Exam 3: Assessment

Which of the following are cues rather than inferences? Select all that apply.

The nurse is interviewing a patient with a recent onset of migraine headaches. The patient is very anxious and cannot seem to focus on what the nurse is saying. Which comment by the nurse is best when beginning to gather data about the headaches?

The nurse is collecting data on a new patient at an adult clinic. Which data does the nurse need to validate?

The nurse is providing care to a patient who has left-sided weakness because of a recent stroke. Which type of special needs assessment is most important for the nurse to perform?

The nurse is currently performing the initial assessment on a newly admitted client. The nurse receives notification of another client's admission to the unit. Which professional standard influences the nurse's decision about who will be assigned to perform the assessment of the second client?

A nurse, with a large caseload of patients, needs to delegate some assessment tasks to other members of the healthcare team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) instead of a registered nurse (RN). Which sources does the nurse consult for clarification related to delegation? Select all that apply.

The nurse is preparing to conduct an admission interview with an adult client who is alert and oriented. The client's spouse and two children are visiting and are watching television. Which action by the nurse is conducive to a successful interview?

The nurse on a medical-surgical unit receives the third admission over a period of 1.5 hours. A certified nursing assistant (CNA) offers to assist the nurse with the assessment process. Which response by the nurse is the most appropriate?

A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching?

A patient comes to the urgent care clinic because of injury from stepping on a rusty nail. Which type of assessment does the nurse perform?

Each time the nurse comes into contact with a patient, a systematic observation is made. For which reason is this type of assessment performed so frequently?

The nurse is providing care for a variety of patients in an acute care facility. Which of the following constitutes an ongoing assessment?

The patient comes to the emergency department complaining of chest pain. Which question by the nurse will encourage the patient to provide the most details about the pain?

The nurse is interviewing a patient being admitted for gastrointestinal issues. The patient informs the nurse that he has persistent vomiting and diarrhea. Which type of assessment is the nurse performing by asking, "When did you first begin to have the vomiting and diarrhea?"?