Yoost Chapter 6

Assessment
Click the card to flip 👆
1 / 34
Terms in this set (34)
Assessment
The first step in the nursing process.
Patient interview
a formal, structured discussion in which the nurse questions the patient to obtain demographic information, data about current health concerns, and medical and surgical histories
Patient Interview
Three phases
Orientation, working and termination.
Health History
All pertinent information that can guide the development of a patient centered plan of care.
Inspection
Involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems.
Palpation
Uses touch to asses body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness.
Percussion
Tapping the patients skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures.
Auscultation
Technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity.
primary data
comes directly from the patient
secondary data
information shared by the family members, friends, or other members of the health care team.
subjective datasymptomsobjective datasignscuehint or an indication of a potential disease process or disorder.Which action by a patient marks the beginning of the physical assessment process? a. redressing after a physical examination b. breathing normally during auscultation c. greeting the nurse in the examination room d. sharing work environment informationAnswer: c Assessment begins at the moment the patient first interacts with the nurse. Redressing takes place at the end of the physical examination. Breathing during auscultation is part of the respiratory assessment, and sharing health history and demographic information takes place during the patient interview.Which factors should be taken into consideration by the nurse before and during a patient interview? (Select all that apply.) a. Distance between the chairs in which the nurse and patient are sitting b. Traditional treatments typically used by the patient to treat disease c. Gender preference for primary care providers d. Physical condition of the patient e. Music preference of the patientAnswer: a, b, c, d The first four factors are important for the nurse to consider when initiating or conducting a patient interview. The distance that is comfortable for personal interaction and gender preferences for care providers are affected by cultural and age norms. During the interview, it is an important aspect of assessment to ask patients about the treatments that they traditionally use in response to illness. Preferred treatments sometimes can be incorporated into care plans. The physical condition of patients affects their ability to answer questions during an interview. It may be necessary to break the interview process into short periods to accommodate the patient who is seriously ill. Music preference is irrelevant because there should not be music playing during the interview because it would be a distraction.Which action by the nurse is most appropriate during the orientation phase of the patient interview? a. always position patients in a comfortable reclined position to ensure their comfort during questioning b. ask which name a patient prefers to be called during care to show respect and build trust. c. quickly conduct a review of systems to determine the need for a complete or focused assessment d. begin with questions about intimacy and sexuality to address sensitive issues first.Answer: b The nurse should provide a personal introduction and establish the name by which the patient wants to be called at the very beginning of the interview as part of the orientation phase. In most cases, the patient and the nurse should be seated at eye level during the interview portion of the assessment. Questions about intimacy and sexuality should be reserved for later in the interview to establish rapport before exploring potentially sensitive issues. A review of systems takes place during the working phase of the nurse-patient interview, just before initiation of the physical assessment.Which activity by the nurse best demonstrates part of the working phase of a patient interview? a. summarizing previously discussed key topics b. including selected family members in care planning c. transferring care responsibilities to the home health nurse d. verifying the name by which a patient prefers to be addressedAnswer: b Care planning takes place during the working phase of the nurse-patient interview. When a patient needs care assistance, it is important for family members who will be helping with the patient's care to be involved in the process. Verifying the name that a patient prefers to be called takes place during the orientation or introductory phase. Summarizing key topics covered in the interview and transferring care responsibilities take place in the termination phase. LO: 6.1Which entry in a patient's electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data? a. Complaining of chest pain b. Apical pulse 110 c. Comatose d. Difficulty swallowingAnswer: c Primary data are obtained from the patient directly. A patient who is comatose is unable to speak and therefore unable to share subjective, primary data. A patient complaining of chest pain has already shared primary, subjective data. A patient with an apical pulse of 110 who is alert or one who has difficulty swallowing may still be able to contribute subjective information to the data collection.Which line of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process? a. "What do you do for a living? Can you describe your work environment?" b. "Is there a family history of heart disease, cancer, high blood pressure, or stroke?" c. "When was your last annual physical? What immunizations did you receive at that time?" d. "Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?"Answer: d During a review of systems, the patient is asked questions about each body system to determine the level of functioning. Asking about work-related information, family history, and immunizations is accomplished during the collection of health history data before initiating the review of systems.Which cue by a patient can be validated by laboratory and diagnostic test results? a. Deeply sighing with fatigue b. Bilateral crackles in the lungs c. Oxygen saturation of 98% on room air d. 2+ pitting edema of the ankles and feetAnswer: a A cue is a behavioral hint of a potential disease process or concern. In this case, the only cue is a deep sigh indicating fatigue. The level of fatigue can be verified by evaluating the patient's hemoglobin and hematocrit levels for anemia. Crackles, oxygen saturation, and pitting edema are all physical assessment findings, not cues.A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively? a. Body systems model b. Physical assessment model c. Head-to-toe assessment model d. Functional health patterns modelAnswer: d Job stress and family relationships data will only be recorded extensively when using the Functional health patterns model. The functional health patterns model is holistic in its approach. The body systems model and head-to-toe assessment model focus on physical rather than psychological or emotional concerns. All three models listed are ways to organize physical assessment findings.When initiating a physical examination, which action should the nurse take first? a. Review of the patient's prior medical records b. Gather admission health history forms c. Assess the patient's vital signs d. Perform light and deep palpation for fluidAnswer: c Assessment of the patient's vital signs begins the physical examination aspect of the assessment process. This provides the nurse with baseline information about cardiac and respiratory function, pain level, and