CoursePoint Chapter 1: The Nurse's Role in Health Assessment

The nurse prepares to collect objective data on a client new to a health clinic. What will the nurse use to collect this data? Select all that apply.

-Palpation -Inspection -Percussion -Auscultation

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

-Situation -Assessment -Recommendation

A client requires soft wrist restraints. What assessments should the nurse perform to ensure the client's safety? Select all that apply.

-hydration status -skin integrity -elimination -circulation

The nurse is collecting data from a client. Which of the following best reflects objective data?

Appearance

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

This type of assessment includes a health history and physical assessment.

Comprehensive

Which of the following statements best conveys the rationale for health promotion in a school setting?

Healthy child development is a critical health determinant because of its implications for lifelong health.

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?

Physiologic, psychological, sociocultural, developmental, and spiritual data

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?

Review the client's medical record.

Why is it important for a new nurse, working on a step-down unit, to know the standards of care for the facility in which the nurse is working?

Standards of care often set the time frame for assessing the clients on the unit

After performing a comprehensive assessment on a client, the nurse notes the following. Which part of the nursing process is the nurse performing? Nursing Notes: ● Client reports pain in bilateral lower extremities when walking short distances, relieved with rest. ● Pulses are weak, barely palpable in bilateral lower extremities. ● Bilateral feet are cool to touch ● Total cholesterol > 200. ● Client smokes two packs of cigarettes daily for past 20 years.

analysis of assessment findings

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

comprehensive

The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg, O2 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

evaluate an outcome

A nurse is gathering subjective data. Which of the following would the nurse be most likely to assess?

feelings of happiness

A client has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this client?

knowledge deficit

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?

open the client's airway

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history?

perform a physical examination

The nurse prepares to complete a holistic assessment of a client with a chronic health problem. Which areas will the nurse include in this assessment? Select all that apply.

-Spiritual -Physiologic -Sociocultural -Psychological -Developmental

A nurse is performing a focused assessment on a client admitted with symptoms of meningitis who underwent a lumbar puncture this morning and is now reporting a headache and photophobia. The nurse identifies clear drainage on the dressing and redness and swelling around the site. The nurse documents which of the following objective findings in the chart? Select all that apply.

-redness around the site -clear drainage on dressing -swelling

Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first?

Conduct a focused assessment.

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

Functional

The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority?

significantly impaired hearing

What is the primary function of the health care team?

to decide the best overall care

The nurse is conducting a health assessment on a client presenting to the emergency room with a critical condition. The nurse should initially ask questions regarding which topic(s) during the initial assessment? Select all that apply.

-medications -allergies -adverse reactions

A nurse working in a long-term care facility is performing a comprehensive assessment on an 84-year-old male resident. Click to highlight the findings that will require follow-up. Client is awake, alert, and oriented. Client walks with a cane. Abdomen is soft and nontender, last bowel movement was charted 7 days ago. No urine output has been charted in the last 24 hours. Skin is warm, dry, pink, and intact. Vital signs: temperature, 97.9°F (36.6°C); heart rate 120 beats/min and irregular; oxygen saturations 88% on room air.

-last bowel movement was charted 7 days ago -No urine output has been charted in the last 24 hours -heart rate 120 beats/min and irregular -oxygen saturations 88% on room air.

A nurse is completing an assessment that will involve gathering subjective and objective information. Which data would the nurse identify as objective? Select all that apply.

-physician's report -BP 135/78, heart rate 74 beats/min, respirations 16 breaths/min -

The nurse is gathering objective information from the medical record of a newly admitted client to the medical-surgical unit of an acute care facility. Which of the following data would the nurse consider as a priority in assessing the client? Select all that apply.

-recent changes in the client's blood pressure readings -the client's medical diagnosis -recent abnormal laboratory findings

A nurse analyzes the data obtained from an initial assessment of a new client: weight gain of 15 lbs in 3 months, intolerance to cold, constipation, and lethargy. The nurse determines the client may have hypothyroidism and develops several nursing diagnoses with interventions to address the client concerns. Which action should the nurse take next?

Implement interventions

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

The nurse performs an assessment on a newly admitted client. Data analysis reveals temperature 100.9 F (38.3 C), BP 82/58 mm Hg, 02 Saturation 91% RA, productive cough, lethargy, diaphoresis, WBC 15,000 mm3, Hemoglobin 9 g/dL, Hematocrit 29%. What action should the nurse take next?

develop diagnosis

While assessing a client, the nurse notes that the client is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process?

emotional

A 38-year-old client has been admitted to the emergency department (ED) with reports of abdominal pain and vomiting for the past 6 hours. Which type of assessment will the nurse complete on this client?

focused assessment

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?

natural senses

After completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing?

nursing diagnosis

The nurse notes that an intervention provided to a client for a specific health problem was not effective. The nurse continues to monitor and care for the client. Which type of assessment is the nurse performing?

ongoing or partial assessment

A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take?

perform an emergency assessment

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first:

review the client's health care record.

When the client begins to cry, the nurse recognizes the need to focus the assessment on the client's emotional health. What factor will have the greatest effect on the nurse's ability to gather information concerning why the client is crying?

the rapport that exists between the nurse and the client

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

physiologic status