Ch. 14 Assessing Flashcards
The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant’s skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed?
A) Comprehensive
B) Initial
C) Time-lapsed
D) Quick priority
d. Quick priority assessments (QPAs) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care facility or service. The time-lapsed assessment is scheduled to compare a patient’s current status to baseline data obtained earlier.
The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: “Why are you doing a history and physical exam when the doctor just did one?” Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply.
A) “The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths.”
B) “It’s hospital policy. I know it must be tiresome, but I will try to make this quick!”
C) “I’m a student nurse and need to develop the skill of assessing your health status and need for nursing care.”
D) “We want to make sure that your responses to the medical exam are consistent and that all our data are accurate.”
E) “We need to check your health status and see what kind of nursing care you may need.”
F) “We need to see if you require a referral to a physician or other health care professional.”
a, e, f. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient’s responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient’s health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient’s strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.
A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate?
A) Correct the initial assessment form.
B) Redo the initial assessment and document current findings.
C) Conduct and document an emergency assessment.
D) Perform and document a focused assessment of skin integrity.
d. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.
A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor’s best reply?
A) “There’s a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!”
B) “You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care.”
C) “No one ever really learns how to do this well because each history is different! I often feel like I’m starting afresh with each new patient.”
D) “Don’t worry about learning all of the questions to ask. Every facility has its own assessment form you must use.”
b. Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking.
The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all that apply.
A) A patient tells the nurse that she is feeling nauseous.
B) A patient’s ankles are swollen.
C) A patient tells the nurse that she is nervous about her test results.
D) A patient complains that the skin on her arms is tingling.
E) A patient rates his pain as a 7 on a scale of 1 to 10.
F) A patient vomits after eating supper.
a, c, d, e. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting.
When a nurse enters the patient’s room to begin a nursing history, the patient’s wife is there. After introducing herself to the patient and his wife, what should the nurse do?
A) Thank the wife for being present.
B) Ask the wife if she wants to remain.
C) Ask the wife to leave.
D) Ask the patient if he would like the wife to stay.
d. The patient has the right to indicate whom he would like to be present for the nursing history and exam. The nurse should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife.
A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, “How would you describe your health status and well-being?” The nurse also asks the patient, “What do you do to keep yourself healthy?” Which model for organizing data is this nurse following?
A) Maslow’s human needs
B) Gordon’s functional health patterns
C) Human response patterns
D) Body system model
b. Gordon’s functional health patterns begin with the patient’s perception of health and well-being and progress to data about nutritional–metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow’s model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.
The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action?
A) Inform the charge nurse.
B) Inform the surgeon.
C) Validate the finding.
D) Document the finding.
c. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy.
A student nurse tells the instructor that a patient is fine and has “no complaints.” What would be the instructor’s best response?
A) “You made an inference that she is fine because she has no complaints. How did you validate this?”
B) “She probably just doesn’t trust you enough to share what she is feeling. I’d work on developing a trusting relationship.”
C) “Sometimes everyone gets lucky. Why don’t you try to help another patient?”
D) “Maybe you should reassess the patient. She has to have a problem—why else would she be here?”
a. The instructor is most likely to challenge the inference that the patient is “fine” simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving.