temperature. The nurse should review the patient's prior medical records before the interview or after the patient interaction to fill in gaps. Admission health history forms need to be gathered before initiating the interview, and abdominal palpation takes place about halfway through the head-to-toe physical examination.If the nurse discovers that a patient's right elbow is swollen and painful during a physical examination, which action should the nurse take next? a. Apply ice to decrease swelling and reduce pain b. Percuss the area to determine the presence of fluid c. Perform passive range of motion to promote flexibility d. Inspect the patient's left elbow to compare its appearanceAnswer: d A major aspect of assessment is checking for symmetry. If an abnormality is observed on one side of a patient's body, the next step in the assessment is to compare that area with the other side. Applying ice is premature until the assessment is complete and an underlying cause of the swelling and pain is understood. Percussion is not indicated for assessment of a swollen elbow. Performing passive range of motion is not appropriate before identifying an injury or disease and determining its extent.1. Which piece of assessment data may be accurately obtained during the observation phase? a. Pulse irregularity b. Slow capillary refill c. Elevated temperature d. Presence of body odorANS: D The nurse uses the senses of sight, hearing, and smell during the observation phase of assessment. The presence of body odor is the only patient data listed that can be accurately assessed during the observation phase. Pulse irregularity, slow capillary refill, and elevated temperature all require vital sign assessment or palpation.2. Patients from which generation would be most comfortable with the nurse using electronic resources for health screening? a. Baby boomers b. Generation X c. Millennials d. VeteransANS: C Millennials are typically very computer literate or technology natives. Of the generations listed, millennials would be the most comfortable with accessing electronic resources for health screening.3. Which type of question would be best for the nurse to use when trying to determine the extent of a patient's knowledge concerning a disease process? a. Open ended b. Direct c. Close ended d. FocusedANS: A Open-ended questions are best utilized to elicit a narrative response. Direct, focused, or close-ended questions are effective tools to guide an interview process and obtain demographic or specific information rather than a breadth or depth of data.4. Which statement by the nurse best describes health history assessment? a. "The first patient interview is the best source of all essential health history data." b. "When health history data is updated, patient information collected earlier is no longer useful." c. "Collection of health history information is ongoing and methodical throughout patient interaction." d. "Gathering health history data is best accomplished in a random, relaxed fashion as topics arise."ANS: C A patient's health history is continuously evolving. Therefore, collection of health history data is ongoing and organized to avoid omission of critical information. Every patient interaction provides an opportunity to collect essential health history information. Older health history data are useful for reference regardless of how old the information may be. Health history information should be collected systematically in an established format to address essential topics and avoid accidental omissions.5. Which statement illustrates appropriate documentation following palpation? a. Abdomen soft, non-tender without distention b. Density noted over kidney margins bilaterally c. Reddened area 3 inches in diameter noted on left thigh d. Heart sounds distant over the mitral and tricuspid valvesANS: A The only documentation statement indicating palpation is assessment of the abdomen. Density is assessed via percussion. Reddened areas are identified through inspection and heart sounds are assessed through auscultation.6. What type of assessment is most appropriate for a patient newly admitted to the hospital for intermittent loss of vision in the left eye? a. Emergency b. Complete c. Focused d. TriageANS: B In this case, a complete assessment including examination of the cranial nerves is necessary upon admission to the acute care setting. Focused or clinical assessments will follow throughout the patient's hospitalization and at follow-up outpatient visits. There is no indication that the admission requires an emergency assessment or that triage to classify treatment priorities among patients is needed.7. Which statement is the best example of subjective, secondary data? a. Unlicensed assistive personnel reports patient's blood pressure is 138/84 b. Patient complains of extreme fatigue and dizziness when walking in the room c. Nurse states that the patient's chest x-ray has a shadow in the left upper lobe d. Spouse reports patient has been vomiting intermittently for the last 48 hoursANS: D Subjective, secondary data is spoken information or symptoms shared by someone other than the patient. Blood pressure readings and chest x-ray findings are examples of objective data. Patient statements are primary, subjective data.8. A patient is admitted to the nursing unit with numbness and tingling in the right hand, pain in the cervical spine, and occasional loss of consciousness. Into which functional health pattern would the nurse organize this data? a. Self-perception and self-concept b. Coping and stress tolerance c. Cognition and perception d. Activity and exerciseANS: C All of the patient's assessment findings are related to neurological functioning, which should be organized under the area of cognition and perception. Concerns regarding identity and body image would be documented under the health pattern of self-perception and self-concept. Stress tolerance and support system information would be recorded in the coping and stress management area. Assessment findings related to the cardiac, respiratory, and musculoskeletal systems are documented as part of the activity and exercise functional health pattern.9. Which information gathered during assessment is considered to be subjective data? a. The client's urine is dark and foul-smelling. b. The patient's 24-hour urine output is 1800 mL. c. The patient indicates pain and burning are present when urinating. d. The patient is taking an antibiotic for a urinary tract infection.ANS: C Patient verbalizations are subjective data. The rest of the options are pieces of data observed by the nurse and are considered objective data.10. The most important source in data collection is/are a. nursing literature. b. the patient. c. medical records. d. family members.ANS: B The best source of information about the patient is the patient, not the family, the medical record, or nursing literature.1. Which action(s) should the nurse take during the termination phase of the patient interview? (Select all that apply.) a. Express appreciation for the patient's participation. b. Review key assessment findings that were noted. c. Validate information covered with the patient. d. Allow the patient to add additional insights.ANS: A, B, C, D The termination phase includes all of the actions mentioned. During the termination phase, interaction should be drawn to a logical conclusion and information should be reviewed, clarified, and verified prior to initiating care. Appreciation for the patient's participation should be acknowledged and the patient should be encouraged to add any additional information or thoughts that come to mind prior to ending the interaction.