Chapter 1: The Nurse's Role in Health Assessment

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.

"I feel so tired sometimes." Client complains of a headache "My father died of a heart attack." Rationale: Subjective data include information obtained from the client through interviewing and therapeutic communication skills and are sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Feeling tired, complaints of a headache, and the statement about the client's father dying of a heart attack reflect subjective information. Weight, lung sounds, and pupil reaction are examples of objective data.

The nurse recognizes the goals and objectives of the Healthy People 2030 guidelines when creating a plan of care that addresses which client-centered goal(s)? Select all that apply.

- living a healthy lifestyle - disease prevention - improving one's quality of life - increasing the longevity of one's life Rationale: The goals and objectives of Healthy People 2030 include promoting a healthy lifestyle, disease prevention, improved quality of life, and length of a person's life. Although important to the general wellness achieved by any individual, health care costs are not addressed by the Healthy People 2030 guidelines.

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which client would the nurse most likely expect to facilitate a referral?

A 50-year-old client newly diagnosed with diabetes Rationale: During the comprehensive assessment, the nurse identifies problems that require the assistance of other health care professionals. A client who is newly diagnosed with diabetes would benefit from a referral to a diabetes education program. Assistance from other health care professionals would not necessarily be required for the older adult client, the client wanting a vaccination, or the teenager seeking information.

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 Rationale: Accurate documentation provides a baseline so that changes are noted between assessments.

The nurse is collecting data from a client. Which of the following best reflects objective data?

Appearance Rationale: Appearance is something that can be directly observed by the nurse and is considered objective data. Religion and occupation are biographical data that are considered subjective. Age is considered to be subjective data because it is reported by the client. The nurse should assess whether the client appears to be their stated age.

When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?

Diagnosis Rationale: Diagnosis occurs when the data has been analyzed and a professional judgment occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan. Evaluation assesses whether the outcome criteria have been met.

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 Rationale: Empathy is an intuitive awareness of what the client is going through; it helps the nurse to be effective in providing for the client's needs while remaining compassionately detached. Inspection and palpation are skills that help the nurse in collecting objective data of the client's physical characteristics. Sympathy is a feeling that would make the nurse as emotionally distraught as the client; this hampers the ability of the nurse to provide client care.

The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg, O2 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

Evaluate an outcome. Rationale: The nurse has already assessed the client, analyzed the data, determined the client was hyperthermic (nursing diagnosis), and administered a medication (implemented an intervention); therefore, the next step is to evaluate the client's response.

A client has been admitted with new onset hypertension with a past medical history of asthma, type 2 diabetes, and hypercholesterolemia. After developing a nursing care plan, the nurse reports findings to the health care provider. After receiving medication orders from the health care provider, the nurse administers several medications for hypertension. What is the next best action of the nurse?

Evaluate patient outcome. Rationale: The nurse should evaluate the effectiveness of the antihypertensive medications. The plan of care will not be updated until the interventions are evaluated. Nursing diagnosis and comprehensive assessments have already been completed.

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?

Expansion of health care networks Rationale: Opportunities for nurses with advanced assessment skills will be enhanced by the expansion of health service networks, increasing complexity of acute care, growing aging population with complex morbidities, expanding health care needs of single parents, increasing impact of children and homeless on communities, intensifying mental health issues, and increasing reimbursement for health care promotion and preventive services. Public mistrust of physicians is not a noted phenomenon.

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?

Focused assessment Rationale: The nurse would most likely perform a focused assessment, which is done when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A comprehensive assessment is completed for this client when he or she first visited the office. An ongoing assessment is completed to evaluate problems identified earlier, to determine any changes. This would be the type of assessment done when the client returns after receiving treatment for current complaints. An emergency assessment is done if the client presented with with a life-threatening complaint or problem.

For which client should a nurse perform a focused assessment?

Four-day history of sore throat and fever with enlarged lymph nodes Rationale: A client with a sore throat and fever with enlarged lymph nodes requires only a focused assessment by the nurse. A focused assessment consists of a thorough assessment of a particular client problem. An elevated blood pressure with no previous history of heart problems requires an initial or comprehensive assessment. Right upper abdominal pain that radiates into the groin area is an emergency situation and the nurse should collect only the data necessary to make a quick diagnosis for immediate treatment. A client with diabetes has a chronic, ongoing health problem that needs reassessment and possibly a change in treatment.

