Chapter 11 Assessment

Rationale: The part of the interview that is focused on gathering data from theclient is the body. The nurse uses open and closed questions. The opening is thepart of the interview when the nurse establishes rapport with the client. Theclosing is the conclusion of the interview. The examination is the gathering ofobjective data.

Rationale: The status of a specific problem identified in an earlier assessment isrepresentative of problem-focused assessment.

Rationale: Most schools of nursing and health care agencies have developed theirown structured assessment format.

Rationale: The nurse strives for a less formal atmosphere, where the nurse andclient can feel on more equal terms, such as when the client is in bed and the nursesits on a chair at a 45-degree angle to the bed. When the nurse stands at the foot ofthe bed and the client is in bed, the nurse may intimidate the client, who feels thenurse has greater status. When the nurse and client are seated in chairs at rightangles it is less formal; the nurse and client are too close together for the client tofeel comfortable. The client may feel that his personal space is being invaded.When the client is in bed and the nurse stands at the side of the bed, the nurse isin a position where the client may feel intimidated because the nurse is not at eyelevel.

A. Rationale: Frameworks help the nurse be systematic in data collection. Othermembers of the health care team may use very different conceptual organizingframeworks so data may not correlate. Cost-effective care is more likely to occurwith systematic application of the nursing process, but use of a framework forassessment alone may not accomplish this goal. Because the framework isstructured and because of the nature of client needs/problems, creativity andintuition in care planning are not assured.

Rationale: Identifying problems/needs is part of nursing diagnosis. For example,a client with difficulty breathing would have Impaired Gas Exchange related toconstricted airways as manifested by shortness of breath (dyspnea) as a nursingdiagnosis. Organizing the family history is part of the assessment phase.Establishing goals is a part of the planning phase. Administering an antibiotic ispart of the implementation phase.

Rationale: To observe is to gather data by using the senses. Observation is aconscious, deliberate skill that is developed through effort and with an organizedapproach. Although nurses observe mainly through sight, most of the senses areengaged during careful observations.

initial assessment

problem-focused assessment

emergency assessment

time-lapsed reassessment