Exam 6: Assessment

The nurse is admitting a patient for uncontrolled diabetes mellitus. The nurse suspects that the patient could benefit from diabetic teaching. To corroborate her suspicion, during the patient interview the nurse: (Select all that apply.)

A patient is transported to the emergency room 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:

The nurse is preparing to begin a physical examination for a patient with open lesions on the lower extremities. Which should the nurse evaluate during the physical assessment? (Select all that apply.)

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 the interview, the nurse should:

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?" The best response by the nurse is:

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. The framework that provides the most holistic view of the patient's condition is:

An in-depth health history: (Select all that apply.)

The charge nurse is planning vital sign assignments for the unlicensed assistive personnel (UAP) on a busy medical-surgical unit. Which patients are appropriate for the UAP to obtain vital signs? (Select all that apply.)

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 sugar water." These types of data are considered:

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 of the following frameworks would the nurse most likely choose to document this data?

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 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 of the following techniques would the nurse use to collect this data?

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." The nurse should:

The unlicensed nursing assistive person (UAP) reports to the nurse that a patient is crying during a comedy show on television. The nurse's best response should be:

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

Patient-centered care requires the nurse to: (Select all that apply.)

The nurse is performing an assessment of a patient's right kidney. The nurse bluntly strikes the area of the costovertebral angle while observing the patient's reaction. The physical assessment technique being used is:

The nurse is caring for a patient with pneumonia. The patient is a retired soldier who served in World War II. In light of this, the nurse should:

The nurse is using a stethoscope to assess a patient's cardiac status. This assessment technique is known as:

The nurse is performing her initial assessment of the day when she notices that the patient has a facial droop that he did not have yesterday and that was not reported in the hand-off report from the night nurse. The nurse proceeds to assess the neurological status of the patient. This type of assessment is known as: