Chapter 16 - Nursing Assessment Potter and Perry ALL ANSWERS 100% CORRECT SPRING FALL-2022/2023 SOLUTION GUARANTEED GRADE A+

A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: Patient's level of function. Patient's willingness to perform self-care. Patient's level of consciousness. Patient's health management values. - Patient's level of function. Rationale: Observing a patient perform activities physical, socially, psychologically, and developmentally assesses his or her level of function. In the case of this question the nurse assesses physical functional level. Observation does not measure willingness to perform self-care but the ability to do so. Observing physical performance of self-hygiene is not a measure of level of consciousness nor does it reveal a patient's values. 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? Orientation Working phase Data validation Termination - Working phase Rationale: The gathering of information is the working phase of a patient-centered interview. The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? Select all that apply Listen attentively to the patient's story. Use gestures that reinforce your questions or comments. Stand back away from the bedside. Maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue. - Use gestures that reinforce your questions or comments. Listen attentively to the patient's story. Use gestures that reinforce your questions or comments. Maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue. Rationale: Approaches for collecting an older-adult assessment include listening patiently, using nonverbal communication when a patient has a hearing deficit, and maintaining patientdirected eye gaze. Leaning forward, not backward, shows interest in what the patient has to say. 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: Cue. Reflection. Clinical inference. Probing. - Clinical inference. 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 a