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Examen

Nursing Assessment Practice Questions

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13 páginas
2024/2025 Escrito para el año académico
Institución Nursing Assessment Practice
Grado Nursing Assessment Practice
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A client interview consists of three phases. The nurse recognizes that those phases are: 1.Orientation, working, termination 2.Introduction, controlling, selection 3.Introduction, assessment, conclusion 4.Orientation, documentation, database 4 The three phases of an interview are orientation, working, and termination. During the admission history, the client states that he has trouble breathing at night. In obtaining data for a problem-oriented database, the nurse should first question the client about: 1.The onset and duration of his present breathing problem 2.His personal smoking, alcohol use, and exercise practices 3.Any extended family members who have diagnosed heart disease 4.Changes in other body systems that the client perceives as problematic 1 A client's database originates with the client's perception of a symptom or health problem. If an illness is present, the nurse gathers essential and relevant data about the nature and onset of symptoms. The problem-seeking technique takes the information provided in the client's story to more fully describe and identify the client's specific problems. Habits and lifestyle patterns such as smoking, alcohol use, and exercise may be assessed in an admission history. However, it is not the first question the nurse should ask when obtaining data for a problem-oriented database after the client reports having a health problem. Information regarding family history, such as members who had heart disease, may be obtained in an admission history. However, if a client reports a problem, the nurse should first follow-up with questions relevant to the nature and onset of symptoms. The nurse may inquire about changes in other body systems during an admission history; however, if the client reports a problem, the nurse should first follow-up using a problem-oriented approach. This would include asking specific questions about the client's health problem, such as the nature and onset of symptoms. The nurse begins the assessment of a client that has come to the emergency department experiencing chest pain by asking the client about: 1.A family history of heart problems 2.Medications currently being taken at home 3.Questions or concerns about hospitalization 4.The onset, severity, and duration of the chest pain 4 If a client comes to the emergency department with chest pain, the nurse should first ask the client about the onset, severity, and duration of the chest pain. In an emergency situation, the client's current health problem becomes the priority assessment. Initially, the nurse should not ask questions regarding family history. Gathering data about the problem currently affecting the client has greater priority. Asking the client about medications taken at home is appropriate, but not at this time. The priority is to assess the symptoms the client is experiencing. Asking the client about concerns regarding hospitalization is not the priority. A nurse seeks to organize the data obtained from the client in a logical manner. The organizational method that identifies relationships between factors and symptoms in the database is known as: 1.Clustering data 2.Validating data 3.Peer reviewing 4.Problem statement 1 Clustering data means the nurse organizes the information obtained into meaningful clusters. A cluster is a set of signs or symptoms grouped together in a logical order. When clustering data, the nurse identifies relationships between factors and symptoms. Validating data means to compare the data obtained with another source to ensure its accuracy. Peer review is the evaluation of the quality of the work effort of an individual by his or her peers. After validating data and clustering data, the nurse may formulate a problem statement, usually in the form of a nursing diagnosis. The client recently became febrile and stated he "felt hot." The nurse takes the client's temperature and finds it to be 38.2° C. In addition, the pulse rate is 88 beats per minute, and his blood pressure is 168/80 mm Hg. Which of the following is an example of subjective data? 1.Pulse rate of 88 beats per minute 2.Blood pressure of 168/80 mm Hg 3.The statement regarding his feeling hot 4.The supported fact that he became febrile 3 Subjective data are client's perceptions about their health problems. The statement by the client regarding his feeling hot is an example of subjective data. A pulse rate of 88 beats per minute is an example of objective data. Objective data are observations or measurements made by the data collector. A blood pressure of 168/80 mm Hg is something that can be measured, and therefore is an example of objective data. Becoming febrile can be determined by measurement, and therefore is an example

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Nursing Assessment Practice Questions
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Aiiclientiiinterviewiiconsistsiiofiithreeiiphases.iiTheiinurseiirecognizesiithatiithoseiiphasesiiare:
1.Orientation,iiworking,iitermination
2.Introduction,iicontrolling,iiselection
3.Introduction,iiassessment,iiconclusion
4.Orientation,iidocumentation,iidatabase 4

