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Chapter 3. Nursing Process Assessment questions and answer 2020 solution

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Chapter 3. Nursing Process Assessment questions and answer 2020 solution ____ 1. What is the role of the Joint Commission in regard to patient assessment? The Joint Commission 1) States what assess... ments are collected by individuals with different credentials 2) Regulates the time frames for when assessments should be completed 3) Identifies how data are to be collected and documented 4) Sets standards for what and when to assess the patient The Joint Commission sets detailed standards regarding what and when to assess but does not address credentials. Nurse practice acts specify what data are collected and by whom. Agency policy may set time frames for when assessments should be done and how they should be documented. Nursing knowledge identifies how data are to be collected. ____ 2. Which of the following is an example of data that should be validated? 1) The clients weight measures 185 lb at the clinic. 2) The clients liver function test results are elevated. 3) The clients blood pressure is 160/94 mm Hg; he states that that is typical for him. 4) The client states she eats a low-sodium diet and reports eating processed food. Validation should be done when the clients statements are inconsistent (processed foods are generally high in sodium). Validation is not necessary for laboratory data when you suspect an error has been made in the results. Personal information that patients might be embarrassed about, such as weight, is best validated with a scale. ____ 3. Which of the following examples includes both objective and subjective data? 1) The clients blood pressure is 132/68 and her heart rate is 88. 2) The clients cholesterol is elevated, and he states he likes fried food. 3) The client states she has trouble sleeping and that she drinks coffee in the evening. 4) The client states he gets frequent headaches and that he takes aspirin for the pain. Elevated cholesterol is objective, and states he likes fried food is subjective. Objective data can be observed by someone other than the patient (e.g., from physical assessments or lab and diagnostic tests). Subjective data are information given by the client. Blood pressure and heart rate measurements are both objective. States . . . trouble sleeping and . . . drinks coffee . . . are both subjective. States . . . frequent headaches and . . . takes aspirin . . . are both subjective. ____ 4. The Joint Commission requires which type of assessment to be performed on all patients? 1) Functional ability 2) Pain 3) Cultural 4) Wellness The Joint Commission requires that pain and nutrition assessment be performed on all patients. Other special needs assessments should be performed when cues indicate there are risk factors. ____ 5. Which of the following is an example of an ongoing assessment? 1) Taking the patients temperature 1 hour after giving acetaminophen (Tylenol) 2) Examining the patients mouth at the time she complains of a sore throat 3) Requesting the patient to rate intensity on a pain scale with the first perception of pain 4) Asking the patient in detail how he will return to his normal exercise activities An ongoing assessment occurs when a previously identified problem is being reassessedfor example, taking an hourly temperature when a patient has a fever. Examining the mouth is a focused assessment to explore the patients complaint of sore throat. Asking for a pain rating is a focused assessment at the first complaint of pain. A detailed interview about exercise is a special needs assessment; there is no way to know if it is initial or ongoing. [Show More]

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