assessment during a crisis to identify life-threatening problems.
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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? - Ignore the client's nonverbal behavior. - Validate the data. - Chart the data. - Ignore the client's answer.
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Validate the data p. 211 Rationale: Data needs 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).
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The nursing student demonstrates accurate application of the assessment phase of the nursing process by performing which action? - asking the client whether the client has cultural preferences - coming up with the nursing diagnosis based on potential health risk - developing a plan to manage the client's health problems - determining if the client's goals for wellness have been met
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- asking the client whether the client has cultural preferences p. 203 Rationale: 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 if the client's goals for wellness have been met occurs at the evaluation phase of the nursing process.
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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? - Obtain the client's records from admissions to other institutions. - Supplement the client's information by speaking with family or friends. - Limit the assessment to objective data. - Perform the assessment in several short episodes rather than at one sitting.
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Supplement the client's information by speaking with family or friends. p. 209 Rationale: 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. Utilizing 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.
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Which items reflect the assessment phase of the nursing process? Select all that apply. - The nurse and the client determine a tolerable pain level. - The client states, "I rarely sleep more than 6 hours." - The client's abdomen is firm and distended with hypoactive bowel sounds. - The nurse assists the client with coughing and deep breathing every hour. - Asking the client, "How would you rate your pain?"
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Asking 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." p. 207-208 Rationale: 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.
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The nurse is conducting a nursing assessment with a client who is unwilling to participate in the interview process. If the nurse makes a diagnostic error it would most likely be because of: - misinterpretation of data. - omission of pertinent data. - failure to validate the data. - failure to analyze the data.
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omission of pertinent data p. 211 Rationale: The diagnostic process is dependent on complete and accurate data. A nursing assessment with a client who is unwilling to participate in the interview process would most likely result in incomplete data. Omission of pertinent data would lead to diagnostic errors.
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The nurse is interviewing a client who was admitted to the acute care facility. During the interview, the client states, "Sometimes I get a bit fuzzy after I take my medicine." Which response by the nurse would be most appropriate? - "What medications are you taking currently?" - "Are you experiencing lightheadedness with the medication?" - "Can you tell me what you mean when you say 'fuzzy'?" - "That's not unusual. I've heard several clients tell me the same thing."
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"Can you tell me what you mean when you say 'fuzzy'?" p. 205 Rationale: The most appropriate response would be to clarify what the client means by 'fuzzy'. This response indicates that the nurse was actively listening to and hearing what the client had said. Telling the client that his complaint is not unusual ignores what the client has said and blocks communication. Asking if the client is experiencing lightheadedness shifts the focus of the interview to the nurse and the nurse's interpretation, rather than to what the client is reporting. Asking the client about the medications being taken changes the subject and is inappropriate.
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Which statement made by the nurse indicates data that would be documented as part of an objective assessment? - "The UAP reports blood in the client's stool." - "The client's sister reports that the client has unrelieved pain." - "The client's right leg is cold to the touch, from the knee to the foot." - "The client reports eating all of today's breakfast."
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"The client's right leg is cold to the touch, from the knee to the foot." p. 208 Rationale: Objective data is information that is observable and measurable, such as observing that the client's right leg is cold to the touch. Subjective data is information that the client or someone else reports, such as reporting unrelieved pain, blood in the stool, or eating one's supper.
