ch12 assessing – Flashcards
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A patient is receiving home care due to an unstable blood pressure. Which of the following nursing interventions is a priority?
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Assess the patient's blood pressure
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A nurse is assessing a client admitted to the health care facility with angina. Which of the following would be most appropriate for the nurse to use to collect subjective data?
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interview
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When assessing the client's pulse, the nurse is using the following assessment technique
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palpation
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The purpose of obtaining a nursing history is to
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Identify actual and potential nursing diagnoses
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After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which of the following questions is the most appropriate conclusion to the interview?
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"Is there anything else we should know in order to care for you better?"
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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?
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The nurse should consult with another nurse for that colleague's description of the assessment or observations.
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A client reports to a health care facility with complaints of 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?
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Client himself
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When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?
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focus
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The nurse is interviewing a client with complaints of chills, fever, malaise, and cough. During the working phase of the client interview, the nurse:
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Asks the client to describe symptoms
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During the interview component of the health assessment, the nurse conveys to the client that the information is important by
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Sitting at eye level with the client
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During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should
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Inform the client of the maintenance of confidentiality
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An older adult male with a history of benign prostatic hyperplasia presents to the emergency room with complaints of urinary retention. The nurse collects data related to the patient'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?
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Focused assessment
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The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements that are universal to all persons. What model for organizing the assessment data is the nurse using?
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Human Needs (Maslow) model
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What must the nurse do to identify actual or potential health problems?
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Gather data from sources
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How should a nurse best document the assessment findings that have caused her to suspect a patient is depressed following his below-the-knee amputation?
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"Patient states, 'I don't see the point in trying anymore.'"
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A nurse is asking questions about a client's sexual history. It is important for the nurse to
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Collect data in a quiet, private environment
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A unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first?
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The patient's airway should be assessed.
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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:
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Objective 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 does which of the following?
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Uses broad, open statements
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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, she stated that she was planning to leave her husband. On the next visit in 2 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
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Time-lapsed
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The nurse is reviewing information about a client and notes the following assessment data. Which of the following data cues does the nurse recognize as subjective data?
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Pain rating is 7
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The nurse is interviewing a client who is admitted to the healthcare facility with difficulty breathing. When beginning the interview, the nurse observes that the client is too breathless to answer. Which of the following would be most appropriate for the nurse to do?
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Defer the non-urgent questions until a more suitable time
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The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?
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Continue the health history with questions focusing on respiratory function.
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A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which of the following?
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Client
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The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's health status. Which of the following would the nurse identify as a subjective cue?
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Sharp pain in the knee
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A client has been discharged from an acute care facility. The first task a home health nurse must accomplish is
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Establish the client's database
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The nurse is assessing a male patient with a diagnosis of vascular dementia. As a result of his cognitive deficit, the patient 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?
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Supplement the patient's information by speaking with family or friends.
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A client visits the healthcare facility for a regular check-up. The nurse integrates the functional health pattern model when assessing the client. Which of the following best describes how the nurse collects and organizes the data?
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Focuses on client's normal, altered, and risk for altered function
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A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information?
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Client's wife
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While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which of the following actions clearly demonstrates assessing?
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The nurse asking if the client is having pain.
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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?
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Focus assessment
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When documenting subjective data, the nurse should do which of the following?
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Use the patient's own words placed in quotation marks.
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Which of the following patient situations most likely warrants a time-lapsed nursing assessment?
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An elderly resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.
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The nurse has entered a patient's room to find the patient diaphoretic (sweat-covered) and shivering, inferring that the patient has a fever. How should the nurse best follow up this cue and inference?
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Measure the patient's oral temperature.
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A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data?
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Nausea
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Before conducting a health assessment on a client, the nurse should first
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Introduce herself or himself to the client
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The nurse observes the client as he walks into the room. What information will this provide the nurse?
