Which of the following is an example of a time-lapse reassessment?
Bob is a nurse in a long-term skilled nursing facility. Noreen is a new client. Bob wants to gather information from Noreen, which includes her health status and any problematic health patterns, and to get a baseline for Noreen's overall functioning.
Daren is a nurse in a hospital who happens to walk by a room and notices a client down on the floor. Daren immediately assesses the client for airway, breathing, and circulation. Once the presence of these three is established, Daren calls for help and begins a quick neurological exam.
Natalia is a visiting nurse who has an appointment with Donald, an 85-year-old man with mobility issues. Natalia has worked with Donald in the past on the ways in which he can prevent falls. Today she wants to assess how he is doing with the fall prevention strategies they practiced before.
Joan is a nurse who is just coming on to her shift. She has received client reports from the nurse leaving the floor. To start off her day, she goes into each of her client's rooms and performs a focused physical assessment based on each individual's diagnosis.
Percussion sounds:
Resonance (over part air & part solid) loud, low, long, hollow
Hyper-Resonance (over mostly air) very loud,low,long, booming
Tympany (heard over air) loud, high, moderate, drum-like
Dullness (heard over more solid tissue) medium, medium, moderate, thud-like
Flatness (heard over very dense tissue) soft, high, short, flat
...[normal lung]
...[lung with emphysema]
...[puffed out cheek/gastric bubble]
...[diaphragm, pleural effusion, liver]
...[muscle, bone, sternum, thigh]
Admission assessment
p. 203-204
Rationale: An admission assessment, also referred to as an initial assessment, is performed when the client enters a health care facility, receives care from a home health agency, or is seen for the first time in an outpatient clinic. A focus assessment collects data about a problem that has already been identified. This type of assessment has a narrower scope and a shorter time frame than the admission assessment. The nurse applies methods relevant to assessing the previously targeted problem. Time-lapse reassessment, another type of assessment, takes place after the initial assessment to evaluate any changes in the client's health. Nurses perform time-lapse reassessments when substantial periods of time have elapsed between assessments (e.g., periodic outpatient clinic visits, home health visits, health and developmental screenings). Emergency assessment takes place in life-threatening situations in which the preservation of life is the top priority. Time is of the essence for rapid identification of, and intervention for, the client's health problems.
asking the client whether the client has cultural preferences
Assessing the client involves gathering information about the client's physical and emotional health; cognition; spiritual, cultural, or religious preferences; and sociodemographics.
Developing a plan to manage the client's health problems falls within the planning phase of the nursing process.
Coming up with the nursing diagnosis falls within the diagnosing phase of the nursing process.
Determining if the client's goals for wellness have been met occurs at the evaluation phase of the nursing process.
assess peripheral vascular status when examining the lower extremities.
When you assess the legs you will be assessing the parts of the skin (color and condition of skin on legs), peripheral vascular system (pulses, color, edema, lesions of legs), musculoskeletal system (movement, strength, and tone of legs), and neurologic system (ankle and patellar reflexes, clonus).