Answer to Question 1
ANS: 1
Clustering data means the nurse organizes the information obtained into meaningful clusters. A cluster is a set of signs or symptoms grouped together in a logical order. When clustering data, the nurse identifies relationships between factors and symptoms. Validating data means to com-pare the data obtained with another source to ensure its accuracy. Peer review is the evaluation of the quality of the work effort of an individual by his or her peers. After validating data and clus-tering data, the nurse may formulate a problem statement, usually in the form of a nursing diag-nosis.
Answer to Question 2
ANS: 4
If a client comes to the emergency department with chest pain, the nurse should first ask the cli-ent about the onset, severity, and duration of the chest pain. In an emergency situation, the cli-ent's current health problem becomes the priority assessment. Initially, the nurse should not ask questions regarding family history. Gathering data about the problem currently affecting the cli-ent has greater priority. Asking the client about medications taken at home is appropriate, but not at this time. The priority is to assess the symptoms the client is experiencing. Asking the client about concerns regarding hospitalization is not the priority.
The nurse conducts the health history as the first step in the nursing assessment
Establishing a caring and trusting relationship helps the client come to terms with a terminal illne
B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs.
The surgical nurse assists the client into the correct position
Weber test: Place the base of the tuning fork on top of the client’s head.
Typical Organization of the CPT Manual