Health Assessment Ch. 1

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

Evaluation

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? A) "I'm going to assess the client now so that I can begin formulating the care plan." B) "The client has been ordered a nutritional consult; I do the health assessment right after that is finished." C) "The health assessment will be more thorough if I wait until the client is pain free." C) "I'll do the health assessment when the client's family leaves so that distractions will be minimal."

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

14. 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? A) Natural senses B) Biomedical knowledge C) Simple technology D) Critical pathways

A

A nurse is conducting a health assessment. How will the information collected from the client be used? A) as a basis for the nursing process B) to illustrate nursing competence C) to facilitate nurse-client caring D) as one component of medical care

A) as a basis for the nursing process

21. 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. A) I feel so tired sometimes. B) Weight- 145 lbs C) Lungs clear to auscultation D) Client complains of a headache E) My father died of a heart attack. F) Pupils equal, round, and reactive to light

A,D,E

When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what? A. Assessment B.Diagnosis C.Planning D.Evaluation

B.Diagnosis

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) The focused assessment should be done before the physical exam. B) The focused assessment replaces the comprehensive database. C) The focused assessment addresses a particular client problem. D) The focused assessment is done after gathering subjective data.

C

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first? A) Collect objective data B) Validate the data C) Collect subjective data D) Document the data

C) Collect subjective data

A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next? A) Cluster client cues. B) Identify client concerns. C) Evaluate outcome. D) Implement an intervention

C) Evaluate outcome.

As a nurse becomes more proficient and comfortable in his or her role, what increases? A) Confidence and knowledge base B) Time management and confidence C) Knowledge base and expertise D) Expertise and time management

C) Knowledge base and expertise

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? A) Emergency B) Initial comprehensive C) Ongoing or partial D) Focused or problem-oriented

C) Ongoing or partial

**A nurse is gathering subjective data. Which of the following would the nurse be most likely to assess? a) Feelings of happiness b) Posture c) Mood d) Behavior

a) Feelings of happiness EXPLANATION: Subjective data are sensations, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Happiness is a feeling and therefore subjective. Posture, mood, and behavior are observable and considered objective 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? a) Collect subjective data related to the client's overall health. b) Perform a rapid assessment for prompt treatment. c) Determine any changes from the baseline data. d) Evaluate whether outcomes of treatment are met.

c) Determine any changes from the baseline data.

The result of a nursing assessment is the A) prescription of treatment. B) client's physiologic status. C) formulation of nursing diagnoses. D) documentation of the need for a referral.

formulation of nursing diagnoses.

4. 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? A) Review the client's medical record. B) Obtain basic biographic data. C) Consult clinical resources explaining the client's diagnosis. D) Validate information with the client.

A

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? A) Nursing intervention B) Nursing goal C) Nursing evaluation D) Nursing assessment

A) Nursing intervention

5. Which of the following client situations would the nurse interpret as requiring an emergency assessment? A) A pediatric client with severe sunburn B) A client needing an employment physical C) A client who overdosed on acetaminophen D) A distraught client who wants a pregnancy test

C

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

C,B,A,E,D

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

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? A) Alert the critical assessment team. B) Notify the health care provider. C) Conduct a focused assessment. D) Perform a comprehensive head-to-toe assessment.

Conduct a focused assessment. - the nurse would perform a focused assessment based on the observed neurological changes. The nurse would need to obtain more information before alerting the critical assessment team or contacting the health care provider; some actions would include completing the physical neurological exam, checking blood glucose, checking for changes in medications that may have contributed to the change in mental status, and reviewing the a.m. labs for abnormal sodium level.

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? A) Perform a musculoskeletal examination B) Take anthropometric measurements C) Obtain a 24-hour diet recall D) Collect subjective data related to overall function

D) Collect subjective data related to overall function

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? a) Focuses primarily on the client's physiologic development status b) Physiologic, psychological, sociocultural, developmental, and spiritual data c) Involves the client's musculoskeletal system and activities of daily living d) Focuses only on the client's psychological, sociocultural, and spiritual well-being

b) Physiologic, psychological, sociocultural, developmental, and spiritual data Explanation: A nursing health assessment includes physiologic, psychological, sociocultural, developmental, and spiritual data. Medical health assessment focuses primarily on the client's physiologic development status. The assessment by a physical therapist focuses mainly on the client's musculoskeletal system and activities of daily living.

