Health Assessment Prep U Chapter 1
When assisting a client with health promotion, what must the nurse also nurture?
A healthy environment
A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest prioroty by the staff triaging the client?
Airway
How does a nurse facilitate the nursing health assessment?
Asking the appropriate questions
Using both verbal and nonverbal clues given by the client, what is the nurse constantly doing?
Assessing
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
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?
Critical thinking
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?
Empathy
During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. What category of health is affecting this client?
Environmental
An assessment that concentrates on patterns of role performance that all humans share is called what?
Functional
The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive data. What assessment is the preceptor talking about?
Head-to-toe
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 it implications for lifelong health.
A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?
I'm sorry, but assessment is ongoing and continuous.
The nurse prepares to analyze a list of a client's health problems. In which order will the nurse complete critical thinking of these problems?
Identify abnormal data and strengths Cluster the data Draw inferences and identify problems Propose possible nursing diagnoses Check for defining characteristics of the diagnoses Conform or rule out nursing diagnoses
When doing an overall assessment of a client, the nurse is able to utilize findings and do what?
Identify in what areas the client needs the most care
As a nurse becomes more proficient and comfortable in his or her role, what increases?
Knowledge base and expertise
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, read the client's chart and questions the nurse. The supervisor should point out to the nurse that which of the following error is most likely to occur due to the nurse's lapse?
Making incorrect nursing judgements or diagnoses
What is an example of assessment in everyday life?
Measuring the remaining tread on a car tire to determine whether it is time to replace it
A client asks why the nurse and the healthcare provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments?
Nurses focus on the diagnosis of actual human responses to disease or life events.
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 an example of?
Nursing Intervention
After receiving morning report the nurse prepares to assess a client who was admitted the night before. Which type of assessment will the nurse complete at this time?
Ongoing
A nurse recommends that a client come back once every 3 months in the coming year to heave his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?
Ongoing or partial
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 exhibiting critical thinking in which client care situation?
Performing a focused assessment on a client who is complaining of shortness of breath
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 RN is implementing which level of intervention when administering immunizations at a pediatric clinic?
Primary
What is the primary function of the health care team?
To decide the best overall care
A nurse provides care for a client with impaired respiratory function. The nurse frequently assess the client's skin color and temperature of the extremities. What is the purpose of the ongoing or partial assessment?
To determine any changes from the baseline data
A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?
To establish a database against which subsequent assessments can be measured.
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.
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 a client first enters the hospital for an elective surgical procedure, the nurse should perform as assessment termed
comprehensive.
An assessment of a client who already has a complete recorded database in the system and returns to the healthcare agency with a specific concern is referred to as a(n)
focused or problem-oriented assessment
The result of a nursing assessment is the
formulation of nursing diagnoses.
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
physiologic status
When a 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 get information concerning why the client is crying?
the rapport that exists between the nurse and the client
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 if the client has achieved the outcome criteria of the treatment?
Evaluation
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 paramount in health promotion?
Working with the individual client Developing the nursing care plan
Before beginning a comprehensive assessment of an adult client, the nurse should explain the the client that the purpose of the assessment is to
arrive at conclusions about the client's health
When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?
Diagnosis
How does a nurse decide what health-promotion activities are necessary for a particular client?
Nurse collaborate with clients to identify areas in which clients are willing to make changes.
The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions.
Use evidence-based techniques.