Health Assessment Chapter 1-2 Practice Qu
Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern?
"Do you have family who visit you regularly?"
When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient says the doctor already did an exam. The best response by the nurse would be
"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."
When assisting a patient with health promotion, what must the nurse also nurture?
A healthy environment
A new RN tells her preceptor that she has always had trouble remembering all the steps of the nursing process. The preceptor tells the new grad that an easy way is to think about the anagram
ADPIE--assessment, diagnosis, planning, implementation, evaluation
How does a nurse best facilitate the nursing health assessment?
Asking the appropriate questions
The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step?
Diagnostic reasoning skills are required to interpret data accurately.
Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of
Healthy People 2020
The nurse gathers the following data: complaint of headache and sore throat, redness noted on pharynx with white exudates on tonsils, minimal cough, temperature 100.6F orally. It was noted that the patient had another sore throat 2 weeks ago. The most appropriate nursing diagnosis for this data would be
Impaired comfort related to headache and sore throat pain
After collecting subjective and objective data for the admission database, what is the nurse's next action?
Validate the client's identified problems
The nurse observes no urine output in a client's indwelling urinary catheter drainage bag. What is the nurse's first action?
Verify positioning of the catheter
A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data?
anxious appearance
The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should
avoid premature judgments about the client
When planning a community program related to Healthy People 2020, the critical first step involves
defining the community
While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process?
emotional
OLD CART is a mnemonic that will help the nurse remember the steps in the nursing process
false
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)
focused or problem-oriented assessment
A patient who is 2 days postoperative reports pain and requests pain medication. After assessing the patient's pain level, the nurse decides to give the patient oral Percocet instead of intravenous morphine. The nurse is doing which step of the nursing process?
implementation
The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following?
nursing diagnosis
Which statement would demonstrate the correct method for writing an evaluation of patient progress after implementing the nursing process?
patient ambulated 3/3 times during a planned 8-hour period
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
physiologic status
The nurse is developing goals after completing the assessment of a newly admitted medical patient. The nurse would document the goals under which part of the nursing process?
planning
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
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
take a complete health history
The nurse discusses ear plugs for a patient with low tone deafness when working in a noisy environment. The nurse is utilizing
tertiary prevention
What is the primary function of the health care team?
to decide the best overall care
Subjective and objective data are both important parts of an assessment. Subjective data are things the patient or his or her family tells the nurse.
true
When clustering data, age can be a factor in determining the number of nursing diagnoses. The younger child typically has one diagnosis because he or she is more likely to have a single disease.
true
A client presents to the emergency department following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states he cannot feel his leg. The nurse notes that the client is lethargic and mildly confused. What subjective data should the nurse document on this client?
unable to feel his leg
One characteristic of a nurse who is a critical thinker is the ability to
validate information and judgments
The nurse recognizes the following to be a necessary component of performing an accurate assessment. (Select all that apply.)
collection an organization of data validation of data documentation of data
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
comprehensive
Although the assessment phase of the nursing process precedes the other phases, the assessment phase is
continuous
The depth and scope of nursing assessment has expanded significantly over the past several decades primarily because of
rapid advances in biomedical knowledge and technology
A hospital nurse is in the process of analyzing physical assessment data the nurse has collected on a patient. Which characteristics of critical thinking should the nurse employ in the analysis? Select all that apply.
reflect on thoughts before reaching a conclusion use past clinical experience to build knowledge use rationale to support opinions and decisions
The nurse is grouping subjective and objective data. Which data would the nurse list as subjective?
headaches began 3 days ago
Considering the acronym OLD CART, the nurse is asking a newly admitted patient questions during the assessment process. The patient is a 35-year-old man who presents with pain in the upper arm since lifting weights 3 days ago. What question would be appropriate to ask that would give information for the "D" in the acronym?
"Does the pain come and go or is it constant?"
When answering questions about health during a presentation at a women's club luncheon, the nurse emphasizes that prevention of disease is multifaceted but is connected directly to
a healthy lifestyle
When utilizing the website www.healthypeople.gov, the nurse notes completion of the first two areas in the acronym MAP-IT while working on a project for a Hispanic community within a large city. What action by the nurse would fulfill the next step in this process?
developing a goal for the community involved
The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to
discuss the plan with the patient
During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is
primary prevention