Prep U TTE The Nurses Role in Health Assessment: Collecting and Analyzing data

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 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 the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments?

"Nurses focus on the diagnosis of actual human responses to disease or life events."

During a health assessment, a client shares, "I get a little dizzy when I get up from my chair too quickly." Which question will the nurse ask the client first when attempting to identify client needs and potential health risks?

"What do you mean by 'a little dizzy'?"

When the nurse is performing a physical examination on admission of a client to the medical unit, the client says the doctor already did an exam. The best response by the nurse would be

"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."

A student nurse is learning to document an initial assessment. What would theinstructor tell the student that accurate documentation of this specific assessment best provides?

A baseline for comparison with future findings

The nurse is admitting a client to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment?

A focused assessment is more in-depth on specific issues, unlike a comprehensive assessment

When assisting a client with health promotion, what must the nurse also nurture?

A healthy environment

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

Which assessment finding should the nurse document as objective data?

Body functions

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?

Collect subjective and objective data related to overall function

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

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?

Diagnosis

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

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?

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?

Empathy

Revising the plan as needed occurs in what part of the nursing process?

Evaluation

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

What are the primary frameworks used in conducting a health assessment? Select all that apply.

Head to toe Body systems Functional systems

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 nurse is working with an obese man who has type II diabetes mellitus. After interviewing this client, the nurse has established that he is aware of the seriousness and risks of his conditions, is motivated to make lifestyle changes to improve his health, and believes that following the diet and exercise plan that the nurse has helped him create is feasible and would be effective in helping him meet his health goals. The nurse is using which of the following tools or resources in assessment of this client?

Health Belief Model

The nurse prepared to complete a comprehensive health assessment on a client in the community. What should the nurse expect to complete when performing this assessment? Select all that apply.

Health history Physical examination

After a health assessment the nurse determines that a client would benefit from health promotion interventions. Which item should the nurse refer to when determining the best actions for the client?

Healthy People 2020

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 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

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

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

How does a nurse decide what health-promotion activities are necessary for a particular client?

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

The client has a murmur. This is what type of data?

Objective

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

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 nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history?

Perform Physical Examination

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

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

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 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

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

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to

arrive at conclusions about the client's health.

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.

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

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

comprehensive

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

physiologic status

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first

review the client's health care record

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

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?"

When making rounds, the RN should prioritize follow-up care for which client?

An oncology client with a cough but no fever

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment?

Body systems

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 client presents to the health care facility with reports of new onset of chest pain of 3 days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse to perform for this client?

Comprehensive

What is one way nurses use critical thinking in regard to the nursing process?

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

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

What are the types of nursing assessments? (Select all that apply.)

Focused Emergency Comprehensive

For which client should a nurse perform a focused assessment?

Four-day history of sore throat and fever with enlarged lymph nodes

An assessment that concentrates on patterns of role performance that all humans share is called what?

Functional

The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students know that this type of information is assessed in what type of assessment?

Functional

Which of the following is an example of a recent trend in nursing roles?

Gathering forensic evidence for a legal proceeding

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

As a nurse becomes more proficient and comfortable in his or her role, what increases?

Knowledge base and experience

A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?

Nursing Process

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 cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing?

Ongoing

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 client's airway

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

Shortness of breath

Why is the nurse always reassessing the client for changes?

To achieve the best results

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

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 recognizes the value of the Healthy People 2020 guidelines when creating a plan of care that addresses which client-centered goals? Select all that apply

living a healthy lifestyle disease prevention improving one's quality of life increasing the longevity of one's life

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