Health Ch 1 Prep U Analyzing data to make accurate clinical judgments
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 3 clients whose care involves complex situations and multiple responsibilities. What is the key resolving problems for this nurse?
critical thinking
When the nurse clusters the data to make a judgement or statement about the client's condition, this is known as what?
diagnosis
A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time?
emergency
A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation on 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. Which category of health is affecting this client?
environmental
Revising the plan as needed occurs in what part of the nursing process?
evaluation
Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next?
evaluation
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
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
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 10 times every hour. What is this action an example of?
nursing intervention
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
A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take?
perform an emergency assessment
The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?
The seriousness of a client's condition
A student 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
When assisting a client with health promotion, what must the nurse also nurture?
a healthy environment
What are nurses able to detect through the health assessment?
areas in need of health adjustments
How does a nurse bast facilitate the nursing health assessment?
asking the appropriate questions
A client who underwent abdominal surgery this morning reports feeling weak and dizzy. The nurse also observed a decrease in urine output in the last hour. What action should the nurse take first?
assess the client
Consider the nurse's role in the health assessment of a client. What action will the nurse perform initially when admitting a client to a long term care facility?
collecting information regarding the client's health status
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 use findings for which primary purpose?
identify in what areas the client needs the most care
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 judgements or diagnoses
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
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 priority?
significantly impaired hearing
A nurse is performing a focused assessment on a client admitted with symptoms of meningitis who underwent a lumbar puncture this morning and is now reporting a headache and photophobia. The nurse identifies clear drainage on the dressing and redness and swelling around the sire. The nurse documents which of the following objective findings in the chart? Select all that apply
swelling redness around the site clear drainage on dressing
The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes in inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following?
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?
to determine any changes from the baseline data
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
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"
Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the US". The educator bases her response on the knowledge of
Healthy people 2030
A client has been admitted with new onset of 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 nest best action of the nurse?
evaluate patient outcome
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
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
focused or problem-oriented assessment
