Chapter 16: Nursing Assessment

1. The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse a. Completes a comprehensive database. b. Identifies pertinent nursing diagnoses. c. Intervenes based on patient goals and priorities of care. d. Determines whether outcomes have been achieved. a. Completes a comprehensive database. The assessment phase of the nursing process involves data collection to complete a thorough patient database. Identifying nursing diagnoses occurs during the diagnosis phase. The nurse carries out interventions during the implementation phase, and determining whether outcomes have been achieved takes place during the evaluation phase of the nursing process. 2. A nurse using the problem-oriented approach to data collection will first a. Complete an observational overview. b. Disregard cues and complete the database questions in chronological order. c. Focus on the patient's presenting situation. d. Make accurate interpretations of the data. c. Focus on the patient's presenting situation. A problem-oriented approach focuses on the patient's current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection. 3. After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistant. With this in mind, what clinical decision should the nurse make? a. Administer scheduled medications assuming she would have been informed if the vital signs were abnormal. b. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return. c. Ask the nursing assistant to record the patient's vital signs before administering medications. d. Omit the vital signs because the patient is presently in no distress. c. Ask the nursing assistant to record the patient's vital signs before administering medications. The nurse should ask the nursing assistant to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action. 4. Subjective data include a. A patient's feelings, perceptions, and reported symptoms. b. A description of the patient's behavior. c. Observations of a patient's health status. d. Measurements of a patient's health status. a. A patient's feelings, perceptions, and reported symptoms. Subjective data include the patient's feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition. Data sometimes reflect physiological changes, which you further explore through objective data collection. Describing the patient's behavior, observations made, and measurements of a patient's health status are all examples of objective data. 5. A patient expresses fear of going home and being alone. Her vital signs are stable and her incision is nearly completely healed. The nurse can infer from the subjective data that a. The patient can now perform the dressing changes herself. b. The patient can begin retaking all her previous medications. c. The patient is apprehensive about discharge. d. Surgery was not successful. c. The patient is apprehensive about discharge. Subjective data include expressions of fear of going home and being alone. These data indicate that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed.