Fundamentals of Nursing and Midwifery 2e

Chapter 15 Assessing

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care. Sometimes the phases of the process interact or overlap.’ d. ‘Think about this person. Non-pharmacological interventions wouldn’t be effective with her.’ 2. When a person you are admitting to the unit asks you why you are doing a health history and physical exami- nation since the doctor just did one, your best reply is: a. ‘In addition to providing us with valuable information about your health status, the nursing and midwifery assessment will allow us to plan and deliver individualised, holistic person-centred care that draws on your strengths.’ b. ‘It’s hospital policy. I know it must be tiresome, but I will try to make this quick.’ c. ‘I’m a student nurse/midwife and need to develop the skill of assessing your health status and need for care. This information will help me develop a person-centred plan of care, individualised to your unique needs.’ d. ‘We want to make sure that your responses are consistent and that all our data are accurate.’ 3. When you receive the shift report, you learn that the person that you are caring for has no special skin care needs. You are surprised during the bath to observe red- dened areas over bony prominences. You should: a. Correct the initial assessment form b. Redo the initial assessment and document current findings c. Conduct and document an emergency assessment d. Perform and document a focused assessment on skin integrity 4. Fearful of attempting your first health history, you ask your facilitator how anyone ever learns everything you have to ask to get good baseline data. You are most likely to hear: a. ‘There’s a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!’ b. ‘You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care.’ c. ‘No-one ever really learns how to do this well because each history is different! I often feel like I’m starting afresh with each new person.’ d. ‘Don’t worry about learning all of the questions to ask. Every facility has its own assessment form you must use.’ 5. A person complains about feeling nauseated after lunch. This is an example of what type of data? a. Subjective b. Objective c. Signs and symptoms d. Overt 6. When you enter the person’s room to begin your health history, the person’s wife is there. You should:

a. Introduce yourself to both and thank the wife for being present b. Introduce yourself to both and ask the wife if she wants to remain c. Introduce yourself to both and ask the wife to leave d. Introduce yourself and ask the person if he would like the wife to stay 7. The person you are assessing is Vietnamese and does not speak English. Her son is with her and does speak English. How should you respond? a. Ask the son if he is willing to translate and be sure to thank him if he says yes b. Determine if the son can translate medical informa- tion and if so, begin c. After determining that the son can translate, evalu- ate if he can do so objectively and if the person wants him to serve in this capacity d. Explain to the son that hospital policy discourages using family members as interpreters and you will need to organise a hospital-approved interpreter 8. You are surprised to detect an elevated temperature (39.5°C) in a person scheduled for surgery. The person has been afebrile and shows no other signs of being 9. You tell your facilitator that the person you are nursing is fine and has ‘no complaints’. You are likely to hear: a. ‘You made an inference that she is fine because she has no complaints. How did you validate this?’ b. ‘She probably just doesn’t trust you enough to share what she is feeling. I’d work on developing a trusting relationship.’ c. ‘Sometimes everyone gets lucky. Why don’t you try to help another person?’ d. ‘Maybe you should reassess the person. She has to have a problem—why else would she be here?’ 1. The correct answer is c . There may be much interaction and overlap among the process of care phases. In this case, though you want to evaluate the effect of the med- ication you administered (options a and b ), there is no reason to wait for this to happen before exploring other valid options. Answer d is incorrect because it is not possible to judge the effectiveness of non-pharmacolog- ical methods before their use, and the facilitator’s response possibly indicates a prejudice toward comple- mentary and alternative modalities. 2. The correct answer is a . Though it may be true that you need to develop assessment skills ( c ), the chief reason you are doing a history and examination is because there needs to be a documented admission assessment to serve Answers with rationale febrile. The first thing you do is to: a. Inform the charge nurse/midwife b. Inform the surgeon c. Validate your finding d. Document your finding