Theiithreeiiphasesiiofiianiiinterviewiiareiiorientation,iiworking,iiandiitermination.
Duringiitheiiadmissioniihistory,iitheiiclientiistatesiithatiiheiihasiitroubleiibreathingiiatiinight.iiIniiobtainingii
dataiiforiiaiiproblem-orientediidatabase,iitheiinurseiishouldiifirstiiquestioniitheiiclientiiabout:

1.Theiionsetiiandiidurationiiofiihisiipresentiibreathingiiproblem

2.Hisiipersonaliismoking,iialcoholiiuse,iiandiiexerciseiipractices

3.Anyiiextendediifamilyiimembersiiwhoiihaveiidiagnosediiheartiidisease

4.Changesiiiniiotheriibodyiisystemsiithatiitheiiclientiiperceivesiiasiiproblematic 1

Aiiclient'siidatabaseiioriginatesiiwithiitheiiclient'siiperceptioniiofiiaiisymptomiioriihealthiiproblem.iiIfiianiiill
nessiiisiipresent,iitheiinurseiigathersiiessentialiiandiirelevantiidataiiaboutiitheiinatureiiandiionsetiiofiisympto
ms.iiTheiiproblem-
seekingiitechniqueiitakesiitheiiinformationiiprovidediiiniitheiiclient'siistoryiitoiimoreiifullyiidescribeiiandiii
dentifyiitheiiclient'siispecificiiproblems.iiHabitsiiandiilifestyleiipatternsiisuchiiasiismoking,iialcoholiiuse,iia
ndiiexerciseiimayiibeiiassessediiiniianiiadmissioniihistory.iiHowever,iiitiiisiinotiitheiifirstiiquestioniitheiinurs
eiishouldiiaskiiwheniiobtainingiidataiiforiiaiiproblem-
orientediidatabaseiiafteriitheiiclientiireportsiihavingiiaiihealthiiproblem.iiInformationiiregardingiifamilyiihi
story,iisuchiiasiimembersiiwhoiihadiiheartiidisease,iimayiibeiiobtainediiiniianiiadmissioniihistory.iiHowever
,iiifiiaiiclientiireportsiiaiiproblem,iitheiinurseiishouldiifirstiifollow-
upiiwithiiquestionsiirelevantiitoiitheiinatureiiandiionsetiiofiisymptoms.iiTheiinurseiimayiiinquireiiaboutiicha
ngesiiiniiotheriibodyiisystemsiiduringiianiiadmissioniihistory;iihowever,iiifiitheiiclientiireportsiiaiiproblem,ii
theiinurseiishouldiifirstiifollow-upiiusingiiaiiproblem-
orientediiapproach.iiThisiiwouldiiincludeiiaskingiispecificiiquestionsiiaboutiitheiiclient'siihealthiiproblem,
iisuchiiasiitheiinatureiiandiionsetiiofiisymptoms.

Theiinurseiibeginsiitheiiassessmentiiofiiaiiclientiithatiihasiicomeiitoiitheiiemergencyiidepartmentiiexperienc
ingiichestiipainiibyiiaskingiitheiiclientiiabout:

1.Aiifamilyiihistoryiiofiiheartiiproblems
2.Medicationsiicurrentlyiibeingiitakeniiatiihome
3.Questionsiioriiconcernsiiaboutiihospitalization
4.Theiionset,iiseverity,iiandiidurationiiofiitheiichestiipain 4

Ifiiaiiclientiicomesiitoiitheiiemergencyiidepartmentiiwithiichestiipain,iitheiinurseiishouldiifirstiiaskiitheiiclient
iiaboutiitheiionset,iiseverity,iiandiidurationiiofiitheiichestiipain.iiIniianiiemergencyiisituation,iitheiiclient'siicu

, rrentiihealthiiproblemiibecomesiitheiipriorityiiassessment.iiInitially,iitheiinurseiishouldiinotiiaskiiquestions
iiregardingiifamilyiihistory.iiGatheringiidataiiaboutiitheiiproblemiicurrentlyiiaffectingiitheiiclientiihasiigrea

teriipriority.iiAskingiitheiiclientiiaboutiimedicationsiitakeniiatiihomeiiisiiappropriate,iibutiinotiiatiithisiitime.ii
Theiipriorityiiisiitoiiassessiitheiisymptomsiitheiiclientiiisiiexperiencing.iiAskingiitheiiclientiiaboutiiconcernsi
iregardingiihospitalizationiiisiinotiitheiipriority.

