Chapter 11 Assessing

Chapter 11  Assessing

Complete Chapter Questions And Answers
 

Sample Questions

1.
Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?
A)
“Assessment data about the client should be collected continuously.”
B)
“Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses.”
C)
“Assess your client at least hourly if the client’s vital signs are unstable, and every two hours if the vital signs are stable.”
D)
“Assessment data should be collected prior to the physician rounding on the unit.”
Ans:
A

Feedback:

Data about the client are collected continuously because the client’s health status can change quickly.

2.
The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using?
A)
Human Needs (Maslow) model
B)
Functional Health Patterns model
C)
Human Response Patterns model
D)
Body System model
Ans:
A

Feedback:

The nurse is following the Human Needs model based on Maslow’s Hierarchy of Human Needs. The Functional Health Patterns model was developed by Gordon and is a framework that identifies 11 functional health patterns and organizes data according to these patterns. The Body System model is often used by the medical community, and it organizes data according to organ and tissue function in various body systems. The Human Response Pattern model focuses on a unitary person.

3.
A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation?
A)
Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward.
B)
Encourage the novice nurse to develop his or her own tool for data collection.
C)
Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the correct interpretation.
D)
Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for communication skills.
Ans:
A

Feedback:

The novice nurse can improve interpretation skills by independently observing the same situation with a peer, comparing notes afterward, and role-playing various validation techniques.

4.
When documenting subjective data, the nurse should do which of the following?
A)
Use the client’s own words placed in quotation marks.
B)
Paraphrase the information stated by the client.
C)
Validate the information with the client’s family prior to documentation.
D)
Record the information using nonspecific words.
Ans:
A

Feedback:

Subjective data should be recorded using the client’s own words, whenever possible. Quotation marks should be used around the client’s statement. The tendency to use nonspecific terms that are subject to individual definition or interpretation should be avoided.

5.
The nurse has entered a client’s room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?
A)
Measure the client’s oral temperature.
B)
Ask a colleague for assistance.
C)
Give the client a clean gown and warm blankets.
D)
Obtain an order for blood cultures.
Ans:
A

Feedback:

An inference must be followed by a validation process. In this case, the inference of fever is best validated or rejected by measuring the client’s temperature. This should precede interventions such as blood work or even providing a warm blanket.