Chapter 14 Assessment THE POINT Questions With
Complete Solutions
A 24-year-old client presents to the emergency department with
signs and symptoms of a sickle cell crisis. The nurse quickly
obtains the necessary laboratory tests to assist with the
assessment, as well as conducts an assessment of the client to
determine the proper nursing care the client will require. Which
type of assessment did the nurse perform in this situation?
Correct Answers Emergency
Explanation:
The nurse should complete an emergency assessment which will
focus on the sickle cell crisis so that immediate care can be
started to best treat the client. A focused assessment is
conducted when more data are needed about a specific situation
or health concern. The initial, comprehensive assessment is
conducted to establish the client's medical and health condition.
It will identify potential concerns as well as identify what the
client is doing to ensure a healthy life.
A 33-year-old client is brought to the urgent care center,
doubled over in pain and crying. Upon assessment, the client
admits to nausea and vomiting ×3 during the morning. Which
action should the nurse prioritize after noting right lower
quadrant (RLQ) rebound tenderness, blood pressure of 130/92
mm Hg, and pulse 100 beats/min and weak? Correct Answers
Notify the health care provider immediately
Explanation:
The client needs immediate attention and care due to the
possibility of having appendicitis. The nurse would complete an
emergency assessment and follow the policies of the facility to
,ensure proper care. It would be inappropriate to have the client
wait 30 minutes to see if there is any improvement in the signs
or symptoms. It would be improper to start an IV without the
health care provider's prescription. The health care provider
would need to evaluate the client and make the diagnosis
because this action is outside the scope of practice for the nurse.
A 57-year-old client presents to the clinic with a report of
abdominal pain. The client underwent a sigmoid colostomy 3
months ago for colon cancer. The client's recovery had been
uneventful until 1 week ago. Which sign(s) or symptom(s)
should the nurse prioritize in the assessment? Select all that
apply. Correct Answers Absence of bowel sounds
Tenderness around ostomy
Redness at ostomy stie
Explanation:
The absence of bowel sounds, tenderness and redness around the
ostomy site are all red flags that there is a problem related to the
previous surgery which needs to be evaluated and treated. The
nurse would conduct a focused assessment to determine what
needs to be addressed first and provide the best care for the
client. The semisoft fecal material in the bag is an expected
finding. A negative reading on the fecal occult testing would
indicate there is no bleeding in the colon.
A client comes to a health care facility reporting abdominal pain
and vomiting. The client's spouse informs the nurse that the
client went out for dinner the previous night. The report that the
client went out for dinner the previous night is example of data
from which type of source? Correct Answers The primary
source of information is the client. The client's spouse, friends,
,and test results would be secondary sources of data. There are no
tertiary or quaternary sources of assessment data.
A client comes to the emergency department with a productive
cough and an elevated temperature. Which type of assessment
would the nurse most likely perform on this client? Correct
Answers Focused
Explanation:
In a focused assessment, the nurse gathers information about a
specific problem that has already been identified. A head-to-toe
assessment is an initial, complete assessment, typically to assess
for any problems that have not been identified yet. An
emergency assessment is used to identify a life-threatening
problem. A time-lapse reassessment is scheduled to compare
current status with the baseline obtained earlier.
A client is admitted to a hospital unit with scleroderma. The
nurse is unfamiliar with this condition. What is the nurse's best
source of information about this condition? Correct Answers
The nursing and medical literature
Explanation:
In addition to information about medical diagnoses, treatment,
and prognosis, a literature review of nursing and medical
references offers nurses important information about nursing
diagnoses, developmental norms, and psychosocial and spiritual
practices that are helpful when assessing and caring for clients.
Consulting with the client, physician, or client's chart would not
give as comprehensive of a review.
, A client is receiving home care due to an unstable blood
pressure. Which nursing intervention is a priority? Correct
Answers Assess the client's blood pressure.
Explanation:
The priority intervention for the client with an unstable blood
pressure is to first measure the blood pressure. Once the nurse is
certain that this is within safe parameters, the nurse should
assess the client's diet, activity level, and medication regimen.
A client is receiving home care due to an unstable blood
pressure. Which nursing intervention is a priority? Correct
Answers Assess the client's blood pressure.
Explanation:
The priority intervention for the client with an unstable blood
pressure is to first measure the blood pressure. Once the nurse is
certain that this is within safe parameters, the nurse should
assess the client's diet, activity level, and medication regimen.
A client with a history of benign prostatic hyperplasia presents
to the emergency room with reports of urinary retention. The
nurse collects data related to the client's voiding patterns, weight
gain, fluid intake, urine volume in the bladder, and level of
suprapubic discomfort. What type of assessment is the nurse
performing? Correct Answers Focused
Explanation:
The nurse is performing a focused assessment, which involves
gathering data about a specific problem that has already been
identified. An initial assessment involves the nurse collecting
data concerning all aspects of the client's health. An emergency
assessment is performed to identify life-threatening problems. A
Complete Solutions
A 24-year-old client presents to the emergency department with
signs and symptoms of a sickle cell crisis. The nurse quickly
obtains the necessary laboratory tests to assist with the
assessment, as well as conducts an assessment of the client to
determine the proper nursing care the client will require. Which
type of assessment did the nurse perform in this situation?