Aiinurseiiseeksiitoiiorganizeiitheiidataiiobtainediifromiitheiiclientiiiniiaiilogicaliimanner.iiTheiiorganizationa
liimethodiithatiiidentifiesiirelationshipsiibetweeniifactorsiiandiisymptomsiiiniitheiidatabaseiiisiiknowniias:

1.Clusteringiidata
2.Validatingiidata
3.Peeriireviewing
4.Problemiistatement 1

Clusteringiidataiimeansiitheiinurseiiorganizesiitheiiinformationiiobtainediiintoiimeaningfuliiclusters.iiAiicl
usteriiisiiaiisetiiofiisignsiioriisymptomsiigroupediitogetheriiiniiaiilogicaliiorder.iiWheniiclusteringiidata,iitheiin
urseiiidentifiesiirelationshipsiibetweeniifactorsiiandiisymptoms.iiValidatingiidataiimeansiitoiicompareiith
eiidataiiobtainediiwithiianotheriisourceiitoiiensureiiitsiiaccuracy.iiPeeriireviewiiisiitheiievaluationiiofiitheiiqu
alityiiofiitheiiworkiieffortiiofiianiiindividualiibyiihisiioriiheriipeers.iiAfteriivalidatingiidataiiandiiclusteringiida
ta,iitheiinurseiimayiiformulateiiaiiproblemiistatement,iiusuallyiiiniitheiiformiiofiiaiinursingiidiagnosis.
Theiiclientiirecentlyiibecameiifebrileiiandiistatediiheii"feltiihot."iiTheiinurseiitakesiitheiiclient'siitemperatur
eiiandiifindsiiitiitoiibeii38.2°iiC.iiIniiaddition,iitheiipulseiirateiiisii88iibeatsiiperiiminute,iiandiihisiibloodiipressu
reiiisii168/80iimmiiHg.iiWhichiiofiitheiifollowingiiisiianiiexampleiiofiisubjectiveiidata?

1.Pulseiirateiiofii88iibeatsiiperiiminute
2.Bloodiipressureiiofii168/80iimmiiHg
3.Theiistatementiiregardingiihisiifeelingiihot
4.Theiisupportediifactiithatiiheiibecameiifebrile 3

Subjectiveiidataiiareiiclient'siiperceptionsiiaboutiitheiriihealthiiproblems.iiTheiistatementiibyiitheiiclientiire
gardingiihisiifeelingiihotiiisiianiiexampleiiofiisubjectiveiidata.iiAiipulseiirateiiofii88iibeatsiiperiiminuteiiisiianii
exampleiiofiiobjectiveiidata.iiObjectiveiidataiiareiiobservationsiioriimeasurementsiimadeiibyiitheiidataiicoll
ector.iiAiibloodiipressureiiofii168/80iimmiiHgiiisiisomethingiithatiicaniibeiimeasured,iiandiithereforeiiisiianiie
xampleiiofiiobjectiveiidata.iiBecomingiifebrileiicaniibeiideterminediibyiimeasurement,iiandiithereforeiiisiia
niiexampleiiofiiobjectiveiidata.
Theiinurseiidecidesiitoiiinterviewiitheiiclientiiusingiitheiiopen-
endediiquestioniitechnique.iiWhichiiofiitheiifollowingiistatementsiireflectsiithisiitypeiiofiiquestioning?

1."Isiiyouriipainiiworseiioriibetteriithaniiitiiwasiianiihouriiago?"
2."Doiiyouiibelieveiithatiiyouriinauseaiiisiifromiitheiinewiiantibiotic?"
3."Whatiidoiiyouiithinkiihasiibeeniicausingiiyouriicurrentiidepression?"
4."Whatiihaveiiyouiidoneiitoiialleviateiitheiisideiieffectsiifromiiyouriimedications?" 3

Aniiopen-
endediiquestioniipromptsiitheiiclientiitoiidescribeiiaiisituationiiiniimoreiithaniioneiioriitwoiiwords.iiThisiiopti
oniidemonstratesiitheiiopen-
endediiquestioniitechnique.iiThisiiquestioniilimitsiitheiiclient'siianswersiitoiioneiioriitwoiiwords.iiItiiisiianiiex

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Subido en
22 de octubre de 2024
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