Which of the following examples are steps of nursing assessment? (Select all that apply)

An older adult male with a history of benign prostatic hyperplasia (BPH) presents to the emergency room with reports of urinary retention. The nurse collects data related to the client'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 assessment

The nurse is performing a focused assessment that involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the client's health. An emergency assessment is performed to identify life-threatening problems. A time-lapse assessment compares a client's current status to baseline data obtained earlier.

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?

The nurse should consult with another nurse for that colleague's description of the assessment or observations.

A client reports to a health care facility with reporting 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?

Client himself

As the client is in a conscious state, he himself is the primary source of information since he can give firsthand information. The client's wife, friends, and test results would be secondary sources of data.

What must the nurse do to identify actual or potential health problems?

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, the client stated that she was planning to leave her husband. On the next visit in two 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?

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?

When assessing an infant, it is important to involve the:

Which cultural group may interpret touch by another as an invasion of privacy?

The purpose of obtaining a nursing history is to:

identify actual and potential nursing diagnoses.

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?

Assess the client's blood pressure.

The nurse is caring for a 14-year-old adolescent who has just delivered her first baby girl. The adolescent states that she lives with an aunt and has no other family around her. The delivery was uncomplicated and the newborn is healthy. Which of the following would be the primary nursing diagnosis for this patient?

Risk for Impaired Parenting

The nurse is assessing a 3-week-old infant. Which of the following assessment findings would define the priority nursing diagnosis for this patient? The infant has not gained weight since birth. Bowel sounds are present in all quadrants. Breath sounds are clear to auscultation. Mom reports child cries much of the night but sleeps better in the daytime. Mom reports child only breastfeeds about four times in a 24-hour period and she doesn't seem to have much milk.

Ineffective Breastfeeding

The nursing instructor is teaching the students how to do an interview on a client. Which statement made by a student indicates a need for further instruction?

The nurse should show her name badge to the client so he can identify the nurse.

Some clients cannot read and they should not be expected to know a nurse's name and position by reading a name badge.

"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 the impulse to interrupt

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?

The nurse notices during an assessment interview that the client cannot stay on focus and jumps from one topic to another. The client also is speaking very rapidly and at time incoherently. What should the nurse suspect is the main cause of this behavior?

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

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 nurse

The question focuses on independent actions that nurses can perform. Interventions for which the nurse may be legally responsible include increasing the frequency of assessments and initiating necessary changes in the treatment regimen. Nurses are responsible for alerting the appropriate professional whenever assessment data differ significantly from the baseline.

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?

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

Which client situation most likely warrants a time-lapse nursing assessment?

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

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?

"Client states, 'I don't see the point in trying anymore.'"

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 a focus assessment?

adds depth to existing information

A focus assessment adds depth to existing information or the initial database gathered by the nurse. A database assessment provides breadth for future comparisons. A focus assessment does not suggest possible problems facing the client but rather rules out or confirms the client's problems. A focus assessment is not voluminous and comprehensive, like a database assessment, but limited and to the point.

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.

Which would be considered examples of subjective data? Select all that apply.

Comments made by the client's family.
Description of a symptom by a client.
A mother telling a nurse what the baby looked like when he was very ill.

Which of the following are examples of objective data?

laboratory results
breath sounds
a client's temperature

The nurse is caring for a patient with an IV infusion and notes an elevated BP, increased pulse and respirations, dyspnea, crackles, and neck vein distention. Based on the assessment, the nurse suspects:

Which quality does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply.

Respect for client
Competence
Professionalism
Caring

How long the nurse has practiced does not influence this.

When performing an assessment, the nurse should focus on the developmental stage for which client?

While studying methods of data collection, a nursing student learns that there are many different skills involved. Which of the following is a key nursing skill that uses all five senses?

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

The nurse is planning to do a physical assessment on a newly admitted client.The assessment will be a review of systems (ROS). This means the nurse plans to do which of the following?

Complete an exam of all body systems

The nurse is conducting an admission assessment on a client who informs the nurse that dyspnea follows the exertion the client is experiencing. What would be the best way for the nurse to chart this data?