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 2030 Rationale: Healthy People 2030 is a government project intended to increase the quality of life for people in the United States.

A few nursing students revealed to a faculty advisor that they were concerned about the effects of their program demands on their personal health practices. Follow-up with other students indicated that this was a common concern among the student group. Further assessment showed that the students expressed their belief in the importance of maintaining good health practices, but that most students had discontinued weekday efforts because of their focus on school-related stress and limited economic resources. Faculty members supported the concept of integrated health programs and were prepared to develop a program as a project. To assess the need for health promotion among the group of students, which of the following assessment methods would be most useful?

Individual student interview and questionnaire Rationale: Key to any health promotion activity is a thorough assessment of the context and particular needs of the participants. This could be best determined by asking the students what would be more effective than a physical assessment, literature review, tour of the facility, or questionnaire of the faculty members.

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?

Inspection Rationale:Interviewing, therapeutic communication, caring, empathy, and listening skills are needed to obtain subjective data. Inspection, palpation, percussion, and auscultation are used to collect objective data.

Before beginning a health assessment with a client, the nurse reviews Healthy People 2030 because of which of the following reasons?

It identifies heath indicators, appropriate interventions, and resources. Rationale: 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. Its overall goal is to increase quality of life by creating guidelines for a healthy lifestyle as well as educating people and cultivating an awareness that will assist in the elimination of health disparities. Healthy People 2030 does not help determine every client's plan of care. Healthy People 2030 does not serve as a guide for the health assessment nor does it list specific interventions to address specific health problems. Instead, Healthy People 2030 indicators pertinent to individuals are determined as the nurse completes the health assessment on each patient.

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 Rationale: Nursing interventions are used to monitor health status; prevent, resolve, or control a problem; assist with ADLs; or promote optimum health and independence. Nursing goals are the client's desired outcomes. Nursing evaluation is deciding whether the nursing goals have been reached. Nursing assessment is an overview of the client's health status and current problems.

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 Rationale: An ongoing or client assessment occurs after the comprehensive database is established. It is a mini overview of the client's body systems. The initial assessment was completed upon admission. A focused assessment is completed when the database for a client already exists and the client is experiencing a specific problem. An emergency assessment is completed in a life-threatening situation.

Nurses provide both direct and indirect care. What is an example of indirect care?

Participating in a client care conference Rationale: Nurses provide direct care to help restore health for clients with illness in hospitals, clinics, long-term care facilities, and schools. Therefore, adjusting an IV rate, figuring out a medication dosage, and filling out a nursing assessment are all examples of direct client care. The only example of indirect client care is participating in a client care conference.

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. Rationale: The nurse investigating a client problem by performing a focused assessment is exhibiting critical thinking. Transcribing orders, calling a healthcare provider, and answering a call bell are not examples of critical thinking that entail outcome-directed thinking based on the nursing process.

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?

Primary Rationale: Primary prevention involves strategies aimed at preventing problems. Immunizations, health teaching, safety precautions, and nutrition counseling are examples. Secondary prevention includes the early diagnosis of health problems and prompts treatment to prevent complications. Vision screening, Pap smears, blood pressure screening, hearing testing, scoliosis screening, and tuberculin skin testing are examples. Tertiary prevention focuses on preventing complications of an existing disease and helping the client achieve the highest possible level of health. Teaching clients with diabetes about diet, teaching clients with lung disease about use of inhalers, and developing exercise programs for those who have had myocardial infarction are examples. A holistic approach to health care may be applied to all levels of interventions but is not a "level" of intervention itself.

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?

Reassess previously detected problems Rationale: A periodic partial assessment consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes from the baseline data. In addition, a brief reassessment of the client's normal body system or holistic health patterns is performed whenever the nurse or another health care professional has an encounter with the client.

Following completion of the comprehensive health assessment, the nurse periodically performs a partial assessment primarily for which reason?

Reassess previously detected problems Rationale: A periodic partial assessment consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on his or her health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes from the baseline data. In addition, a brief reassessment of the client's normal body system or holistic health patterns is performed whenever the nurse or another health care professional has an encounter with the client.

In which situation should a nurse perform an emergency assessment of a client?

