Chapter 1: The Nurse's Role in Health Assessment

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?

Collect subjective data

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

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

The second standard within the Nursing Scope and Standards of Practice states that the nurse analyzes assessment data to determine the diagnoses or issues. Which activities will the nurse perform when complying with the expectations of the second standard? Select all that apply.

Documents the diagnoses Derives the diagnosis based on assessment data Validates the diagnoses with the client, family, and other health care providers

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?

Establish a baseline for the comparison of future health changes.

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

As part of the nursing profession, nurses function as client advocates. What is one way in which a nurse advocates for a client?

Identifying the side effects of treatment

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

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

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

Following completion of the comprehensive health assessment, the nurse periodically performs a partial assessment primarily for which reason?

Reassess previously detected problems

What are the components of the SBAR? Select all that apply.

Situation Assessment Recommendation

A nurse is conducting a health assessment. How will the information collected from the patient be used?

as a basis for the nursing process

When planning a community program related to Healthy People 2020, the critical first step involves

defining the community

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) 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? 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?

focused or problem-oriented assessment.