Nur 192: chapter 11

Flashcard maker : Deloris Connelly
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?
focused
Which of the following qualities does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply.
• Caring
• Competence
• Respect for client
• Professionalism
\”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?
avoid impulse to interrupt
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?
be able to prioritize
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?
A focused assessment of the specific problems identified
When performing an assessment, the nurse should focus on the developmental stage for which of the following clients?
toddler
During the interview component of the health assessment, how does the nurse convey to the client that the information is important?
eye llevel
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?
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?
consultation
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?
adds depth
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?
client
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?
validate the data
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?
all data collected needs to be validated
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?
subjective
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?
nurse’s focuses on patient’s functional abilities
Which type of assessment would the nurse be expected to perform on the client who is one day post-op following a cholecystectomy?
focused
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 102. 9 F. What should be the nurse’s priority action?
verbally report to physician
A nurse is beginning the preparatory phase of the nursing interview for a patient who fractured his leg in a fall. Which nursing actions occur in this phase of the nursing interview? (Select all that apply.)
The nurse ensures that the interview environment is private and comfortable.
• The nurse arranges the seating in the interview room to facilitate an easy exchange of information.
• The nurse prepares to meet the patient by reading current and past records and reports.
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?
supplement the client’s info
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 which of the following?
body systems
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?
i don’t see the point in trying anymore
The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that which of the following is the best place to get baseline data?
initial comprehensive
During the nursing examination, the nurse notices that the patient, an elderly 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 patient if it is okay to interview her husband for the answers to the interview questions
An unlicensed staff member asks the nurse what the difference is between a medical assessment and a nursing assessment. Which of the following is the nurse’s best response?
A nursing assessment focuses on the client’s response to health problems.
Which of the following patient situations most likely warrants a time-lapsed nursing assessment?
elderly resident of extended care facility
After suffering a wrist fracture in a recent fall, a female client 77 years of age is strongly suspected of having osteoporosis. Which of the following data best demonstrates the nursing focus of assessment?
mobility and independence have declined in recent years
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?
it communicates respect for the client
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?
\”Is there anything else we should know in order to care for you better?\”
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?
a cue
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 nurse
During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:
review as much info as possible
When charting the assessment of a client, the nurse writes,\”Client is depressed.\” This documentation is an example of which of the following?
interpretationn of data
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?
As soon as possible after a client presents for care
A nurse is assessing a patient admitted to the hospital with complaints of left-sided weakness and difficulty speaking. Which assessment contains the data that best represent a nursing assessment?
patient is unable to communicate basic needs
A nurse who recently graduated is performing an assessment on a client who is admitted for nausea and vomiting. While performing the assessment, the client reports mild chest pain. The nurse does not know if the chest pain is related to the GI symptoms or should be reported to the physician.\” What is the nurse’s next best action?
Consult with another nurse
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?
when did you first notice rash on leg
A nurse is interviewing a new patient admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview?
The nurse assesses the patient’s comfort and ability to participate in the interview
Nurses understand the problem that clients have when they are repeatedly asked the same questions. To best avoid this problem from happening, which of the following should nurses do when beginning to collect assessment data?
The nurse understands that when assessing a client, the primary source of client information is the client. However, the nurse identifies other sources of client information can include which of the following? Select all that apply.
The nursing instructor is demonstrating to the class how to perform a physical assessment. Which of the following assessment techniques should be demonstrated by the nursing instructor? Select all that apply.
The nurse is summarizing the key points of the interview. This nursing activity occurs during what phase?
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?
While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, \”The client’s hearing may be impaired on the right side.\” This statement is an example of which of the following?
Which of the following items reflect the assessment phase of the nursing process? Select all that apply.
• \”How would you rate your pain?\”
• Abdomen firm and distended with hypoactive bowel sounds
• \”I rarely sleep more than 6 hours.\”
A client is a poor historian of his past medical history. Whom should the nurse consult about the client’s past history?

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