The client reports feeling dyspneic after exertion

The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? Select all that apply.

38-year-old man
Height: 6' (1.82 m)
Weight: 195 lb (89 kg)

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?

The nurse working at a local community hospital understands the importance of having a client database for continuous data collection. What does the nurse identify as the the primary reason for collecting data continuously?

It is because the client's health status can change quickly

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood count (WBC) lab value. The nurse is gathering which type of data when looking up the lab value?

Nurses collect objective and subjective data during the client interview. Which client data is subjective data? Select all that apply.

-A client describes his pain as an 8 on the pain assessment scale.
-A client feels nauseated after eating his breakfast.
-A client reports being cold and requests an extra blanket.

An assessment involves gathering pieces of information about a client's health status. Which piece of information is subjective?

Client has generalized myalgia or muscle pain.

Which of the following is an example of a time-lapse reassessment?

Natalia is a visiting nurse who has an appointment with Donald, an 85-year-old man with mobility issues. Natalia has worked with Donald in the past on the ways in which he can prevent falls. Today she wants to assess how he is doing with the fall prevention strategies they practiced before.

During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:

review as much information as possible.

During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:

inform the client of the maintenance of confidentiality.

During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

sitting at eye level with the client

The nurse is reviewing information about a client and notes the following assessment data. Which data cue does the nurse recognize as subjective data?

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

The nurse is assessing a man in an outpatient setting. Which of the following assessment findings would lead to the priority nursing diagnosis for this client? Client states,"I don't want to live anymore. My family hates me and I am so tired of being sick. I have a gun and I am seriously thinking of killing myself." The patient reports a 30-year heavy smoking habit and having a cough for about six months. Ascultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminshed bowel sounds. His lips are slightly bluish in color.

A woman has delivered a healthy newborn and is scheduled to go home today, her third post-partum day. Her vital signs are stable. How often would the nurse expect to take the vital signs of a stable in-patient?

The nurse is assessing the blood pressure of a young adult patient. The reading seems low in comparison the trend of other measurements. What might the nurse suspect is the cause of the abnormally low reading? Select all that apply.

the cuff is too large
the arm is above the level of the heart
There is too much background noise
The stethoscope tubing is too long

A client who is bleeding profusely from a stab wound is brought to the emergency department. Which type of assessment is most appropriate for 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?

The nurse is reviewing the laboratory report section of a client's record. For what reason is this important for the nurse to review? Select all that apply.

To confirm previous collected data
To conflict with previous collected data
To help to establish a diagnosis
To monitor clients' responses to treatment

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 39.4 C. What should be the nurse's priority action?

Verbally report the finding immediately to the client's physician

Abnormal assessment findings or changes in the client's health status should be immediately reported to the client's physician or the charge nurse for prompt and appropriate treatment of client health alterations.

The nurse is conducting a client interview and notices that the client answers every questions with a "yes" or "no" response. What is mostly likely the cause of this action by the client?

The nursing instructor is teaching the students about assessments. Which of the following does the instructor list as being most important in order for an assessment to be successful?

The nurse is preparing to perform an assessment on a newly admitted client. What should the nurse do prior to performing this initial assessment?

Review the records available on the client

Records prepared by different members of the healthcare team provide information essential to comprehensive nursing care. The nurse should review records early when gathering data before the first contact with the client

Nurses collect objective and subjective data when performing client assessments. What is an example of objective data?

The skin of a client who has liver failure has a yellowish tint.

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

The nurse is interviewing a client that is newly admitted to the unit. Which techniques used by the nurse will facilitate communication during the interview? Select all that apply.

Use broad opening statements.
Share observations.
Use silence.

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

"The client's right leg is cold to the touch, from the knee to the foot."

At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

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 the rash on your leg?"

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 information by speaking with family or friends.

An unconscious client is brought to the emergency department. Which assessment should be implemented first?

The client's airway should be assessed.

