chapter 1
Physiologic, psychological, sociocultural, developmental, and spiritual data
A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas?
"It determines your health status, risk factors and educational needs to develop a plan of care."
A client asks why a health assessment needs to be done. What should the nurse respond to this client?
physiologic status.
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
Partial
A nurse cares for a client with lung cancer who presents with rust colored sputum and a fever. The nurse performs frequent auscultation of the lungs sounds to determine any changes from the baseline. What type of assessment is the nurse performing?
Objective
A nurse is admitting a client, having completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data?
Diagnostic reasoning
A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use?
Open the client's airway
An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the first action of the nurse?
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)
Mental
As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife. How did you get into my house?". Based upon the client's behavior, which assessment will the nurse now focus upon?
Assessment
Data collection occurs where in the nursing process?
Environmental
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?
Client with 4-day history of sore throat and fever with enlarged lymph nodes
For which of the following clients should a nurse perform a focused assessment?
Asking the appropriate questions
How does a nurse best facilitate the nursing health assessment?
Shortness of breath
In which situation should a nurse perform an emergency assessment of a client?
Evaluation
Revising the plan as needed occurs in what part of the nursing process?
Subjective
The client has a headache. What type of data is this?
Objective
The client has a murmur. This is what type of data?
•Evaluating client outcomes •Collecting information about the health status of the client •Synthesizing collected data
The purpose of a health assessment includes what? (Select all that apply.)
formulation of nursing diagnoses.
The result of a nursing assessment is the
Assessing
Using both verbal and nonverbal clues given by the patient, what is the nurse constantly doing?
Empathy
Which skill does the nurse need to obtain subjective data during the initial comprehensive assessment?
To achieve the best results
Why is the nurse always reassessing the patient for changes?
Body systems
A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment?
Nursing process
A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?
Individual student interview and questionnaire
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?
Critical thinking
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?
Making incorrect nursing judgments or diagnoses
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?
Formation of judgments that may interfere with the interview
A nurse is preparing to interview a client who is a Seventh Day Adventist. The nurse does not agree with this religion's view of modern medicine. Reflection of the nurse on her personal feelings regarding this patient and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation?
Evaluation
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 whether the client has achieved the outcome criteria of the treatment?
To determine any changes from the baseline data
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment?
Determine any changes from the baseline data
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?
Primary
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?
To establish a database against which subsequent assessments can be measured
A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?
•Declining numbers of medical students due to rising costs and focus on primary care •Increasing complexity of acute care •Growing aging population with complex comorbidities •Increasing impact of children and the homeless on communities
A nursing instructor is trying to convince the class of the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors should stressed that will promote opportunities for nurses with advanced assessment skills? Select all that apply.
Airway
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?
A baseline for comparison with future findings
A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides?
Functional
An assessment that concentrates on patterns of role performance that all humans share is called what?
Nurses collaborate with clients to identify areas in which clients are willing to make changes
How does a nurse decide what health-promotion activities are necessary for a particular client?
The client's acuity
The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?
Performing a focused assessemt on a client who is complaining of shortness of breath
The nurse is exhibiting critical thinking in which client care situation?
Head-to-toe
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?
Areas in need of health adjustments
What are nurses able to detect through the health assessment?
•Deciding when physical procedures should be performed on a client •Deciding what client teaching is necessary •Deciding when a client needs to be turned
What are the areas of independent nursing practice? Select all that apply.
Critical thinking
What is a required component of a health assessment?
To treat human responses
What is one of the broad goals within nursing?
Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions
What is one way nurses use critical thinking in regard to the nursing process?
Assessment
What is the foundation of nursing practice?
To decide the best overall care
What is the primary function of the health care team?
To gather information about the health status of the client
What is the primary purpose of health assessment?
Collecting data regarding the nature of the pain
What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain?
comprehensive.
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
A healthy environment
When assisting a patient with health promotion, what must the nurse also nurture?
Identify in what areas the patient needs the most care
When doing an overall assessment of a patient, the nurse is able to utilize findings and do what?
An oncology client with a cough but no fever.
When making rounds, the RN should prioritize follow-up care for which client?
Diagnosis
When the nurse clusters the data to make a judgement or statement about the client's condition, this is know as what?
Body functions
Which assessment finding should the nurse document as objective data?
Measuring the remaining tread on a car tire to determine whether it is time to replace it
Which of the following is the best example of assessment in everyday life?
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 holistic data collection by a nurse?
Comprehensive
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?
Collect subjective and objective data related to overall function.
A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility?
Collect subjective data related to overall function
A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility?
Empathy
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?
U.S. Preventive Services Task Force
A nurse is trying to decide whether to recommend that a pregnant client be screened for HIV. Which of the following resources would best help in this decision?
Making incorrect nursing judgments or diagnoses
A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?
Head to toe
A young adult male nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what?
Nursing intervention
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?
perform a physical examination
The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history?
avoid premature judgments about the client
The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should
take a complete health history
The nurse tells a newly admitted patient that she is going to do a health assessment to help in planning care and educational needs during the patient's hospital stay. Before the physical examination, the nurse should first
• Focused • Emergency • Comprehensive
What are the types of nursing assessments? (Select all that apply.)
Planning
Which part of the nursing process includes the formulation of goals?