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Chapter 016

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 16: Nursing Assessment MULTIPLE CHOICE 1. A client interview consists of three phases. The nurse recognizes that those phases are: 1. Orientation, working, termination 2. Introduction, controlling, selection 3. Introduction, assessment, conclusion 4. Orientation, documentation, database ANS: 4 The three phases of an interview are orientation, working, and termination. DIF: A REF: 236 OBJ: Knowledge TOP: Nursing Process: Asses
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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 1: Nursing !ssessment #$T%P$E C'%CE 1.A client interview consists of three phases. The nurse recognizes that those phases are:1.Orientation, working, termination2.Introduction, controlling, selection.Introduction, assessment, conclusion!.Orientation, documentation, data ase A#$:!The three phases of an interview are orientation, working, and termination.%I&:A'(&:2)O*+:nowledgeTO-:#ursing -rocess: Assessment$/:#/0( test plan designation: 3ealth -romotion and aintenance2.%uring the admission histor4, the client states that he has trou le reathing at night. In o taining data for a pro lem5oriented data ase, the nurse should first 6uestion the client a out:1.The onset and duration of his present reathing pro lem2.3is personal smoking, alcohol use, and e7ercise practices.An4 e7tended famil4 mem ers who have diagnosed heart disease!./hanges in other od4 s4stems that the client perceives as pro lematicA#$:1A client8s data ase srcinates with the client8s perception of a s4mptom or health  pro lem. If an illness is present, the nurse gathers essential and relevant data a out the nature and onset of s4mptoms. The pro lem5seeking techni6ue takes the information  provided in the client8s stor4 to more full4 descri e and identif4 the client8s specific  pro lems. 3a its and lifest4le patterns such as smoking, alcohol use, and e7ercise ma4 eassessed in an admission histor4. 3owever, it is not the first 6uestion the nurse should ask when o taining data for a pro lem5oriented data ase after the client reports having a health pro lem. Information regarding famil4 histor4, such as mem ers who had heart disease, ma4 e o tained in an admission histor4. 3owever, if a client reports a pro lem, the nurse should first follow5up with 6uestions relevant to the nature and onset of s4mptoms. The nurse ma4 in6uire a out changes in other od4 s4stems during an admission histor49 however, if the client reports a pro lem, the nurse should first follow5up using a pro lem5oriented approach. This would include asking specific 6uestions a out the client8s health pro lem, such as the nature and onset of s4mptoms.%I&:A'(&:2O*+:/omprehensionTO-:#ursing -rocess: Assessment$/:#/0( test plan designation: 3ealth -romotion and aintenance os 4 items and derived items ; 2<<=, 2<<> 4 os 4, Inc., an affiliate of (lsevier Inc.  Test *ank .The nurse egins the assessment of a client that has come to the emergenc4 department e7periencing chest pain 4 asking the client a out:1.A famil4 histor4 of heart pro lems2.edications currentl4 eing taken at home.?uestions or concerns a out hospitalization!.The onset, severit4, and duration of the chest painA#$:!If a client comes to the emergenc4 department with chest pain, the nurse should first ask the client a out the onset, severit4, and duration of the chest pain. In an emergenc4 situation, the client8s current health pro lem ecomes the priorit4 assessment. Initiall4, the nurse should not ask 6uestions regarding famil4 histor4. @athering data a out the  pro lem currentl4 affecting the client has greater priorit4. Asking the client a out medications taken at home is appropriate, ut not at this time. The priorit4 is to assess thes4mptoms the client is e7periencing. Asking the client a out concerns regarding hospitalization is not the priorit4.%I&:A'(&:2!1O*+:/omprehensionTO-:#ursing -rocess: Assessment$/:#/0( test plan designation: 3ealth -romotion and aintenance!.A nurse seeks to organize the data o tained from the client in a logical manner. The organizational method that identifies relationships etween factors and s4mptoms in the data ase is known as:1./lustering data2.alidating data.-eer reviewing !.-ro lem statementA#$:1/lustering data means the nurse organizes the information o tained into meaningful clusters. A cluster is a set of signs or s4mptoms grouped together in a logical order. Bhenclustering data, the nurse identifies relationships etween factors and s4mptoms. alidating data means to compare the data o tained with another source to ensure its accurac4. -eer review is the evaluation of the 6ualit4 of the work effort of an individual   4 his or her peers. After validating data and clustering data, the nurse ma4 formulate a  pro lem statement, usuall4 in the form of a nursing diagnosis.%I&:A'(&:2!O*+:/omprehensionTO-:#ursing -rocess: Assessment$/:#/0( test plan designation: 3ealth -romotion and aintenance>.The client recentl4 ecame fe rile and stated he Cfelt hot.D The nurse takes the client8s temperature and finds it to e E.2F /. In addition, the pulse rate is EE eats per minute, and his lood pressure is 1)EGE< mm 3g. Bhich of the following is an e7ample of su Hective data1.