CHAPTER 12 – NURSING ASSESSMENT

An older adult male with a history of benign prostatic hyperplasia (BPH) 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?

– Initial assessment
– Time-lapse assessment
– Emergency assessment
– Focused assessment

Focused assessment

P. 204

Rationale: The nurse is performing a focused assessment that 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 time-lapse assessment compares a client’s current status to baseline data obtained earlier

How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation?

“Client states, ‘I don’t see the point in trying anymore.’” “Client states that his rehabilitation will be unsuccessful.” “Client is demonstrating signs and symptoms of depression.” “Client makes statements indicating a loss of hope.”

“Client states, ‘I don’t see the point in trying anymore.’”

p. 208

Rationale: Subjective data should be recorded using the client’s own words, using quotation marks as appropriate. Paraphrasing the client’s words may lead to assumptions and misrepresentations

A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?

Comprehensive
Focused
Time-lapse
Emergency

Time-lapse

p. 204

Rationale: The time-lapse assessment is scheduled to compare a client’s current status to baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses, are scheduled for periodic time-lapse assessments to reassess health status and to make necessary revisions in the plan of care