Shortness of breath Rationale: An emergency assessment is a very rapid assessment performed in life threatening situations such as drowning, choking, or cardiac arrest. It is also used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. Shortness of breath requires an emergency assessment to promptly assess the client's ability to maintain an adequate airway. A broken arm, body rash, and ear pain require a focused assessment to gather information specific to the problem.

A community health nurse is assessing an older adult client in their home. When the nurse is gathering subjective data, which of the following would the nurse identify?

The client's feelings of happiness Rationale: 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, affect, and behavior are observable and are thus considered objective data.

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 Rationale: Subjective data are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Objective data are what the nurse directly observes when examining the client, such as the range of motion in the client's right arm.

A nurse on the subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice?

The focused assessment addresses a particular client problem. Rationale: A focused assessment gathers specific data for a particular client problem usually discovered during the physical exam. This assessment "focuses" on the particular problem only and does not cover areas unrelated to the problem.

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 Rationale: Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment (emergency assessment). Evaluation is done after an intervention to determine whether the outcomes have been achieved.

The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next?

Validate that the client understands how to use the inhalers. Rationale: The nurse should not assume that the client knows how to administer their medications. The nurse should always validate information, for example, that the client knows how to properly administer the inhalers. If the nurse does not validate that the client knows how to properly administer medication, the treatment may be ineffective.

After performing a comprehensive assessment on a client, the nurse notes the following. Which part of the nursing process is the nurse performing? Nursing Notes: ● Client reports pain in bilateral lower extremities when walking short distances, relieved with rest. ● Pulses are weak, barely palpable in bilateral lower extremities. ● Bilateral feet are cool to touch ● Total cholesterol > 200. ● Client smokes two packs of cigarettes daily for past 20 years.

analysis of assessment findings Rationale: The nurse is analyzing the findings by clustering the cues collected during assessment to determine if a client concern (nursing problem) exists. The notes contain both subjective and objective information related to peripheral arterial disease. The nurse would develop a problem-based plan based on these cues of impaired tissue perfusion and develop and implement interventions to improve the client's circulation. Documentation of the subjective assessment findings occurs during assessment. Once the assessment findings are analyzed, priority nursing diagnoses will be developed and interventions implemented.

A home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct?

focused Rationale: A focused assessment is conducted to assess a specific problem. In this case, the nurse would ask the client about urinary frequency, bowel movements, and diet, and then take vital signs and assess the abdomen. Comprehensive assessments include a detailed health history and physical assessment; ongoing partial assessments are conducted at regular intervals, and emergency assessments are carried out in emergency situations (such as prior to CPR).

An 85-year-old client is being discharged home. Which assessment should the nurse perform to ensure safety? Select all that apply.

mobility sensory structure of the home support system Rationale: To ensure client safety for an older client, the nurse should conduct several focused assessments: mobility (does the client require an assistive device such as a walker); sensory (especially in older adults, visual problems can lead to falls, and decreased sense of smell or taste can lead to fire safety issues or food poisoning); structure of the home (is there a ramp to gain entry into the home; will the client have to ascend stairs); support system (does the client live alone). Other factors that place clients at risk for falls are also considered, such as medications and lines/airway devices (oxygen tanks). Income is not a consideration when assessing home safety.

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

physiologic status. Rationale: The physician performing a medical assessment focuses primarily on the client's physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is

primary prevention Rationale: Exercise and healthy eating improve wellness and help protect from disease and disability, which is primary prevention.

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 Rationale: As a nurse, it is vital to sift through all the client information and make decisions on what information will impact client safety and quality of care. The ability to identify what is important on a daily basis for each individual client is paramount for nursing care. Of the data provided, the client's impaired hearing poses the greatest safety risk and has the greatest impact on the client's quality of life and so has priority. While the other options could be potential factors related to quality of life and safety, the nurse will need to assess them further.

The nurse is assigned the following clients. Which client requires an emergency assessment?

the client who underwent a hysterectomy yesterday and is now reporting shortness of breath and has decreased oxygen saturations Rationale: A client reporting difficulty breathing and who has decreased saturations requires an emergency assessment. This client might be suffering from a pulmonary embolism. Pain after surgery is common; this client would require a focused assessment. Some tingling and numbness in the fingers is common after a cast is placed; this client needs a focused assessment. The nurse would conduct an ongoing/partial assessment on a client with chest pain that has been relieved.