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Information regarding the client's gait
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During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should
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Review as much information as possible
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When assessing an infant, it is important to involve the
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Parents
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The phase of the nursing process when the nurse gathers data about the client to establish a plan of care is the
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Assessment
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Which of the following items reflect the assessment phase? Select all that apply.
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• "How would you rate your pain?" • Abdomen firm and distended with hypoactive bowel sounds • "I rarely sleep more than 6 hours."
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After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which of the following questions is the most appropriate conclusion to the interview?
answer
"Is there anything else we should know in order to care for you better?"
question
The nurse is interviewing a client with complaints of chills, fever, malaise, and cough. During the working phase of the client interview, the nurse:
answer
Asks the client to describe symptoms.
question
A unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first?
answer
The patient's airway should be assessed.
question
Before conducting a health assessment on a client, the nurse should first
answer
Introduce herself or himself to the client
question
A nurse is assessing a client admitted to the health care facility with angina. Which of the following would be most appropriate for the nurse to use to collect subjective data?
answer
Interview
question
During the interview component of the health assessment, the nurse conveys to the client that the information is important by
answer
Sitting at eye level with the client
question
How should a nurse best document the assessment findings that have caused her to suspect a patient is depressed following his below-the-knee amputation?
answer
"Patient states, 'I don't see the point in trying anymore.'
question
An older adult male with a history of benign prostatic hyperplasia presents to the emergency room with complaints of urinary retention. The nurse collects data related to the patient'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?
answer
Focused assessment
question
A client reports to a health care facility with complaints of 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?
answer
Client himself
question
The purpose of obtaining a nursing history is to
answer
Identify actual and potential nursing diagnoses
question
The nurse is reviewing information about a client and notes the following assessment data. Which of the following data cues does the nurse recognize as subjective data?
answer
Pain rating is 7
question
A patient is receiving home care due to an unstable blood pressure. Which of the following nursing interventions is a priority?
answer
Assess the patient's blood pressure
question
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, she stated that she was planning to leave her husband. On the next visit in 2 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?
answer
Time-lapsed
question
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?
answer
The nurse should consult with another nurse for that colleague's description of the assessment or observations.
question
When assessing the client's pulse, the nurse is using the following assessment technique:
answer
Palpation
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In order for a hospital to meet criteria regarding nursing care established by the Joint Commission on Accreditation of Healthcare Organizations, the nurse must conduct which of the following types of assessment?
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Initial
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The nurse observes the client as he walks into the room. What information will this provide the nurse?
answer
Information regarding the client's gait
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After assessment of a patient in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data?
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Auscultation of the lungs
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During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should
answer
Inform the client of the maintenance of confidentiality
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What would be a nursing priority when assessing a patient who weighs 250 pounds and stands 5' 3" tall?
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Assess blood pressure with a large cuff
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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:
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Omission of pertinent data.
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Which activities does the nurse perform during assessment, according to ANA Standards of Practice 1? Select all that apply.
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• Involves the client, family, and other healthcare providers in holistic data collection. • Synthesizes available data to identify patterns and variances.
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A nursing student is discussing assessment findings of an assigned client with the instructor. The instructor determines that the student needs additional assistance and review when the student identifies which of the following as objective data?
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Nursing staff
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A nurse who provides care on a postsurgical unit is expecting three patients to be admitted to the unit from postanesthetic recovery within a short time span. The admission assessment document that is used on the unit is extensive and requires a significant amount of time to complete. Which of the following principles should guide the nurse's assessments?
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Collect data that are helpful when planning and delivering care.
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When collecting subjective and objective data for a database in a client's home, it is important to
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Ask the client to turn off the television
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The nurse is interviewing a patient to obtain a nursing history. What phase of the interview process involves the nurse gathering all the information needed to form the subjective database?
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Working 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 focus assessment?
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Adds depth to existing information
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The nurse is performing a physical assessment of a patient admitted with emphysema. How will the nursing physical assessment differ from a medical physical assessment?
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The nurse's physical assessment will focus on the patient's functional abilities.