Correct Answers Emergency
Explanation:
The nurse should complete an emergency assessment which will
focus on the sickle cell crisis so that immediate care can be
started to best treat the client. A focused assessment is
conducted when more data are needed about a specific situation
or health concern. The initial, comprehensive assessment is
conducted to establish the client's medical and health condition.
It will identify potential concerns as well as identify what the
client is doing to ensure a healthy life.
A 33-year-old client is brought to the urgent care center,
doubled over in pain and crying. Upon assessment, the client
admits to nausea and vomiting ×3 during the morning. Which
action should the nurse prioritize after noting right lower
quadrant (RLQ) rebound tenderness, blood pressure of 130/92
mm Hg, and pulse 100 beats/min and weak? Correct Answers
Notify the health care provider immediately
Explanation:
The client needs immediate attention and care due to the
possibility of having appendicitis. The nurse would complete an
emergency assessment and follow the policies of the facility to
,ensure proper care. It would be inappropriate to have the client
wait 30 minutes to see if there is any improvement in the signs
or symptoms. It would be improper to start an IV without the
health care provider's prescription. The health care provider
would need to evaluate the client and make the diagnosis
because this action is outside the scope of practice for the nurse.
A 57-year-old client presents to the clinic with a report of
abdominal pain. The client underwent a sigmoid colostomy 3
months ago for colon cancer. The client's recovery had been
uneventful until 1 week ago. Which sign(s) or symptom(s)
should the nurse prioritize in the assessment? Select all that
apply. Correct Answers Absence of bowel sounds
Tenderness around ostomy
Redness at ostomy stie
Explanation:
The absence of bowel sounds, tenderness and redness around the
ostomy site are all red flags that there is a problem related to the
previous surgery which needs to be evaluated and treated. The
nurse would conduct a focused assessment to determine what
needs to be addressed first and provide the best care for the
client. The semisoft fecal material in the bag is an expected
finding. A negative reading on the fecal occult testing would
indicate there is no bleeding in the colon.
A client comes to a health care facility reporting abdominal pain
and vomiting. The client's spouse informs the nurse that the
client went out for dinner the previous night. The report that the
client went out for dinner the previous night is example of data
from which type of source? Correct Answers The primary
source of information is the client. The client's spouse, friends,
,and test results would be secondary sources of data. There are no
tertiary or quaternary sources of assessment data.
A client comes to the emergency department with a productive
cough and an elevated temperature. Which type of assessment
would the nurse most likely perform on this client? Correct
Answers Focused
Explanation:
In a focused assessment, the nurse gathers information about a
specific problem that has already been identified. A head-to-toe
assessment is an initial, complete assessment, typically to assess
for any problems that have not been identified yet. An
emergency assessment is used to identify a life-threatening
problem. A time-lapse reassessment is scheduled to compare
current status with the baseline obtained earlier.
A client is admitted to a hospital unit with scleroderma. The
nurse is unfamiliar with this condition. What is the nurse's best
source of information about this condition? Correct Answers
The nursing and medical literature
Explanation:
In addition to information about medical diagnoses, treatment,
and prognosis, a literature review of nursing and medical
references offers nurses important information about nursing
diagnoses, developmental norms, and psychosocial and spiritual
practices that are helpful when assessing and caring for clients.
Consulting with the client, physician, or client's chart would not
give as comprehensive of a review.
, A client is receiving home care due to an unstable blood
pressure. Which nursing intervention is a priority? Correct
Answers Assess the client's blood pressure.
Explanation:
The priority intervention for the client with an unstable blood
pressure is to first measure the blood pressure. Once the nurse is
certain that this is within safe parameters, the nurse should
assess the client's diet, activity level, and medication regimen.
A client is receiving home care due to an unstable blood
pressure. Which nursing intervention is a priority? Correct
Answers Assess the client's blood pressure.
Explanation:
The priority intervention for the client with an unstable blood
pressure is to first measure the blood pressure. Once the nurse is
certain that this is within safe parameters, the nurse should
assess the client's diet, activity level, and medication regimen.
A client with a history of benign prostatic hyperplasia presents
to the emergency room with reports of urinary retention. The
nurse collects data related to the client's voiding patterns, weight
gain, fluid intake, urine volume in the bladder, and level of
suprapubic discomfort. What type of assessment is the nurse
performing? Correct Answers Focused
Explanation:
The nurse is performing a focused assessment, which involves
gathering data about a specific problem that has already been
identified. An initial assessment involves the nurse collecting
data concerning all aspects of the client's health. An emergency
assessment is performed to identify life-threatening problems. A
