Chapter 11 Assessment
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During which stage of the interview should the nurse ask, “How long have you had this symptom?”
Rationale: The part of the interview that is focused on gathering data from theclient is the body. The nurse uses open and closed questions. The opening is thepart of the interview when the nurse establishes rapport with the client. Theclosing is the conclusion of the interview. The examination is the gathering ofobjective data.
To determine the status of a specific problem identified in an earlier assessment represents which formof assessment
?a. Emergency assessment
b. Time-lapsed reassessment
c. Problem-focused assessment
d. The initial assessment
Rationale: The status of a specific problem identified in an earlier assessment isrepresentative of problem-focused assessment.
There are many nursing models and theories used as frameworks for assessment. The one the nursewill use is based on:
a. The policy of the institution.
b. Orem’s Model and Theory
.c. The wellness model
.d. Maslow’s Hierarchy of Needs.
Rationale: Most schools of nursing and health care agencies have developed theirown structured assessment format.
Which of the following positions assumed by the nurse and the client facilitates an easy exchange ofinformation?
a. The client is in bed and the nurse stands at the foot of the bed.
b. The client is in bed and the nurse sits on a chair at a 45-degree angle to the bed.
c. Seated; the nurse places the chairs at right angles to one another, about a foot apart.
d. The client is in bed and the nurse stands at the side of the bed.
Rationale: The nurse strives for a less formal atmosphere, where the nurse andclient can feel on more equal terms, such as when the client is in bed and the nursesits on a chair at a 45-degree angle to the bed. When the nurse stands at the foot ofthe bed and the client is in bed, the nurse may intimidate the client, who feels thenurse has greater status. When the nurse and client are seated in chairs at rightangles it is less formal; the nurse and client are too close together for the client tofeel comfortable. The client may feel that his personal space is being invaded.When the client is in bed and the nurse stands at the side of the bed, the nurse isin a position where the client may feel intimidated because the nurse is not at eyelevel.
The use of a conceptual or theoretical framework for collecting and organizing assessment dataensures which of the following?
A. Correlation of the data with other members of the health care team
B. Utilization of creativity and intuition in creating a plan of care
C. Collection of all necessary information for a thorough appraisal
D. Demonstration of cost-effective care
C.Rationale: Frameworks help the nurse be systematic in data collection. Othermembers of the health care team may use very different conceptual organizingframeworks so data may not correlate. Cost-effective care is more likely to occurwith systematic application of the nursing process, but use of a framework forassessment alone may not accomplish this goal. Because the framework isstructured and because of the nature of client needs/problems, creativity andintuition in care planning are not assured.
(this multiple choice question has been scrambled)
Which of the following behaviors is most representative of the nursing diagnosis phase of the nursingprocess?
a. Establishing short-term and long-term goals
b. Administering an antibiotic
c. Organizing data in the client’s family history
d. Identifying major problems or needs
Rationale: Identifying problems/needs is part of nursing diagnosis. For example,a client with difficulty breathing would have Impaired Gas Exchange related toconstricted airways as manifested by shortness of breath (dyspnea) as a nursingdiagnosis. Organizing the family history is part of the assessment phase.Establishing goals is a part of the planning phase. Administering an antibiotic ispart of the implementation phase.
The data collection method of observation involves a planned communication that provides counseling.
a. True b. False
Rationale: To observe is to gather data by using the senses. Observation is aconscious, deliberate skill that is developed through effort and with an organizedapproach. Although nurses observe mainly through sight, most of the senses areengaged during careful observations.
assessment performed within specified time after admission to a health care agency
ongoing process integrated with nursing care
assessment during any physiologic or psychologic crisis of the client
several months after the initial assessment
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