Exam 6: Assessment

The nurse is preparing to begin a physical examination for a patient with open lesions on the lower extremities. Which would the nurse evaluate during the physical assessment?

The morning nurse is assigned to care for a patient admitted during the night with rectal bleeding. When making rounds, the nurse observes that the patient's face is ashen in color and the skin is cool and clammy. The nurse auscultates the patient's heart and lungs. Which category of physical assessment is the basis for the nurse's response?

The nurse is documenting data collected during a health assessment interview. Which statement by the nurse indicates subjective data?

A patient with moderate lower back pain tells the nurse, "My urine smells awful and is as dark as my glass of tea." Which action by the nurse will assist in validating the patient's concern?

The nurse is using a stethoscope to assess a patient's cardiac status. Which assessment technique is the nurse using?

The nurse knows what should be included in an in-depth health history?

The wound care nurse is assessing a non-healing leg wound on a patient recently admitted for uncontrolled diabetes. The nurse organizes the data using which Gordon's Functional Health Pattern?

The unlicensed nursing assistive person (UAP) reports to the nurse that a patient is crying during a comedy show on television. What would be the best response by the nurse?

The nurse is performing a physical exam on a patient diagnosed with liver failure resulting from chronic alcoholism. The nurse notes that the abdomen is swollen and decides to assess for abdominal skin tenderness and temperature. Which technique would the nurse use to collect this data?

The nurse is monitoring the blood sugar results of a patient receiving an intravenous nutritional supplement. The patient tells the nurse, "I have never had sugar problems before. My doctor says it is because I am getting this IV." These types of data are considered to be which type?

The nurse is assigned the admission health history and physical for a patient diagnosed with a fever of unknown etiology. The patient tells the nurse, "I just don't feel good. I'm so hot and I feel sick to my stomach. Can you ask me those questions later?" What would be the best response by the nurse?

After the patient's data are collected, validated, and interpreted, the nurse organizes the information in a framework (format) that facilitates access by all members of the health care team. What is the framework that provides the most holistic view of the patient's condition?

Patient-centered care requires the nurse to complete which actions?

A patient is transported to the emergency department from a local skilled nursing facility and admitted for a bacterial blood infection. The nurse reviews the transferring physician notes, which indicate that the patient has dementia. The nurse contacts the patient's son for additional health history information. Information provided by the son would be considered which type of data?

The nurse is admitting a patient for uncontrolled diabetes mellitus. The nurse suspects that the patient could benefit from diabetic teaching. What actions by the nurse will assist in validating this suspicion?

During the health history interview, the patient tells the nurse, "Just walking to the mailbox and back makes my calves ache. Is this normal?" Which framework would the nurse most likely choose to document this data?

A nurse is conducting a health interview on a newly admitted patient. To establish a trusting relationship with the patient, the nurse carries out which action?

The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient. During the orientation phase of a patient interview, the nurse carries out what action?

The triage nurse in a hospital emergency department is determining the order of care for several patients. Which patient would the nurse consider as having the highest priority?

The nurse is attempting to get the patient to sign the operative consent. When asked if the health care provider explained the procedure to the patient, the patient replies "Not much." What action will the nurse take next?