Question: Which nursing skill uses all five senses?

Observation

Answer: Observation is the conscious and deliberate use of the five senses (sight, smell, hearing, taste, and touch) to gather data.

Question: The nurse is conducting a client interview and notices that the client answers every question with a “yes” or “no” response. What is most likely the cause of this action by the client?

Pain

Answer: Clients often offer clipped responses and “yes” and “no” answers when in pain, as their main focus is pain relief.

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Question: The nurse, while admitting an older adult client, charts, “The client does not respond when I speak while standing on the client’s right side.” This statement is an example of:

a cue.

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Question: While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, “The client’s hearing may be impaired on the right side.” This statement is an example of:

an inference.

Answer: The judgment a nurse makes about a cue is known as an inference.

Question: Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training?

All data collected need to be validated.

Answer: Validation is the act of confirming or verifying. The purpose of validation is to keep data as free from error as possible. It is an important part of assessment. However, it is neither possible nor necessary to validate all data; nurses should decide which items need verification.

Question: The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment?

Supplement the client’s information by speaking with family or friends.

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Question: For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

Initial

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