** 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? A) The client's feelings of happiness B) The client's posture C) The client's affect D) The client's behavior

A

16. 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? A) Expansion of health care networks B) Decrease in client participation in care C) The shrinking cost of medical care D) Public mistrust of physicians

A

23. 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? A) Inspection B) Therapeutic communication C) Interviewing D) Active listening

A

26. 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 ìa bit sporadic.î How should the nurse best respond to this assessment finding? A) Identify a nursing diagnosis of Ineffective Health Maintenance. B) Identify a collaborative problem that should involve the occupational therapist. C) Make a referral to the unit's social work department. D) Reassess the client's blood glucose level.

A

7. 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? A) Assessment B) Planning C) Implementation D) Evaluation

A

8. 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? A) Reassess previously detected problems B) Provide information for the client's record C) Address areas previously omitted D) Determine the need for crisis intervention

A

***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? A) The client's motivation for change B) The client's medical comorbidities C) The client's learning style D) The client's prognosis for recovery

A) The client's motivation for change - The Health Belief Model is based on three concepts: the existence of sufficient motivation, the belief that one is susceptible or vulnerable to a serious problem, and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost.

13. 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? A) An 80-year-old client who lives with her daughter B) A 50-year-old client newly diagnosed with diabetes C) An adult presenting for an influenza vaccination D) A teenager seeking information about contraception

B

2. 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? A) Gastroenterologist B) ED nurse C) Admissions clerk D) Diagnostic technician

B

24. 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? A) Focus the assessment on the client as a member of her age group. B) Interpret the information about the client in context. C) Corroborate the client's statements with trusted sources. D) Gather information from a variety of sources.

B

3. 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? A) Each step is independent of the others. B) It is ongoing and continuous. C) It is used primarily in acute care settings. D) It involves independent nursing actions.

B

6. 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? A) Current physiologic status B) Effect of health on functional status C) Past medical history D) Motivation for adherence to treatment

B

9. 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? A) A 14-year-old girl who is crying because she thinks she is pregnant B) A 45-year-old man with chest pain and diaphoresis for 1 hour C) A 3-year-old child with fever, rash, and sore throat D) A 20-year-old man with a 3-inch shallow laceration on his leg

B

**The nurse has been assigned the following clients. Which client requires a focused assessment? A) A new admission with a history of congestive heart failure has 3+ pitting edema and shortness of breath with exertion. B) A client who underwent chest tube placement 2 hours prior with 250 mL output this past hour, an increase from 100 mL the hour before, reports feeling a little dizzy. C) A client admitted yesterday with hyperthyroidism with a heart rate of 110 has maintained a heart rate in the 80s for the past 24 hours. D) A postoperative client who underwent a laparoscopic cholecystectomy is ready for discharge.

B) A client who underwent chest tube placement 2 hours prior with 250 mL output this past hour, an increase from 100 mL the hour before, reports feeling a little dizzy. - (EXPLANATION) Output from drains should taper, not increase or decrease suddenly. Increased output from a chest tube and a client reporting dizziness could mean the client is losing too much blood. The nurse should perform a focused assessment on this client. A client with hyperthyroidism who has maintained a normal heart rate for 24 hours would require ongoing assessment. A new admission would require a comprehensive assessment. A client ready for discharge would require an ongoing assessment.

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? A) Review the client's medication administration record for analgesic use. B) Ask the client about the most recent experiences of pain. C) Meet with the client's spouse and daughter to discuss the client's pain. D) Collaborate with the physician who is treating the client.

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

How does a nurse best facilitate the nursing health assessment? A) Maintaining privacy B) Asking the appropriate questions C) Formulating a nursing diagnosis D) Creating a nursing care plan

B) Asking the appropriate questions

A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse? A) Intervene by pulling out the nasogastric tube. B) Assess the nasogastric tube for proper functioning. C) Evaluate output in an hour. D) Develop a plan of care.

