326 Health Assessment Chapter 1

A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?

"I'm sorry, but assessment is ongoing and continuous."

A student nurse is learning to document an initial assessment. What would theinstructor tell the student that accurate documentation of this specific assessment best provides?

A baseline for comparison with future findings

Which assessment finding should the nurse document as objective data?

Body functions

A client presents to the health care facility with reports of new onset of chest pain of three days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse perform for this client?

Comprehensive

A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?

Critical thinking

When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what?

Diagnosis

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?

Empathy

Revising the plan as needed occurs in what part of the nursing process?

Evaluation

A few nursing students revealed to a faculty advisor that they were concerned about the effects of their program demands on their personal health practices. Follow-up with other students indicated that this was a common concern among the student group. Further assessment showed that the students expressed their belief in the importance of maintaining good health practices, but that most students had discontinued weekday efforts because of their focus on school-related stress and limited economic resources. Faculty members supported the concept of integrated health programs and were prepared to develop a program as a project. To assess the need for health promotion among the group of students, which of the following assessment methods would be most useful?

Individual student interview and questionnaire

A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the patient's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?

Making incorrect nursing judgments or diagnoses

Which of the following is the best example of holistic data collection by a nurse?

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings

Which of the following is the best example of assessment in everyday life?

Measuring the remaining tread on a car tire to determine whether it is time to replace it

The nurse is exhibiting critical thinking in which client care situation?

Performing a focused assessment on a client who is complaining of shortness of breath.

A client admitted with reports of nausea and vomiting has not reported any vomiting in the last 6 hours. What initial response should the nurse have regarding this assessment information and its effect on the client's nursing plan of care?

Recognize the need to reevaluate the client's plan of care.

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is

continuous.

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?

Primary

What is one way nurses use critical thinking in regard to the nursing process?

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

Head-to-toe

The nurse is following a structured head-to-toe approach to identify changes in a patient's body systems. Which component of the health assessment is the nurse completing with the patient?

Physical examination

Which actions should a nurse perform before beginning the initial shift assessment of a client? Select all that apply.

Review the client's record before meeting the client Revise nursing care plans to reflect improvements in the clients condition Check the client's status with the nurse of the previous shift

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?

"I'm going to assess the client now so that I can begin formulating the care plan."

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)

focused or problem-oriented assessment

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)

focused or problem-oriented assessment.

During a health assessment, a client shares, "I get a little dizzy when I get up from my chair too quickly." Which question will the nurse ask the client first when attempting to identify client needs and potential health risks?

"What do you mean by 'a little dizzy'?"

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?

Nursing intervention

What is one of the broad goals within nursing?

To treat human responses

A patient is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the patient?

Airway

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

What are the types of nursing assessments?

Focused Emergency Comprehensive

An assessment that concentrates on patterns of role performance that all humans share is called what?

Functional

When doing an overall assessment of a patient, the nurse is able to utilize findings and do what?

Identify in what areas the patient needs the most care

The client has a murmur. This is what type of data?

Objective

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?

Ongoing

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

To establish a database against which subsequent assessments can be measured

During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?

environmental

The result of a nursing assessment is the

formulation of nursing diagnoses.

When assisting a patient with health promotion, what must the nurse also nurture?

A healthy environment

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain?

Collecting data regarding the nature of the pain

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?

Ongoing or partial