If a nurse focuses on a patient's presenting situation and begins with problematic areas such as incisional pain or limited understanding of postoperative
... [Show More] recovery, what approach to assessment is she/he using?
Problem-oriented approach
Before a patient-centered interview, how should the nurse prepare?
1. Review the patient's medical record
2. Review the previous nurse's notes
3. Consider the length of the interview
4. Consider the setting of the interview
How should you begin a patient-centered interview?
Introduce yourself and your position and explain the purpose of the interview.
-Your aim is to set an agenda for how you will gather information about a patient's current chief concerns or problems
Which of the following examples are steps of nursing assessment? (Select all that apply.)
1. Collection of information from patient's family members
2. Recognition that further observations are needed to clarify information
3. Comparison of data with another source to determine data accuracy
4. Complete documentation of observational information
5. Determining which medications to administer based on a patient's assessment data
1. 2. 3.
Rationale: Assessment includes collection of data from secondary sources such as the patient's family. Recognizing that more observation is needed is an example of validation of data. Comparing data to determine accuracy is a feature of interpretation. Although complete documentation is an important step in communicating assessment data, it is not an assessment step.
When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.)
1. An observation of how a patient turns and moves in bed
2. The unit policy and procedure manual
3. The care recommendations of a physical therapist
4. The results of a diagnostic x-ray film
5. Your experiences in caring for other patients with similar problems
1. 3. 4.
Rationale: There are many sources of data for an assessment, including the patient through interview, observations, and physical examination; family members or significant others, health care team members such as a physical therapist, the medical record (which includes x-ray film results, and the scientific and medical literature.
The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of:
1. Cue.
2. Reflection.
3. Clinical inference.
4. Probing.
3.
Rationale: An inference is your judgment or interpretation of cues such as the shuffling gait and reduced leg strength. Any information gathered through your senses is a cue. Probing is a technique used in interviewing. Reflection is an internal process of thinking back about a situation.
A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe?
1. Review of systems approach
2. Use of a structured database format
3. Back channeling
4. A problem-oriented approach
4.
Rationale: This is an example of a problem-focused approach. The nurse focuses on assessing one body system (cardiovascular) to determine the nature of the patient's pain and other presenting symptoms.
The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview?
1. Orientation
2. Working phase
3. Data validation
4. Termination
3. Data validation
Rationale: The gathering of information is the working phase of a patient-centered interview.
A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems?
1. "I can tell that your eating habits have led to your diabetes. Is that right?"
2. "It's been difficult for people to find jobs. Is that why you work part time?"
3. "You have four children; do you have any concerns about going home and caring for them?"
4. "I wish patients understood how overeating affects their health."
3.
Rationale: This is the only assessment approach that is not biased or does not show judgment about the patient's weight or occupational status. With the other options, the nurse is reacting to the patient on the basis of personal stereotypes and biases.
Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care?
1. Probing
2. Open-ended
3. Problem-oriented
4. Confirmation
2.
Rationale: The best interview question for initially determining why a patient is seeking health care is by asking an open-ended question that allows the patient to tell his or her story. This is also a more patient-centered approach. Probing questions are asked after data are gathered to seek more in-depth information. Problem-oriented and confirmation are not types of interview questions.
A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? (Select all that apply.)
1. The skin around the wound is tender to touch.
2. Fluid intake for 8 hours is 800 mL.
3. Patient has a heart rate of 78 beats/min and regular.
4. Patient has drainage from surgical wound.
5. Body temperature is 38.3° C (101° F).
6. Patient states, "I'm worried that I won't be able to return to work when I planned."
1. 4. 5.
Rationale: Tender skin around the wound, drainage from the surgical wound, and a temperature of 38.3° C (101° F) indicate a wound infection. Fluid intake of 800 mL over 8 hours and a heart rate of 78 beats/min and regular are normal assessment findings. A patient's expressed concern about returning to work is his or her subjective response about a separate issue and is insufficient to form a [Show Less]