NURS 224: Nurse's Role in Health Assessment

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) Determine any changes from the baseline data b) Collect subjective data related to the client's overall health c) Perform a rapid assessment for prompt treatment d) Evaluate whether outcomes of treatment are met

a) Determine any changes from the baseline data

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) Inspection

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

Nurses provide both direct and indirect care. What is an example of indirect care? a) Participating in a client care conference b) Adjusting an IV rate c) Calculating a medication dosage d) Completing a nursing assessment

a) Participating in a client care conference

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

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment? a) To determine any changes from the baseline data b) To collect subjective data related to the client's overall health c) To perform a rapid assessment for prompt treatment d) To evaluate whether outcomes of treatment are met

a) To determine any changes from the baseline data

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

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) A 50-year-old client newly diagnosed with diabetes

A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client? a) Breathing b) Airway c) Circulation d) Disability

b) Airway

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 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) Collect subjective data related to overall function c) Take anthropometric measurements d) Obtain a 24-hour diet recall

b) Collect subjective data related to overall function

A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process? a) Interjection of the nurse's thoughts or feelings into the data b) Making incorrect nursing judgments or diagnoses c) Relying on objective and subjective information d) Validating information that is already correct

b) Making incorrect nursing judgments or diagnoses

How does a nurse decide what health-promotion activities are necessary for a particular client? a) Nurses address areas associated with healthy behaviors only b) Nurses collaborate with clients to identify areas in which clients are willing to make changes c) Nurses assess areas in which clients are willing to make changes only d) Nurses construct their own theories to identify perceptions, barriers, and positive outcomes

b) Nurses collaborate with clients to identify areas in which clients are willing to make changes

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) Initial comprehensive b) Ongoing or partial c) Focused or problem-oriented d) Emergency

b) Ongoing or partial

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) ongoing or partial assessment. b) focused or problem-oriented assessment. c) emergency assessment. d) initial comprehensive assessment.

b) focused or problem-oriented assessment.

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? a) lives alone b) significantly impaired hearing c) widowed 2 years ago d) greatly concerned about cost of services

b) significantly impaired hearing

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

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

The nurse is collecting data from a client. Which of the following best reflects objective data? a) Religion b) Occupation c) Appearance d) Age

c) Appearance

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) Assuring valid conclusions from analyzed data

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) Avoid biases and judgments

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain? a) Teaching the client to draw knees to chest to help minimize the pain b) Planning care to help minimize the client's pain c) Collecting data regarding the nature of the pain d) Identifying pain management interventions with input from the client

c) Collecting data regarding the nature of the pain

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) Focused assessment

When doing an overall assessment of a client, the nurse is able to utilize findings and do what? a) Identify what level of prevention the client is at b) Identify in what areas the client can educate his or her family c) Identify in what areas the client needs the most care d) Identify the client's medical diagnosis

c) Identify in what areas the client needs the most care

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time? a) Initial b) Focused c) Ongoing d) Emergency

c) Ongoing

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) The focused assessment addresses a particular client problem.

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? a) "Fortunately, assessment only needs to be done at the beginning of your stay." b) "I'll just need to evaluate you once more, at the end of your stay." c) "Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end." d) "I'm sorry, but assessment is ongoing and continuous."

d) "I'm sorry, but assessment is ongoing and continuous."

An adult client is being admitted to the hospital for a cardiac catheterization related to chest pain and shortness of breath on exertion. What kind of assessment is the admitting nurse going to perform? a) Focused b) Comprehensive c) None, the cardiac catheterization will provide all needed information d) Emergency

d) Emergency

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? a) Inspection b) Palpation c) Sympathy d) Empathy

d) Empathy

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.

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 whether the client has achieved the outcome criteria of the treatment? a) Assessment b) Diagnosis c) Implementation d) Evaluation

d) Evaluation

Revising the plan as needed occurs in what part of the nursing process? a) Assessment b) Diagnosis c) Planning d) Evaluation

d) Evaluation

A nurse is preparing to interview a client who is a Seventh Day Adventist. The nurse does not agree with this religion's view of modern medicine. Reflection of the nurse on her personal feelings regarding this client and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation? a) Initiation of a referral that the client doesn't want b) Omission of pertinent data needed to make a diagnosis c) Performance of unnecessary diagnostic tests d) Formation of judgments that may interfere with the interview

d) Formation of judgments that may interfere with the interview

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) Measure the client's blood glucose four times daily.

The nurse is exhibiting critical thinking in which client care situation? a) Transcribing medication orders onto the nurse's medication administration record. b) Notifying the healthcare provider of a critical lab result. c) Answering the client's call bell alarm while the nursing assistant is at lunch. d) Performing a focused assessment on a client who is complaining of shortness of breath.

d) Performing a focused assessment on a client who is complaining of shortness of breath.