Intro, Techniques, and Health History
Proper positioning, privacy, communication, and appropriate draping help protect this important aspect of patient care.
What is patient dignity?
A client has a temperature that is slightly lower at 7 AM and higher at 5 PM. The client has no other signs of illness. How should the nurse interpret this finding?
What is a normal diurnal variation in temperature?
A client reports pain of 8/10 but is smiling and talking with family. What should the nurse do?
What is accept the client's report and continue assessing the pain rather than judging pain based on appearance?
An older adult presents with sudden confusion and changes in functioning. The nurse should consider this condition, which can increase the risk of functional decline.
What is delirium?
A patient's report of “I have a headache” is an example of this type of data.
What is subjective data?
A nurse documents, “Client appears anxious.” What would make this documentation more objective?
What is documenting the specific observed behaviors, such as pacing, trembling, rapid speech, or facial expression, rather than simply labeling the client as anxious?
While assessing a client's radial pulse, the nurse notices that the beats occur at inconsistent intervals. What should the nurse document?
What is an irregular rhythm?
An older adult reports severe pain after a procedure. A student says, “That's normal because older adults feel more pain.” How should the nurse respond?
What is pain is not an expected finding of aging and should always be assessed
The nurse suspects a client's cognitive function has declined and wants to perform a brief screening tool that assesses areas such as orientation, attention, recall, and language. Which tool should the nurse anticipate?
What is the Mini-Mental State Examination (MMSE)?
This step of the nursing process determines whether the patient's goals and expected outcomes have been achieved.
What is evaluation?
A nurse assumes that every client from a particular cultural group will have the same health beliefs. What should the nurse recognize as the problem?
What is stereotyping?
A student nurse uses their thumb to palpate a client's radial pulse. What should the instructor identify as the problem with this technique?
What is the thumb has its own pulse and can interfere with accurate assessment?
A young child is able to select the facial expression that best represents their pain. Which assessment tool could the nurse use?
What is the Wong-Baker FACES Pain Rating Scale?
A client says, “I have a gun at home, and I plan to use it tonight.” What is the nurse's priority?
What is immediate suicide risk/safety assessment and intervention?
Eye contact, facial expressions, body language, gestures, and tone of voice are all examples of this type of communication.
What is nonverbal communication?
During an assessment, the nurse documents a heart rate of 104 beats/min. Which type of data is this?
What is objective data?
The expected ranges all vitals signs for an adult.
Temp: 96.4F-99.1F (average of 98.6F)
BP: systolic <120, diastolic <80
O2: >90%
Heart Rate/Pulse: 60-100 bpm
Resp: 12-20 breath/min
A client cannot reliably communicate their pain verbally. The nurse evaluates facial expression, leg movement, activity, crying, and consolability. Which tool is the nurse using?
What is the FLACC scale?
A client reports hallucinations and becomes increasingly agitated. What should the nurse assess first?
What is the client's safety and risk of harm to self or others?
A client reports overwhelming sadness, hopelessness, low energy, and loss of interest in activities. Which mental health condition should the nurse screen for?
What is depression?
A nurse is preparing to assess a patient on droplet precautions. Which PPE is most important before entering the room?
What is a mask?
A client has a significant drop in blood pressure after standing and reports dizziness. The nurse recognizes the immediate concern is not simply the abnormal number but the client's increased risk for this complication.
What is syncope and falling/injury?
A client reports pain of 8/10. The nurse administers an ordered pain intervention. Thirty minutes later, the client reports pain of 3/10. What should the nurse do with this information?
What is reassess and document the client's response to the intervention?
A client describes persistent worry and anxiety that is causing significant distress. Which screening tool is specifically designed to assess generalized anxiety symptoms?
What is the GAD-7?
Which is the greatest indicator of immediate suicide risk: feeling hopeless, loss of interest in hobbies, having suicidal thoughts, or having a specific plan and access to the means?
What are a specific plan and access to the means?