The client is brought to the hospital after experiencing a seizure and the nurse collects data from the husband regarding the witnessed seizure activity. This is an example of what type of data?
Support
When the client reports experiencing nausea, the nurse recognizes this data as:
Subjective
Two hours after administration of blood pressure medication, the nurse takes the client's blood pressure. This is an example of what phase of the nursing process?
Evaluation
The nurse is repositioning the client to avoid skin breakdown, which is an example of what phase of the nursing process?
Implementation
Subjective data is important to the nurse's assessment because:
It provides the nurse with information that no one else can offer
The nurse is asking the client how often the nausea occurs and if there is anything that alleviates the problem. This is an example of what method of data collection?
Interviewing
The nurse is admitting the client to the unit and is asking very specific questions related to the client's health history. What type of interview is the nurse performing?
Directive
What nursing framework is based on 11 functional health patterns and collects data about dysfunctional and functional behavior?
Gordon's functional health patterns
The nurse considers advantages of asking open-ended questions are:
They may reveal the interviewee's lack of information, misunderstanding of words, prejudices, or stereotypes
They can convey interest and trust
They are easy to answer and nonthreatening
They can provide information the interviewer may not ask for
The client has had a stroke and has difficulty speaking. An example of the most appropriate form of communication the nurse can use is:
Are you having pain?
In order to facilitate an easy exchange of information, then nurse arranges the environment for the interview with:
The client in bed and the nurse sitting on a chair at a 45-degree angle to the head of the bed
The most important component to the effective use of the nursing process is:
Critical thinking
During the assessment, the nurse:
Collects data
validates data
organizes data
documents data
During the nursing history and physical, the nurse obtains:
Subjective data
objective data
primary data
The nurse determines the status of a specific problem identifies earlier in the shift during:
Problem-focused assessment
The nurse conducts a time-lapsed reassessment in what setting?
In a home care setting
When assessing a critically ill client in the acute care facility, the nurse needs to:
Use initial assessment and emergency assessment
Characteristics of the nursing process include:
Data from each phase is used in the next phase
Decision making is involved in each phase of the nursing process
It is individual and autonomous
It is universally applicable in all settings
The nurse sets a goal for the client to achieve during what step in the nursing process?
Planning
The nurse performs which of the following during the diagnosis phase?
Identify factors that contribute to the problem
The nursing process is:
Client centered
The nurse uses the steps of the nursing process:
In a continuously changing order based on the situation
The nurse is admitting a client to an acute care facility, beginning with the initial assessment, when the client states: "I don't know why you need to know so much about me." The nurse explains the purpose of the assessment is:
To collect information about your past and present health status
To supply a comprehensive understanding of your health needs
To understand your needs related to taking care of yourself at home after discharge
Assessing is the systematic collection of data by the nurse that occurs only within 24 hours of the client's inpatient admission
False
The nurse performs hourly monitoring of the client's urinary output and obtains blood pressure measurements
Collecting data
The nurse develops an intake and output flow chart in order to systematically view the data by time and date
Organizing data
When the nurse determines the client's output to be low, the nurse obtains a daily weight to determine if the client is retaining fluid
Validating data
The nurse writes the amount of urine in the client's catheter at the end of every hour, the client's blood pressure, and the client's daily weight in the client's medical record
Documenting data
The major activities associated with the assessment phase include:
documenting data
organizing data
validating data
collecting data
The nurse collects subjective data when learning that the client is experiencing:
Headache
The client states. "I feel overwhelmed by all the new information you have given me that I need to remember
Subjective, primary
The client's significant other states, "He says it feels like spiders are crawling on his legs, but I don't see them.
Subjective, secondary
The client states, "Blood oozes out of the wound every time I go for a walk.
objective, primary
The client's sister states, "He lives at 402 S Oak St.
Objective, secondary
The nurse removes the dressing and looks at the client's postoperative wound
observing
The nurse asks the client, "How long have you been feeling this pain?
interviewing
The nurse listens to the client's breath sounds and palpates the client's abdomen
assessing
The data collection method of observation involves a planned communication that provides counseling
False
The client is having chest pain. The nurse most appropriately asks:
Please describe your pain
Question Text (Directed interview)
Time is short and specific information is needed
The nurse asks a client. "What happened to your leg?" This is an example of:
An open-ended question
The nurse wishes to determine the client's feelings about a recent diagnosis. Which interview question is most likely to elicit this information?
Tell me about your reactions to the diagnosis
Using the box shown, in the interview phase, what should the nurse consider that might have a cultural aspect?
Distance between nurse and client
A nurse is consulting with an architect to design an outpatient clinic and recommends changes to optimize the interview setting, including:
A well-lit room with individual temperature control
Room for chairs to be placed approximately 3 feet apart
Sound-dampening walls
The best reason for the nurse to base the assessment format on a model is:
Using a model or framework helps organize data collected during assessment
The specific model or theory used by the nurse working in an acute care facility as a framework for assessments is generally based on:
The policy of the institution
The nurse identifies that the client is experiencing chest pain, shortness of breath, nausea, and diaphoresis. This is an example of which phase of the nursing process?
Assessment
The nurse assesses the client and learns the client has been experiencing frequent headaches. The nurse sees the client's past blood pressure measurements have consistently been less than 120/80 mmHg. Upon measuring blood pressure on this occasion, the cl
Subjective data
objective data
primary data
secondary data
Data the nurse collects from the client is considered:
Primary data
The nurse's use of a conceptual or theoretical framework for collecting and organizing assessment data ensures:
Collection of all necessary information for a thorough appraisal
The most important component to the effective use of the nursing process is:
Critical thinking
The nursing process is primarily used by nurses to guide them in:
problem solving
The nurse is reviewing the client's history in the medical record and recognizes this type of data source as:
Secondary
During which stage of the interview should the nurse ask, "How long have you had this symptom?
Body