Ch 3 Nursing Process: Assessment – Flashcards

Delegation, patient care

D. State practice acts Rationale: State practice acts legally define the scope and practice of nursing within the state, and this is what you are accountable for. Hospital policy, ANA, and The Joint Commission all provide standards, guidelines, or positions for nurses to refer to for clarification as to the nurse's role or responsibility in the nursing process.

C. Palpation Rationale: With palpation, you will feel the skin around the wound to determine whether there is swelling or any foreign objects such as dirt, gravel, or twigs in or around the wound. You will also be able to evaluate pain, if elicited. The other responses are incorrect. Auscultation is listening for changes such as decreased breath sounds and heart rate. Percussion is using the fingers and hand to tap on areas of the body to assess for changes. Developmental assessment is important when working with children, but to gather data you will need to talk to the patient to assess verbal skills and comprehension.

D. Walk over to Lucy and introduce yourself by name, position, and role. Rationale: Before beginning any nursing care with a new patient, introduce yourself by name and position (RN), and tell the patient what aspects of care you will be responsible for. None of the other responses is the first thing to do. Asking about calling a family member assumes information about her support system that may not be accurate; she may live in another state or be estranged from her family. Asking if she'd like to talk about what is upsetting her can be supportive, but this does not take into consideration any cultural barriers that may inhibit her from being comfortable talking to you about her personal feelings. Offering her reassurance is not an appropriate response; you have not collected enough data to determine what she is upset about.

B. Objective data Rationale: Objective data are observations and information collected about the patient's condition (e.g., vital signs). The other responses are incorrect. Secondary data are data that are obtained from any source other than the patient. Subjective data are patient statements and information supplied on the intake form. Focused data are in-depth information about abnormal cues or identifies problems with a body part or function.

D. Data that might reveal an interaction with prescribed medications Rationale: Many vitamins and supplements interfere or interact with prescription medications to reduce effectiveness or contribute to side effects. Patients may take specific supplements as part of their cultural practices, to address health concerns, or because they want to maintain a certain level of health; but safety is the primary reason for gathering this information. Medication data would not necessarily provide any information about the patient's culture, osteoporosis, or the value the person places on health.

B. What problems have you had since your injury? Rationale: This question offers the patient the opportunity to express concerns or discuss changes in functioning that have occurred since the injury; it provides opportunity for further exploration. The other questions allow the patient to answer in brief or one-word responses, which limits the data obtained.

C. Focused Rationale: A focused assessment is performed to obtain data about an actual, potential, or possible problem that has been identified. It focuses on a particular topic, body part, or functional ability rather than on overall health status. A psychosocial assessment gathers information about lifestyle, normal coping patterns, understanding of the current illness, personality style, previous mental health disorders, recent stressors, major issues related to the illness, and mental status. A special needs assessment is a type of focused assessment. It provides in-depth information about a particular area of client functioning and often involves using a specially designed form (e.g., nutrition and pain). A comprehensive assessment (also called a global assessment, patient database, or nursing database) provides holistic information about the client's overall health status.

D. A & B Rationale: You obtained this information on a previous shift, and it should be documented validly and reliably. Because this information is important to the patient's discharge planning, it needs to be conveyed to the social worker to be incorporated into the discharge plan. As this is part of discharge assessment data, it is inappropriate to add it to the original database, and information cannot be added to previous documentation.

A. Cue B. Cue C. Inference D. Cue E. Inference Rationale: Cues are what the client says and what you observe. Inferences are judgments and interpretations about what the cues mean.

4) The Joint Commission Rationale: The Joint Commission has developed assessment standards, including that all clients be assessed for pain. The ANA has developed standards for clinical practice, including those for assessment, but not specifically for pain. State nurse practice acts regulate nursing practice in individual states. The NCSBN asserts that the scope of nursing includes a comprehensive assessment but does not specifically include pain.

4) Is the patient in pain? Rationale: H: (Help): Look for signs of patient distress E: (Equipment and Environment): Check for safety hazards and equipment operation. L: (Look more closely): Look more closely at the patient for cues that care may need to be given. P: (People): Who else is in the room?

