Chapter 14 Flashcards
Medical assessments target data pointing to pathologic conditions
While Nursing assessments focus on
The patient’s response to health problems
Five Types of Nursing Assessments:
Comprehensive initial
Focused
Emergency
Time-lapsed
Assessment of communities and special populations
True or false.
A nursing assessment duplicates a medical assessment
by focusing on the patient’s responses to the health
problem.
B. False
Rationale:
A nursing assessment does not duplicate a
medical assessment, rather it focuses on the patient’s
responses to the health problem.
Which one of the following assessments would be
performed on a patient to gather data about his
previously diagnosed liver cancer?
A. Initial comprehensive assessment
B. Focused assessment
C. Emergency assessment
D. Time-lapsed assessment
B. Focused assessment
Rationale:
In a focused assessment, the nurse gathers data
about a condition that has already been diagnosed. An initial
comprehensive assessment is performed shortly after the
patient is admitted to a health care agency or service. When
a physiologic or psychological crisis presents, the nurse
performs an emergency assessment. A time-lapsed
assessment compares a patient’s current status to baseline
data obtained earlier.
Initial Comprehensive Assessment
Performed shortly after admittance to hospital
Performed to establish a complete database for problem
identification and care planning
Performed by the nurse to collect data on all aspects of
patient’s health
Focused Assessment
May be performed during initial assessment or as routine
ongoing data collection
Performed to gather data about a specific problem
already identified, or to identify new or overlooked
problems
Performed by the nurse to collect data about the specific
problem
Emergency Assessment
Performed when a physiologic or psychological crisis
presents
Performed to identify life-threatening problems
Performed by the nurse to gather data about a life-
threatening problem
Time-Lapsed Assessment
Performed to compare a patient’s current status to
baseline data obtained earlier
Performed to reassess health status and make necessary
revisions in care plan
Performed by the nurse to collect data about current
health status of patient
Characteristics of Data
Purposeful
Prioritized
Complete
Systematic
Factual and accurate
Relevant
Four Phases of a Nursing Interview
Preparatory phase
Introduction
Working phase
Termination
During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:
implement supportive nursing interventions.
assess personal feelings regarding similar clinical situations.
review literature pertinent to the client’s attributes.
inform the client of the maintenance of confidentiality.
inform the client of the maintenance of confidentiality.
The nurse on the night shift is caring for a hospitalized client who reports being unable to sleep. The client states, “I just cannot sleep here. I miss my home. There are too many lights and it is too hot.” Which nursing concern does the nurse identify?
altered sleep pattern
social isolation
chronic pain
hyperthermia
powerlessness
altered sleep pattern
When is the best time for a nurse to take a client’s health history?
After the client is settled and feels ready
Within 24 hours of admission
As soon as possible after a client presents for care
Anytime before the client is discharged
As soon as possible after a client presents for care
How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation?
“Client states that rehabilitation will be unsuccessful.”
“Client is demonstrating signs and symptoms of depression.”
“Client makes statements indicating a loss of hope.”
“Client states, ‘I don’t see the point in trying anymore.’”
“Client states, ‘I don’t see the point in trying anymore.’”
Which are examples of subjective data? Select all that apply.
A client’s blood pressure is elevated following physical activity.
A nurse observes redness and swelling at an intravenous site.
A nurse observes a client wringing the hands before signing a consent for surgery.
A client reports being cold and requests an extra blanket.
A client feels nauseated after eating breakfast.
A client describes pain as an 8 on the pain assessment scale.
A client describes pain as an 8 on the pain assessment scale.
A client feels nauseated after eating breakfast.
A client reports being cold and requests an extra blanket.
The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview?
Avoid the impulse to interrupt.
Fill in the words for the client.
Fill in quiet spaces and pauses.
Focus mainly on verbal comments.
Avoid the impulse to interrupt.
Which client situation most likely warrants a time-lapse nursing assessment?
The nurse has responded to the call light of a hospital client who is reporting shortness of breath and chest pain.
A nurse is auscultating the lungs and measuring the oxygen saturation of a client who has pulmonary edema.
A client is being admitted to a general medicine unit after spending several days in the intensive care unit.
An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse’s scheduled monthly visit.
An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse’s scheduled monthly visit.
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.
agrees with each of the client’s statements.
attempts to write down everything the client says.
reassures the client of good outcomes.
uses broad, open statements to communicate with the client.
Which statement made by the nurse indicates data that would be documented as part of an objective assessment?
“The client’s sister reports that the client has unrelieved pain.”
“The client reports nausea following eating.”
“The client’s right leg is cold to the touch, from the knee to the foot.”
“The client reports having heartburn after breakfast.”
“The client’s right leg is cold to the touch, from the knee to the foot.”
Which is the purpose of a focused assessment?
Adds depth to existing information
Suggests possible problems
Provides breadth for future comparisons
Gives a comprehensive volume of data
Adds depth to existing information
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 to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?
Time-lapsed assessment
Developmental stage assessment
Focused assessment
Emergency assessment
Time-lapsed assessment
A nurse practitioner in private practice with a health care provider is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client’s commitment to this intended change. What type of assessment is the nurse practitioner implementing?
Focused
Time-lapse
Complete
Emergency
Time-lapse
The nurse watches a 43-year-old client walk into the room and notes the client is slightly limping on the left foot when walking. The nurse also notes the client has difficulty sitting in the chair and sits down carefully with the left leg slightly held forward. The client notes having had difficulty walking for the past year and it is getting worse. A previous ultrasound of the foot revealed a Morton neuroma. The client reports continued pain in the left foot when walking or standing for long periods of time. A physical examination reveals pain and tenderness on palpation of the upper left foot, skin is cool to touch with no redness noted, pedal pulse is 78 beats/min and regular. Which action by the nurse demonstrates the observation phase of an assessment?
Measuring the pedal pulse
Watching client walk into room
Palpating the skin for pain and temperature
Reviewing past records for ultrasound
Watching client walk into room
A 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 health care provider
The case manager
The nursing supervisor
The nurse
The nurse
Which is the primary reason for a nurse collecting data continuously on a client?
Most facilities require it for reimbursement.
The client’s health status can change quickly.
It gives the nurse more information to document on the client.
It makes the client feel as if the nurse is spending more time with the client.
The client’s health status can change quickly.
Which is an example of objective data?
The skin of a client who has liver failure has a yellowish tint.
A client with inner ear infections reports dizziness.
A client reports feeling very anxious about tests the client is undergoing.
A client receiving chemotherapy reports nausea.
The skin of a client who has liver failure has a yellowish tint.
When assessing the firmness of a client’s abdomen, the nurse should use which assessment technique?
Auscultation
Palpation
Inspection
Percussion
Palpation
The nurse is comparing a client’s current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment?
Time-lapsed assessment
Emergency assessment
Initial assessment
Patient centered assessment method (PCAM)
Time-lapsed assessment
