Nurse's Role
Which individual typically would be responsible for collecting the subjective data on a client?
Nurse
The nurse typically collects the subjective data, especially those related to the client's overall function.
During which of the following phases of the interview process will the nurse assure the client that all personal data the client discusses with the nurse will be kept confidential?
B.) Introductory
The nurse is to collect a throat culture from a client. The nurse demonstrates the best adherence to standard precautions by using which piece of protective equipment?
Gloves
as part of a mental status assessment, the nurse asks a client to draw the face of a clock. the nurse is assessing which of the following?
Visual perceptual and construction ability
the nurse is preparing to assess vital signs. Which vital sign would the nurse assess first?
Temperature
The client's temperature is measured first. doing so puts the client at ease and causes him or her to remain still for several minutes. This is important because pulse, respiration, and BP are influenced by activity and anxiety
A nurse on a postsurgical unit is admitting a client's cholecystectomy. What is the overall purpose of assessment for this client?
Making clinical judgement
The purpose of nursing health assessment is to collect subjective and objective data to determine a client's overall level of functioning to make a professional clinical judgement. Collecting and validating data means to this end. The primary purpose of assessment is not to assist the primary care provider.
When describing the purpose for obtaining a comprehensive health history to a client, which would the nurse include as primary?
Provides a focus for the physical exam
the nurse is preparing to assess a client's peripheral pulse. the nurse would place the client in which position?
Supine
A nursing student has been assigned to care for a client whose history suggests the need for a mental status assessment. This client most likely has a history of health problems affecting what body system?
Neurologic
A nurse documents a client's radial pulse as 2+, indicates what?
It occludes with moderate pressure
The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process?
A.) Each step is independent of the others
B.) It is ongoing and continuous
C.) It is used primarily in an acute care setting
D.) It involves independent nursing actions
B.) it is ongoing and continuous
Although the assessment phase of the nursing process precedes other phases in the formal nursing process, nurses are always aware that assessments is ongoing and continuous throughout all the phases of the nursing process
A new graduate nurse asks another more experienced nurse about the best way to assess a patient's dietary habits. which suggestion would be most appropriate?
Obtain 24 hour diet recall
The nurse places a client complaining of back pain in the dorsal recumbent position. Which area would the nurse be least likely to assess with the client in this position?
Abdomen
the nurse is assessing a client using the Glasgow coma scale. The client demonstrates eye opening to verbal command, responds using inappropriate language, and is able to obey verbal commands when the nurse asks the client to move the arm. What total score should the nurse document for the client?
12
A nurse obtains the blood pressure in a client who is lying down. What would the nurse expect to find?
The blood pressure will be slightly lower than standing readings
After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identified which phase as being foundational to all other phases?
Assessment
Assessment is the first and most critical phase of the nursing process. if data is collected is inadequate or inaccurate, incorrect nursing judgements may be made that adversely affect the remaining phases of the process
A nurse is creating a genogram for a client's family health history. The nurse would use which of the following to denote the client's female relatives?
Circle
The nurse is evaluating the setting for a client's physical examination. the nurse ensure that the setting has which of the following? select all that apply.
Adequate lighting, cool room temperature, quiet surroundings, soft chair or table, table for equipment, door or curtain
Adequate lighting, Quiet surroundings, Table for equipment, door or curtain
The nurse utilized the Depression Questionnaire on a client who has recently moved to a long-term care facility. The total score is 22. What would the nurse to do next?
Refer for further evaluation
the nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment findings?
Auscultate the client's apical pulse
A 38-year-old client has been admitted to the ER with reports of abdominal pain and vomiting for the past 6 hours. Which type of the assessment will the nurse complete on this client?
Focused assessment
The nurse is completing a review of systems for a client. Which of the following information would the nurse document related to the client's musculoskeletal system? Select all that apply.
Joint stiffness, Rhinorrhea, SOB, Chest pain, Muscle strength, Swelling
Joint stiffness, Muscle weakness, Swelling
A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from post-anesthetic recovery. The nurse should plan to perform which technique first?
Inspection
Assessment of a client who has suffered a recent stroke reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?
Obtunded, stupor, Coma, Lethargy
Coma
the nurse reviews temperature measurements for assigned clients. Which measurement should the nurse identify as being elevated?
99.5 F oral, 100.5 rectal, 97.9 axillary, 100.1 temporal
100.5 F axillary