16. Nursing assessment

Question 1

Assessment

Answer 1

First step of the nursing process. Activities required in the first step are data collection, validation, sorting, and documentation. The purpose is to gather information for health problem identification.

Question 2

Back channeling

Answer 2

Active listening technique that prompts a respondent to continue telling a story or describing a situation. Involves use of phrases such as “Go on, ” “Uh-huh, ” and “Tell me more.”

Question 3

Closed-ended questions

Answer 3

Form of question that limits a respondent’s answer to one or two words.

Question 4

Cue

Answer 4

Information that a nurse acquires through hearing, visual observations, touch, and smell.

Question 5

Inference

Answer 5

(1) Judgment or interpretation of informational cues. (2) Taking one proposition as a given and guessing that another proposition follows.

Question 6

Nursing health history

Answer 6

Data collected about a patient’s present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness.

Question 7

Nursing process

Answer 7

Systematic problem-solving method by which nurses individualize care for each patient. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

Question 8

Objective data

Answer 8

Information that can be observed by others; free of feelings, perceptions, and prejudices.

Question 9

Open-ended questions

Answer 9

Form of question that prompts a respondent to answer in more than one or two words.

Question 10

Review of systems (ROS)

Answer 10

Systematic collection of subjective information from patients about the presence or absence of health-related issues in each body system.

Question 11

Subjective data

Answer 11

Information gathered from patient statements; the patient’s feelings and perceptions. Not verifiable by another except by inference.

Question 12

Validation

Answer 12

Act of confirming, verifying, or corroborating the accuracy of assessment data or the appropriateness of the care plan.

Question 13

A home health nurse is visiting a 62-year-old Hispanic woman diagnosed with type 2 adult-onset diabetes mellitus following a 2-day stay at a local hospital. The physician ordered home health with placement of the patient on a diabetic protocol for education about diabetes mellitus and a new medication and diet counseling. The patient lives with her 73-year-old husband, who has progressive dementia. Their daughter checks on her parents daily, buys groceries, and helps with home maintenance. The nurse conducts an initial history to gather information about the patient’s condition. Which of the following data cues combine to reveal a possible health problem? (Select all that apply.)

1. First time hospitalized
2. Unable to describe diabetes
3. Takes anti-inflammatory for arthritis
4. Has limited health literacy
5. Husband is able to perform self-bathing
6. Patient unable to identify food sources on prescribed diet
7. Patient has reduced vision and wears glasses
8. Patient prescribed an oral hypoglycemic drug

Answer 13

2. Unable to describe diabetes
3. Has limited health literacy
4. Patient unable to identify food sources on prescribed diet
5. Patient has reduced vision and wears glasses

Question 14

Match the following assessment activity with the type of assessment (A. Problem-focused or B. Comprehensive):

___1. Assessment conducted at beginning of a nurse’s shift

Answer 14

A. Problem-focused

Question 15

Match the following assessment activity with the type of assessment (A. Problem-focused or B. Comprehensive):

___2. Review of a patient’s chief complaint

Answer 15

A. Problem-focused

Question 16

Match the following assessment activity with the type of assessment (A. Problem-focused or B. Comprehensive):

___3. Completion of admitting history at time of patient admission to a hospital

Answer 16

B. Comprehensive

Question 17

Match the following assessment activity with the type of assessment ( A. Problem-focused or B. Comprehensive):

___4. Completion of the Long Term Care Minimum Data Set during an older adult’s admission to a nursing home

Answer 17

B. Comprehensive

Question 18

A nurse initiates a brief interview with a patient who has come to the medical clinic because of self-reported hoarseness, sore throat, and chest congestion. The nurse observes that the patient has a slumped posture and is using intercostal muscles to breathe. The nurse auscultates the patient’s lungs and hears crackles in the left lower lobe. The patient’s respiratory rate is 22 breaths/min compared with an average of 16 breaths/min during previous clinic visits. The patient tells the nurse, “It’s hard for me to get a breath.” Which of the following data sets are examples of subjective data? (Select all that apply.)