4) Take a thorough look at the patient? Rationale: H: (Help): Look for signs of patient distress E: (Equipment and Environment): Check for safety hazards and equipment operation. L: (Look more closely): Look more closely at the patient for cues that care may need to be given. P: (People): Who else is in the room?

1) Is the oxygen running? Rationale: H: (Help): Look for signs of patient distress E: (Equipment and Environment): Check for safety hazards and equipment operation. L: (Look more closely): Look more closely at the patient for cues that care may need to be given. P: (People): Who else is in the room?

2) Who else is in the room with the patient? Rationale: H: (Help): Look for signs of patient distress E: (Equipment and Environment): Check for safety hazards and equipment operation. L: (Look more closely): Look more closely at the patient for cues that care may need to be given. P: (People): Who else is in the room?

2) The client states she feels feverish; you measure the oral temperature at 98°F. Rationale: Validation should be done when subjective and objective data do not make sense. For instance, data are inconsistent when the patient feels feverish and you obtain a normal temperature. The other distractors do not offer conflicting data. Validation is not usually necessary for laboratory test results.

4) Sitting, facing the client in a chair at the client's bedside, using active listening Rationale: Active listening should be used during an interview. The nurse should face the patient, have relaxed posture, and keep eye contact. Asking "why" may make the client defensive. Note taking interferes with eye contact. The client may not understand medical terminology or healthcare jargon.

1) A body systems model 4) Gordon's functional health patterns Rationale: Nursing models produce a holistic database that is useful in identifying nursing rather than medical diagnoses. Body systems and head-to-toe are not nursing models, and they are not holistic; they focus on identifying physiological needs or disease. Maslow's Hierarchy of Needs is not a nursing model, but it is holistic, so it is acceptable for identifying nursing diagnoses. Gordon's functional health patterns constitute a nursing model.

1) Used a vague generality 3) Used a "waffle" word (e.g., seems) Rationale: The nurse recorded a vague generality: "he had a good night." The nurse did not use the patient's exact words, but she did not quote the patient at all, so that is not one of her errors. The nurse used the "waffle" word "seems" instead of documenting what the patient said or did to lead her to that conclusion. The nurse recorded these inferences: "worried" and "had a good night."

1) Assessment 2) Implementation Rationale: Assessment occurs when the nurse is gathering data (i.e., observing blood in the urine). Implementation occurs when the nurse is performing a nursing action (i.e., inserting a urinary catheter). Diagnosis occurs when the nurse analyzes the data and states what they mean—which she did not do in this situation. Planning: Interventions occurs when the nurse is considering the patient diagnoses and goals and deciding what actions need to be taken.

4) Assessment is related to and overlaps with other steps of the nursing process. Rationale: The scenario best illustrates that assessment is related to and overlaps with other steps of the nursing process. In this case, while the nurse is implementing (inserting a catheter), she has the opportunity to assess the patient (observe the appearance of the urine). Therefore, implementation provides the opportunity for assessment (the two steps are related) and assessment occurs during (overlaps with) implementation. The scenario says nothing about other nursing process steps—only assessment and implementation. Although blood in the urine is a patient response, there is nothing in the scenario about disease processes. There is nothing in the scenario about delegation, nor whether this is a professional nurse inserting the catheter.

2) Interview the patient about the history of her present illness Rationale: The history of present illness is an in-depth exploration of the patient's chief complaint, which in this case you can assume is shortness of breath. In that exploration, the nurse will ask when the problem began, how often it occurs, what makes it worse, what the patient has done to relieve it, how the person's health has changed from her usual status, and what effect the illness has had on her daily life. A comprehensive admission assessment would include the history of the present illness, but would also include a great deal of other information. This question asks about specific data, which are found in the history of the present illness. A review of body systems might also produce the desired data, but it too would provide much additional data. Information about the patient's expectations for care might provide data about the patient's knowledge about the illness and what she wants the nurses to do; but it would likely not provide the specific data the question asks for.

4) Sets standards for what and when to assess the patient. Rationale: The Joint Commission sets detailed standards regarding what and when to assess, but does not address credentials. Nurse practice acts specify what data are collected and by whom. Agency policy may set time frames for when assessments should be conducted and how they should be documented. Nursing knowledge identifies "how" data are to be collected.