Chapter 16 Nursing Assessment/Nursing Process- Standards P/P
Mr. Chuck Rhodes is admitted to the medical-surgical unit for unrelenting abdominal pain.
... [Show More] Mr. Rhodes is a 37-year-old
fireman. He has been intermittently vomiting for the past 2 days. His wife has accompanied him to the hospital. Mr.
Rhodes has never been hospitalized. Crystal is the student nurse who has been assigned to admit Mr. Rhodes. Crystal is
in her first clinical rotation. Crystal goes into Mr. Rhodes’ room, introduces herself, and explains that she will be collecting
information that is needed for his admission. Mr. Rhodes is agreeable and asks Crystal to call him Chuck.
1. Crystal starts the data collection. What would she want to accomplish during the interview? (Select all that apply.)
A. Establish a caring, therapeutic relationship with Chuck and his wife.
B. Determine what Chuck’s goals and expectations are regarding hospitalization.
C. Gain insight about Chuck’s concerns and worries.
D. Determine Chuck’s medical diagnosis.
E. Obtain cues about which parts of the interview may require further investigation.
Rationale:
Pg #
The admission interview should include the details of the patient from past medical and surgical to present medical
conditions. It should include physical and physiological assessment to plan for care. Patient’s concerns should be
assessed. It is important to establish a trusting relationship between the patient and their family members in order to
plan for their treatment.
2. During the initial interview, Crystal notices that Chuck is grimacing and will not make eye contact with her. She wants
to get more information. Which question is most appropriate to help Crystal in her assessment?
A. Do you hurt?
B. Do you feel like you are going to vomit?
C. How are you feeling now?
D. Do you need pain medicine?
Rationale:
Pg#
Grimacing tells us that the patient feels discomfort, pain that cannot express in words.
3. Crystal is assessing Chuck using Gordon’s functional health patterns. This is an example of which approach to
comprehensive assessment?
Rationale:
Pg #
Assignment Questions Week 2 – Prof B NR 222
1
Gordon’s functional health patterns is used in nursing process to ensure extensive assessment of the patient. It contains
eleven categories. This is an example of a structured database format.
Look at Chapter 16 in P/P figure 16-6 Concept Mapping and concept mapping section in the chapter (please look at
Chap 17 for the list of nursing dx).
Answer the following: [Show Less]