-ulse rate of EE eats per minute os 4 items and derived items ; 2<<=, 2<<> 4 os 4, Inc., an affiliate of (lsevier Inc. 1)52  Test *ank 2.*lood pressure of 1)EGE< mm 3g.The statement regarding his feeling hot!.The supported fact that he ecame fe rileA#$:$u Hective data are client8s perceptions a out their health pro lems. The statement 4 the client regarding his feeling hot is an e7ample of su Hective data. A pulse rate of EE eats  per minute is an e7ample of o Hective data. O Hective data are o servations or measurements made 4 the data collector. A lood pressure of 1)EGE< mm 3g is something that can e measured, and therefore is an e7ample of o Hective data. *ecomingfe rile can e determined 4 measurement, and therefore is an e7ample of o Hective data.%I&:A'(&:2!O*+:/omprehensionTO-:#ursing -rocess: Assessment$/:#/0( test plan designation: 3ealth -romotion and aintenance).The nurse decides to interview the client using the open5ended 6uestion techni6ue. Bhichof the following statements reflects this t4pe of 6uestioning1.CIs 4our pain worse or etter than it was an hour agoD2.C%o 4ou elieve that 4our nausea is from the new anti ioticD.CBhat do 4ou think has een causing 4our current depressionD!.CBhat have 4ou done to alleviate the side effects from 4our medicationsDA#$:An open5ended 6uestion prompts the client to descri e a situation in more than one or two words. This option demonstrates the open5ended 6uestion techni6ue. This 6uestion limits the client8s answers to one or two words. It is an e7ample of a closed5ended 6uestion. The 6uestion in this option limits the client8s answer to one or two words such as C4esD or Cno.D It is an e7ample of a closed5ended 6uestion. This option onl4 re6uires a few words to form an answer. It does not use the open5ended 6uestion techni6ue.%I&:A'(&:2=O*+:/omprehensionTO-:#ursing -rocess: Assessment$/:#/0( test plan designation: 3ealth -romotion and aintenance.The nurse is gathering a nursing health histor4 on the client. The client tells the nurse thathe Hust lost his Ho . +o loss est fits into which of the following categories1.&amil4 histor42.-s4chosocial histor4.*iographical histor4!.(nvironmental histor4A#$:2 os 4 items and derived items ; 2<<=, 2<<> 4 os 4, Inc., an affiliate of (lsevier Inc. 1)5  Test *ank The ps4chosocial histor4 reveals the client8s support s4stem, if there are an4 recent lossesor stressful events, and how the individual copes with such stressors. The loss of a Ho would fit the ps4chosocial histor4 categor4. &amil4 histor4 is used to o tain data a out immediate and lood relatives to determine whether the client is at risk for illnesses of a genetic or familial nature. It also provides information a out the famil4 itself. The   iographical histor4 provides factual demographic data a out the client. The environmental histor4 provides data a out the client8s home and working environments.%I&:A'(&:2!1O*+:/omprehensionTO-:#ursing -rocess: Assessment$/:#/0( test plan designation: 3ealth -romotion and aintenanceE.The nurse is going to perform the admission histor4 for a newl4 admitted client on the medical unit. The optimum time for completion of the histor4 is planned for:1./oordination with the ph4sician8s visit2.The time when the client8s famil4 are visiting.Immediatel4 efore the client8s scheduled 'I testing!.After the client has ecome comforta l4 oriented to the roomA#$:!/ompletion of the admission histor4 is scheduled for a time when interruptions 4 other staff or visiting famil4 mem ers are minimal. The nurse should create an environment where the client feels comforta le. /onducting the admission histor4 after the client8s orientation to the room and completion of lunch would e optimum ecause the client will not e distracted 4 hunger, and the interview will less likel4 e interrupted. The admission histor4 should e scheduled for a time when interruptions 4 other staff are minimal. %uring the ph4sician8s visit would not e an optimum time. The nurse should  provide an environment private enough to allow the client to e comforta le when  providing personal information. Inclusion of famil4 mem ers should e left up to the client to decide. Information o tained should remain confidential. Immediatel4 efore a client8s testing would not e an optimum time for o taining a nursing histor4. The client ma4 feel more an7ious a out the upcoming test, impeding communication, and there ma4not e sufficient time allowed to gather all of the information.%I&:A'(&:2)O*+:/omprehensionTO-:#ursing -rocess: Assessment$/:#/0( test plan designation: 3ealth -romotion and aintenance=.The nurse has completed an assessment and found that the client has Can activit4 and e7ercise a normalit4.D This t4pe of wording indicates that which of the following organizing formats has een used1.'eview of s4stems2.#ursing health histor4.@ordon8s functional health patterns!.*iographical information data aseA#$: os 4 items and derived items ; 2<<=, 2<<> 4 os 4, Inc., an affiliate of (lsevier Inc. 1)5!

Chapter 014

Jul 23, 2017

Chapter 015

Jul 23, 2017
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