The nurse observes the client as he walks into the room. What information will this provide the nurse?

information regarding the client's gait

Before conducting a health assessment on a client, what should the nurse do first?

Introduce herself to the client.

The night shift RN is caring for a hospitalized adult client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client?

The nurse is assessing the spine of a 63-year-old woman who states, "I hope I don't end up with a big hump on my back like my mother did." The nurse knows the patient is referring to a condition known as:

The nurse is conducting a health history on a newly admitted client. Which aspect of the client should the nurse include while doing the history? Select all that apply.

Health status
Strengths
Health problems
Health risks

A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client?

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?

A nursing instructor teaching about assessment data identifies a need for further instruction when a student makes which of the following statements?

"The client is always the best source for collecting data."

The nurse must be familiar with the client record in order to provide care effectively. Which parts of the client record include only the findings of physicians? Select all that apply.

Medical history
Physical exam
Progress notes

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?

The nurse is conducting an interview on a newly admitted client. Which of the following is recommended when conducting a client/nurse interview?

Focus full attention on the client.

A client comes to the emergency department with a stab wound and is bleeding profusely. Which type of assessment should the nurse perform on this client immediately?

A nurse is interviewing a hospitalized patient. Which nurse-patient positioning facilitates an easy exchange of information?

If the patient is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

During the nursing examination, the nurse notices that the client, an older adult 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 client if it is okay to interview her husband for the answers to the interview questions

A nurse is beginning the preparatory phase of the nursing interview for a client who fractured the left 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 client by reading current and past records and report

Providing a private and comfortable environment, arranging seating, and reading current/past records about a client all take place during the preparatory phase of the nursing interview.

The nurse states his/her name during the introductory phase.

The nurse assesses the client's comfort and ability to participate during the introductory phase.

The nurse recapitulates the interview during the concluding phase.

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:

In order for a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall?

Assess blood pressure with a large cuff.

The nurse has identified a priority problem on her unit. Which statement is true regarding addressing a priority problem?

A priority problem requires a nursing intervention before another problem is addressed.

The nurse is caring for a patient for the third day in a row on the hospital unit. At his evening vital sign assessment, the nurse notices the radial pulse is much slower than his apical pulse. This finding is new. Which of the following would the nurse do next?

Notify the physician of the change and document the finding.

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?

The nurse is caring for an older adult client admitted to the hospital for a respiratory condition. What type of data should the nurse review prior to caring for this client? Select all that apply.

Consultations
Lab reports
Medical history
Progress notes
X-Ray reports

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

The nursing student demonstrates accurate application of the assessment phase of the nursing process by performing which action?

asking the client whether the client has cultural preferences

Assessing the client involves gathering information about the client's physical and emotional health; cognition; spiritual, cultural, or religious preferences; and sociodemographics.

Developing a plan to manage the client's health problems falls within the planning phase of the nursing process.

Coming up with the nursing diagnosis falls within the diagnosing phase of the nursing process.

Determining if the client's goals for wellness have been met occurs at the evaluation phase of the nursing process.

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview?

"Is there anything else we should know in order to care for you better?"

A client has been discharged from an acute care facility with a referral for a home health nurse to make an assessment. What is the priority action by the home health nurse on the initial home visit?

establish the client's database.

The RN is interviewing an 80-year-old woman admitted to the hospital for evaluation of her diabetes. The client states she enjoys being in the hospital because she lives alone and does not have many friends. She states her husband died 1 year ago and she is no longer able to drive. She relies on her daughter who lives one hour away to shop for her once a week. The client states, "My daughter can never stay long, she is just in and out in no time." Which nursing diagnoses would be appropriate for this client? Select all that apply.

Risk for Loneliness
Powerlessness

The nurse records the name, age, and genetic background of the client after obtaining this data. This data are components of which action?

The nurse is collecting data from a client during a complete assessment. What is the nurse demonstrating when the documentation of the assessment is performed in a timely precise manner?

What are the 5 steps in the patient assessment sequence?

What is an example of a nursing assessment?

What are the six steps of the nursing process quizlet?

What are the components of nursing assessment?