Author Question: A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's ... (Read 69 times)

aabwk4 · **on:** Jul 23, 2018

A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment?

A) Initial assessment
B) Focused assessment
C) Time-lapsed reassessment
D) Emergency assessment

Question 2

The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's health status. Which of the following would the nurse identify as a subjective cue?

A) Sharp pain in the knee
B) Small bloody drainage on dressing
C) Temperature of 102 degrees F
D) Pulse rate of 90 beats per minute

sultana.d · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: B

The nurse is performing a focused assessment to determine whether the problem still exists, and whether the status of the problem has changed. An initial or admission assessment is the initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction. Time-lapsed reassessment is performed after the initial assessment when substantial periods of time have elapsed between assessments. An emergency assessment is performed any time a physiologic, psychological, or emotional crisis occurs.

Answer to Question 2

Ans: A

Sharp pain in the knee is an example of a subjective cue. Subjective cues are imperceptible, immeasurable, and abstract. Small bloody drainage on dressing, a temperature of 102 degrees F, and a pulse rate of 90 beats per minute are examples of objective cues.