TBRQ Ch: 16 - Nursing Assessment Flashcards
Which of the following examples are steps of nursing assessment? (Select all that apply.)
- Collection of information from patient’s family members
- Recognition that further observations are needed to clarify information
- Comparison of data with another source to determine data accuracy
- Complete documentation of observational information
- Determining which medications to administer based on a patient’s assessment data
Answer: 1, 2, 3.
Assessment includes collection of data from secondary sources such as the patient’s family. Recognizing that more observation is needed is an example of validation of data. Comparing data to determine accuracy is a feature of interpretation. Although complete documentation is an important step in communicating assessment data, it is not an assessment step.
A nurse assesses a patient who comes to the pulmonary clinic. “I see that it’s been over 6 months since you’ve been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you’ve been in following his plan?” The nurse’s assessment covers which of Gordon’s functional health patterns?
- Value-belief pattern
- Cognitive-perceptual pattern
- Coping–stress-tolerance pattern
- Health perception–health management pattern
Answer: 4.
The nurse’s assessment covers health perception and health management pattern, which is a patient’s self report of how he or she manages their health and their knowledge of preventive health practices. The coping stress tolerance pattern would include questions focused on how the patient manages stress and sources of support. An assessment covering the value belief pattern leads a patient to describe patterns of values, beliefs and life goals. An assessment of the cognitive-perceptual pattern includes questions that focus on the patient’s language adequacy, memory and decision making ability.
When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.)
- An observation of how a patient turns and moves in bed
- The unit policy and procedure manual
- The care recommendations of a physical therapist
- The results of a diagnostic x-ray film
- Your experiences in caring for other patients with similar problems
Answer: 1, 3, 4.
There are many sources of data for an assessment, including the patient through interview, observations, and physical exam; family members or significant others, health care team members like a physical therapist, the medical record which includes x ray results and the scientific and medical literature.
The 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:
- Cue.
- Reflection.
- Clinical inference.
- Probing.
Answer: 3.
An inference is your judgment or interpretation of cues, such as the shuffling gait and reduced leg strength. Any information gathered through your senses is a cue. Probing is a technique used in interviewing. Reflection is an internal though process of thinking back about a situation.
A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient’s room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient’s heart rate and blood pressure and asks him, “Tell me where your pain is.” Which of the following assessment approaches does this scenario describe?
- Review of systems approach
- Use of a structured database format
- Back channeling
- A problem-oriented approach
Answer: 4.
This is an example of a problem focused approach. The nurse focuses on assessing one body system (cardiovascular) to determine nature of the patient’s pain and other presenting symptoms.
The nurse asks a patient, “Describe for me a typical night’s sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview?
- Orientation
- Working phase
- Data validation
- Termination
Answer: 2.
The gathering of information is the working phase of a patient-centered interview.
A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse’s cultural competence in assessing the patient’s health care problems?
- “I can tell that your eating habits have led to your diabetes. Is that right?”
- “It’s been difficult for people to find jobs. Is that why you work part time?”
- “You have four children; do you have any concerns about going home and caring for them?”
- “I wish patients understood how overeating affects their health.”
Answer: 3.
This is the only assessment approach that is not biased or showing judgment about the patient’s weight or occupational status. With the other options, the nurse is reacting to the patient based on personal stereotypes and biases.
Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care?
- Probing
- Open-ended
- Problem-oriented
- Confirmation
Answer: 2.
The best interview question for determining initially the reason a patient is seeking healthcare is by asking an open ended question that allows the patient to tell their story. This is also a more patient-centered approach. Probing questions are done after data are gathered to seek more in depth information. Problem oriented and confirmation are not types of interview question.
A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? (Select all that apply.)
- The skin around the wound is tender to touch.
- Fluid intake for 8 hours is 800 mL.
- Patient has a heart rate of 78 beats/min and regular.
- Patient has drainage from surgical wound.
- Body temperature is 38.3° C (101° F).
- Patient states, “I’m worried that I won’t be able to return to work when I planned.”
Answer: 1, 4, 5.
Tender skin around the wound, drainage from the surgical wound, and a temperature of 101° indicate a wound infection. Fluid intake of 800 mL over 8 hours and a heart rate of 78 and regular are normal assessment findings. A patient’s expressed concern about returning to work is a patient’s subjective response about a separate issue and insufficient to form a pattern.
A nurse is checking a patient’s intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing:
- Patient’s level of function.
- Patient’s willingness to perform self-care.
- Patient’s level of consciousness.
- Patient’s health management values.
Answer: 1.
Observing a patient perform activities physical, socially, psychologically and developmentally assesses their level of function. In the case of this question the nurse assesses physical functional level. Observation does not measure willingness to perform self care but the ability to do so. Observing physical performance of self-hygiene is not a measure of level of consciousness nor does it reveal a patient’s values.
A nurse makes the following statement during a change-of-shift report to another nurse. “I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair.” What can the nurse who is beginning a shift do to validate the previous nurse’s assessment findings when she conducts rounds on the patient? (Select all that apply.)
- The nurse asks the patient to rate his pain on a scale of 0 to 10.
- The nurse asks the patient what caused his fall.
- The nurse asks the patient if he has had pain in his back in the past.
- The nurse assesses the patient’s lower-limb strength.
- The nurse asks the patient what pain medication is most effective in managing his pain.
Answer: 1, 4.
Validation of assessment data is the comparison of data with another source to determine data accuracy. The nurse compares data reported by the previous nurse with data collected directly with the patient, including assessing pain on the rating scale and assessing the patient’s lower limb strength. Asking the patient what caused his fall and asking about past back pain would offer the nurse new information about the patient.
A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, “How do you see yourself now?” On the basis of Gordon’s functional health patterns, which pattern does the nurse assess?
- Health perception–health management pattern
- Value-belief pattern
- Cognitive-perceptual pattern
- Self-perception–self-concept pattern
Answer: 4.
This is an example of assessment of a patient’s feelings about his worth and body image which is the self-perception and self-concept health pattern.
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.
- “You say you’ve lost weight. Tell me how much weight you’ve lost in the last month.”
- “My name is Todd. I’ll be the nurse taking care of you today. I’m going to ask you a series of questions to gather your health history.”
- “I have no further questions. Thank you for your patience.”
- “Tell me what brought you to the hospital.”
- “So, to summarize, you’ve lost about 6 lbs in the last month, and your appetite has been poor—correct?”
Answer:
2, 4, 1, 5, 3.
During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing?
- So you’ve had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct?
- Have you taken anything for your headaches?
- Tell me what makes your headaches begin.
- Uh huh, tell me more.
Answer: 3.
A probing question such as “Tell me what makes your headaches begin” encourages a more full description of a situation by asking an open ended question. The statement “So you’ve had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct?” is a summarative statement. Asking whether the patient has taken anything for the headaches is a close ended question. Saying “Uh huh, tell me more” is an example of back channeling.
The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? (Select all that apply.)
- Listen attentively to the patient’s story.
- Use gestures that reinforce your questions or comments.
- Stand back away from the bedside.
- Maintain direct eye contact.
- Ask questions quickly to reduce the patient’s fatigue.
Answer: 1, 2, 4.
Approaches for collecting an older adult assessment include listening patiently, using nonverbal communication when a patient has a hearing deficit, and maintaining patient-directed eye gaze. Leaning forward, not backward shows interest in what the patient has to say.