1. Heart rate of 22 breaths/min and chest congestion
2. Lung sounds revealing crackles and use of intercostal muscles to breathe
3. Patient statement, “It’s hard for me to get a breath”
4. Slumped posture and previous respiratory rate of 16 breaths/min
5. Patient report of sore throat and hoarseness

Answer 18

3. Patient statement, “It’s hard for me to get a breath”
4. Patient report of sore throat and hoarseness

Question 19

The nurse asks a patient the following series of questions: “Describe for me how much you exercise each day.” “How do you tolerate the exercise?” “Is the amount of exercise you get each day the same, less, or more than what you did a year ago?” This series of questions would likely occur during which phase of a patient-centered interview?

1. Orientation
2. Working phase
3. Data interpretation
4. Termination

Answer 19

2. Working phase

Question 20

A nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient’s legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of:

1. Reflection
2. Clinical inference
3. Cue
4. Validation

Answer 20

2. Clinical inference

Question 21

A nurse inspects a patient’s sacral pressure injury and notices that the wound is 6 cm (2.4 inches) in diameter with inflammation. The nurse gently applies pressure around the wound, with the patient acknowledging pain. The nurse asks the patient to rate the level of pain on a scale from 0 to 10. A final assessment includes reviewing the electronic health record for how frequently the patient was turned in the last 12 hours.
Fill in the spaces below to identify the following concepts: assessment activity or cue.

The nurse inspects (a. _____) a patient’s sacral pressure injury and notices that the wound is 6 cm (2.4 inches) in diameter (b. _____) with inflammation (c. _____). The nurse gently applies pressure (d. ____) around the wound, with the patient acknowledging pain (e. _____). The nurse asks the patient to rate the level of pain on a scale (f. _____) from 0 to 10. A final assessment includes reviewing the electronic record (g. _____) for how frequently the patient was turned in the last 12 hours.

Answer 21

The nurse inspects (a. assessment activity) a patient’s sacral pressure injury and notices that the wound is 6 cm (2.4 inches) in diameter (b. cue) with inflammation (c. cue). The nurse gently applies pressure (d. assessment activity) around the wound, with the patient acknowledging pain (e. cue). The nurse asks the patient to rate the level of pain on a scale (f. assessment activity) from 0 to 10. A final assessment includes reviewing the electronic record (g. assessment activity) for how frequently the patient was turned in the last 12 hours.

Question 22

In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history?

1. Current medications
2. Patient expectations of planned surgery
3. Review of patient’s family support system
4. History of allergies
5. Patient’s explanation for what might be the cause of symptoms that require surgery

Answer 22

5. Patient’s explanation for what might be the cause of symptoms that require surgery

Question 23

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask.

1. “You say you’ve lost weight. Tell me how much weight you’ve lost in the past month.”
2. “My name is Terry. I’ll be the nurse taking care of you today.”
3. “I have no further questions. Is there anything else you wish to ask me?”
4. “Tell me what brought you to the hospital.”
5. “So, to summarize, you’ve lost about 6 pounds in the past month, and your appetite has been poor—correct?”

Answer 23

2. “My name is Terry. I’ll be the nurse taking care of you today.”
3. “Tell me what brought you to the hospital.”
4. “You say you’ve lost weight. Tell me how much weight you’ve lost in the past month.”
5. “So, to summarize, you’ve lost about 6 pounds in the past month, and your appetite has been poor—correct?”
6. “I have no further questions. Is there anything else you wish to ask me?”

Question 24

Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? (Select all that apply.)

1. Recognize normal changes associated with aging.
2. Avoid direct eye contact.
3. Lean forward and smile as you pose questions.
4. Allow for pauses as patient tells his story.
5. Use the list of questions from the clinic assessment form to complete all data.

Answer 24

1. Recognize normal changes associated with aging.
2. Lean forward and smile as you pose questions.
3. Allow for pauses as patient tells his story.