PrepU - CH.1 Nurse's role in health assessment: collecting and analyzing data
When assisting a client with health promotion, what must the nurse also nurture?
A healthy environment
The client has a murmur. This is what type of data?
Objective
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
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
Revising the plan as needed occurs in what part of the nursing process?
Evaluation
What are the types of nursing assessments? (Select all that apply.)
-Focused -Emergency -Comprehensive
A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides?
A baseline for comparison with future findings
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?
Head-to-toe
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
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?"
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?
"I'm going to assess the client now so that I can begin formulating the care plan."
A nurse has completed assessment of a client with Alzheimer's disease and documentation of the information obtained from the client and now needs to analyze the data collected. Which nursing actions should be included in this phase of the nursing process? Select all that apply.
-Identification of collaborative problems -Identification of the need for referrals -Formulation of nursing diagnosis(es)
What are nurses able to detect through the health assessment?
Areas in need of health adjustments
An assessment that concentrates on patterns of role performance that all humans share is called what?
Functional
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 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, reads the client's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?
Making incorrect nursing judgments or diagnoses
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?
To determine any changes from the baseline data
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
physiologic status.
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 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."
A client asks why a health assessment needs to be done. What should the nurse respond to this client?
"It determines your health status, risk factors and educational needs to develop a plan of care."
The nurse is completing an admission database entry and must include priority nursing diagnoses for the plan of care. Which statement describes a nursing diagnosis?
A clinical judgment about client responses to health difficulties.
How does a nurse best facilitate the nursing health assessment?
Asking the appropriate questions
When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?
Diagnosis
A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use?
Diagnostic reasoning
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
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
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
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
Which of the following is the best example of assessment in everyday life?
Measuring the remaining tread on a car tire to determine whether it is time to replace it
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?
Ongoing or partial
The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?
Primary
A client admitted with reports of nausea and vomiting has not reported any vomiting in the last 6 hours. What initial response should the nurse have regarding this assessment information and its effect on the client's nursing plan of care?
Recognize the need to reevaluate the client's plan of care.
A nurse is working with a client who has AIDS. Which of the following is an example of subjective data that might be gathered for this client?
The client's pain level
A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data?
The client's range of motion in her right arm
What is the primary function of the health care team?
To decide the best overall care
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 a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
comprehensive.
During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?
environmental
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.
The result of a nursing assessment is the
formulation of nursing diagnoses.
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
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? Drag statements into the proper order.
-Identify abnormal data and strengths -Cluster the data --Draw inferences and identify problems -Propose possible nursing diagnoses -Check for defining characteristics of the diagnoses -Confirm or rule out nursing diagnoses
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?
Airway
A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?
Nursing process
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?
Uses evidence-based techniques
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?
Ongoing
The nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what?
Head to toe
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
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?
Nursing intervention
A nurse is admitting a client, having completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data?
Objective
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.
