ADPIE NCLEX; Questions and Answers 100% Correct

ADPIE NCLEX ; Questions a nd Answers 100% Correct Read the following scenario and identify the term for the characteristics of patient data that are numbered below. The nurse is conducting an initial assessment of a 79 year old female patient admitted to the hospital with a diagnosis of dehydration. The nurse: (1) uses clinical reasoning to gather the appropriate patient data, (2) first ask the patient about the most important details leading to her diagnosis, (3) collects as much information as possible to understand the patient's health problems, (4) collects the patient data in an organized manner, (5) verifies that the data obtained is pertinent to the patient care plan, and (6) records the data according to agency policy. 1. Purposeful - The nurse identified the purpose of the nursing assessment (comprehensive) and gathers the appropriate data. 2. Prioritized - The nurse gets the most important information first. 3 . Complete - The nurse gathers as much data as possible to understand the patient health problem and develop a plan of care. 4. Systematic - The nurse gathers the information in an organized manner. 5. Factual & Accurate - The nurse verifies that the information is reliable. 6. Recorded in a standard manner - The nurse records the data according to agency policy so that all caregivers can easily access what is learned. The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? a. comprehensive b. initial ADPIE NCLEX ; Questions a nd Answers 100% Correct c. time -lapsed d. quick priority d The nurse is admitting a 35 year old pregnant women to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statement best explains the primary reasons a nursing assessment is performed? select all that apply a. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b. "It's hospital policy, I know it must be tiresome, but I will try to make it quick." c. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." d. "We want to make sure your responses to the medical exam are consistent and that all you data is accurate." e. "We need to check your health status to see what kind of nursing care you may need." f. "We need to see of you require a referral to a physician or other health professio aef When you receive the shift report, you learn that you patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate? a. correct the initial assessment form b. redo the initial assessment and document current findings c. conduct and document an emergency assessment ADPIE NCLEX ; Questions a nd Answers 100% Correct d. perform and document a focused assessment of skin integrity d A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever lens all the questions a nurse must ask to get a good baseline of data. What would be the instructors best reply? a. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep" b. "You can make the basic questions part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c. "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh each new patient" d. "Don't worry about learning all the questions to ask. Every agency has its own assessment form you must use." b The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions are examples of subjective data? Select all that apply a. a patient tells the nurse that she feels nauseous b. a patients ankles are swollen c. a patient tells the nurse that she is nervous about her test results d. a patient complains of having a rash on her arm that is itchy e. a patient rates his pain as a 7 on a scale of 1 to 10 f. a patient vomits after eating dinner acde