B) Assess the nasogastric tube for proper functioning.

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? A) Body system B) Head-to-toe C) Functional D) Focused

B) Head-to-toe

**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. A) the client's tonsillectomy 45 years ago B) recent abnormal laboratory findings C) recent changes in the client's blood pressure readings D) the client's medical diagnosis E) the client's recent divorce

B) recent abnormal laboratory findings C) recent changes in the client's blood pressure readings D) the client's medical diagnosis

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. A) headache B) swelling C) photophobia D) redness around the site E) clear drainage on dressing

B) swelling D) redness around the site E) clear drainage on dressing EXPLANATION: Objective data are referred to as signs that can be observed and measured... a headache nor photophobia cannot be directly observed or measured.

An assessment that concentrates on patterns of role performance that all humans share is called what? A. Focused B. Functional C. Body systems D. Head-to-toe

B. Functional

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? A. the client's ability to communicate verbally B.the rapport that exists between the nurse and the client C. the type and degree of physical issues the client is experiencing D.the nurse's ability to ask relevant questions

B.the rapport that exists between the nurse and the client

**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? A) The client's age B) The unit's protocols C) The client's acuity D) The nurse's potential for liability

C

10. 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? A) Determine if pertinent data has been omitted B) Identify the need for referral C) Avoid biases and judgments D) Construct a plan of care

C

11. 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? A) Family history B) Occupation C) Appearance D) History of present health concern

C

25. 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? A) Comprehensive assessment B) Ongoing assessment C) Focused assessment D) Emergency assessment

C

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? A) Guaranteeing a continual assessment process B) Identifying abnormal data C) Assuring valid conclusions from analyzed data D) Allowing for drawing inferences and identifying problems

C

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? A) Collect objective data. B) Validate important data. C) Collect subjective data. D) Document the data.

C

When assisting a patient with health promotion, what must the nurse also nurture? A) School/work attendance B) Knowledge of the Healthy People 2020 indicators C) A healthy environment D) Family communication

C) A healthy environment - In order to assist a client with health promotion, a healthy environment must also be nurtured.

Before beginning a health assessment with a client, the nurse reviews Healthy People 2030 because of which of the following reasons? A) It serves as a guide for the health assessment. B) It addresses most client health problems. C) It identifies heath indicators, appropriate interventions, and resources. D) It helps determine the client's plan of care.

C) It identifies heath indicators, appropriate interventions, and resources. - (EXPLANATION) Healthy People 2030 is a framework that identifies heath indicators, appropriate interventions, and resources in the United States. The goals and objectives serve to improve the health of individuals and communities, targeting the next 10 years.

12. 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? A) Encourage the client to increase oral fluid intake. B) Provide the client with a bedtime protein snack. C) Assist the client with personal hygiene. D) Measure the client's blood glucose four times daily.

D

15. 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? A) Documentation B) Informatics C) Diversification D) Technology

D

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? A) Collecting accurate data B) Assisting the primary care provider C) Validating previous data D) Making clinical judgments

D

What are nurses able to detect through the health assessment? A) Areas that need continuous care B) Areas that need in-hospital care C) Areas that need referral to a specialist D) Areas in need of health adjustments

D) Areas in need of health adjustments

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? A) Identify the most appropriate forms of medical intervention for the client. B) Determine the most likely prognosis for the client's health problem. C) Identify the status of the client's airway, breathing, and circulation. D) Establish a baseline for the comparison of future health changes.

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

An instructor is describing a comprehensive nursing health assessment to a group of students. The instructor determines that the teaching was successful when the students identify which of the following as the overall purpose? A) Collect large quantity of data B) Assist the physician C) Validate previous data D) Make a clinical judgment

D) Make a clinical judgment

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history? A. cluster the data B. perform a physical examination C. document the findings D. determine a problem list

b. perform a physical examination[Rational: The health assessment includes a health history & physical examination. After completing the health history, nurse should complete physical examination. Clustering data & determining a problem list would occur after the physical examination is complete. Documentation of the findings would occur while conducting the health history & after completing the physical examination. p 5]