Jensen Chapter One

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?"

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

A 45-year-old man with chest pain and diaphoresis for 1 hour

The nurse is analyzing the data obtained from the following clients. Which client would the nurse expect to facilitate a referral?

A 50-year-old client newly diagnosed with diabetes

Which skill does the nurse need to obtain subjective data during the initial comprehensive assessment?

Empathy

The nurse is performing a health assessment on a community-dwelling client who is recovering from hip replacement surgery. Which of the following actions should the nurse prioritize during assessment?

Interpret the information about the client in context.

The nurse prepares to collect objective data on a client new to a health clinic. What will the nurse use to collect this data? Select all that apply

Palpation Inspection Percussion Auscultation

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 Explanation:

The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first?

Review the client's medical record.

What are the components of the SBAR? Select all that apply.

Situation Background Assessment Recommendation

Why is it important for a new nurse, working on a step-down unit, to know the standards of care for the facility in which the nurse is working?

Standards of care often set the time frame for assessing the clients on the unit

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

appearance

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

comprehensive.

The client has been seen in this office for the past five years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?

focused assessment

tertairy prevention

focuses on preventing complications of an existing disease and promoting health to the highest level. ex) Diet teaching and exercise programs

The three major frameworks to organize assessment findings include the functional assessment based on Gordon's functional patterns, the systematic ___________ assessment, and body systems assessment.

head to toe

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 pt's airways

Evidence-based nursing provides individualized nursing care from best _____________ and scientific findings.

research

There are 10 areas of focus in the U.S. Department of Health and Human Services Healthy People 2020 which provides strategies based on health promotion and ___________ reduction strategies.

risk

primary prevention

strategies that lead to preventing disease/problem ex) immunizations, health teaching, safety precautions, and nutrition counseling

Health assessment is the first step of the nursing process and includes the health assessment, which is _______________ data, and the physical assessment, which is ______________ data.

subjective objective

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

After completing a health history, the nurse determines that a patient would benefit from interventions to address the Healthy People 2020 indicator associated with the prevalence and mortality of chronic disease. What assessment data would related to this indicator? (Select all that apply.)

Prescribed medication for hypertension Diagnosed with heart disease three years ago Skin cancer lesion removed surgically four years ago

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 who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable?

The client's acuity

While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process?

emotional

t/f: The purpose of the nurse performing the health assessment is to discover symptoms that support the medical diagnosis.

false

t/f: Five nursing values are used by the nurse to guide professional roles.

true

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?

The client's motivation for change

Diagnostic reasoning is a seven-step process of _____________________; the nurse gathers and clusters data, draws inferences, and develops nursing diagnoses.

critical thinking

t/f: The type of assessment used during a life-threatening situation is the focused assessment.

false

t/f: the nursing process consists of three parts: assessment, planning, and evaluation.

false

secondary prevention

includes the early diagnosis of health problems and prompts treatment to prevent complications. ex) Vision screening, Pap smears, BP screening, hearing testing, scoliosis screening, and tuberculin skin testing

t/f:According to the American Nurses Association, the professional nurse's role involves four broad areas that define nursing practice.

true