Ch 1 Nurse's Role

A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify?

ANS: A) Expansion of health care networks

A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify?

ANS: A) The client's feelings of happiness

The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following?

ANS: A) The client's motivation for change

The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply.

ANS: A, D, E

A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment?

ANS: B) ED nurse

In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation?

ANS: B) Effect of health on functional status

The nurse is performing a health assessment on a community-dwelling client who is recovering from hip replacement surgery. Which of the following actions should the nurse prioritize during assessment?

ANS: B) Interpret the information about the client in context.

The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process?

ANS: B) It is ongoing and continuous.

Which of the following client situations would the nurse interpret as requiring an emergency assessment?

ANS: C) A client who overdosed on acetaminophen

A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following?

ANS: C) Avoid biases and judgments

A nurse has received a report on a client who will soon be admitted to the medical unit from the emergency department. When preparing for the assessment phase of the nursing process, which of the following should the nurse do first?

ANS: C) Collect subjective data.

A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?

ANS: C) Focused assessment

A nurse on a postsurgical unit is admitting a client following the client's cholecystectomy (gall bladder removal). What is the overall purpose of assessment for this client?

ANS: D) Making clinical judgments

An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem?

ANS: D) Measure the client's blood glucose four times daily.

When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force?

ANS: D) Public mistrust of physicians

After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases?

ANS: A) Assessment

A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is a bit sporadic. How should the nurse best respond to this assessment finding?

ANS: A) Identify a nursing diagnosis of Ineffective Health Maintenance.

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?

ANS: A) Inspection

An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession?

ANS: A) Natural senses

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason?

ANS: A) Reassess previously detected problems

The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first?

ANS: A) Review the client's medical record.

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

ANS: B) A 45-year-old man with chest pain and diaphoresis for 1 hour

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral?

ANS: B) A 50-year-old client newly diagnosed with diabetes

The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data?

ANS: C) Appearance

A nurse has documented the findings of a comprehensive assessment of a new client. What is the primary rationale that the nurse should identify for accurate and thorough documentation?

ANS: C) Assuring valid conclusions from analyzed data

A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable?

ANS: C) The client's acuity

A nurse on the hospital's subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice?

ANS: C) The focused assessment addresses a particular client problem.

The nurse has been applying the nursing process in the care of an adult client who is being treated for acute pancreatitis. Place the nurse's actions in their proper sequence from first to last.

ANS: C, B, A, E, D C) Collecting information about the client B) Determining client's nursing problem A) Identifying outcomes E) Carrying out interventions D) Determining outcome achievement

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment?

ANS: D) Establish a baseline for the comparison of future health changes.

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?

ANS: B) Ask the client about the most recent experiences of pain.