PrepU Ch.1

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? A) "Do you have family who visit you regularly?" B) "What amount of cleaning have you been doing in the past?" C) "Have you tried to schedule a cleaning service?" D) "Are you friendly with your neighbors?"

"Do you have family who visit you regularly?" Ref: (ch.1 pg.4)

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) Data on the patient's prognosis for recovery B) Information on the effectiveness of interventions C) A baseline for comparison with future findings D) Information on the nurse's cultural competence

A baseline for comparison with future findings Ref: (ch.1 pg.6)

What are nurses able to detect through the health assessment? A) Areas that need continuous care B) Areas that need in-hospital care C) Areas that need referral to a specialist D) Areas in need of health adjustments

Areas in need of health adjustments Explanation: Through the health assessment nurses are able to detect areas in need of health adjustments

What is paramount in health promotion? (Select all that apply.) A) Working with the individual patient B) Demonstrating authority C) Emphasizing the risks of poor health practices D) Developing the nursing care plan E) Limiting the involvements of the patient's friends and family

Developing the nursing care plan & Working with the individual patient Ref: (ch.1 pg.5)

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? A) Inspection B) Palpation C) Sympathy D) Empathy

Empathy Explanation: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. Ref: (ch.1 pg 9)

Revising the plan as needed occurs in what part of the nursing process? A) Assessment B) Diagnosis C) Planning D) Evaluation

Evaluation Ref:(ch.1 pg.4)

Which of the following is an example of a recent trend in nursing roles? A) Gathering forensic evidence for a legal proceeding B) Using auscultation to examine heart sounds C) Using palpation to assess the abdomen of a pregnant woman D) Performing visual inspection of a client's eyes to detect illness

Gathering forensic evidence for a legal proceeding Ref: (ch.1 pg.3)

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? A) Nursing Intervention B) Nursing goal C) Nursing evaluation D) Nursing assessment

Nursing Intervention Ref: (ch.1 pg 9)

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? A) "Fortunately, assessment only needs to be done at the beginning of your stay." B) "I'll just need to evaluate you once more, at the end of your stay." C) "Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end." D) "I'm sorry, but assessment is ongoing and continuous."

"I'm sorry, but assessment is ongoing and continuous." Ref: (ch.1 pg.3)

For which of the following clients should a nurse perform a focused assessment? A) Client with elevated blood pressure with no previous history of heart problems B) Client with 4-day history of sore throat and fever with enlarged lymph nodes C) Client with right upper abdominal pain that radiates into the groin area D) Diabetic with elevated blood sugars for the past 2 weeks

Client with 4-day history of sore throat and fever with enlarged lymph nodes Ref: (ch.1 pg 6)

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed A) Entry B) Exploratory C) Focused D) Comprehensive

Comprehensive Ref: (ch.1 pg.5)

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? A) Diagnostic reasoning B) Physical assessment C) Critical thinking D) Nursing care plan

Critical thinking Ref: (ch.1 pg.9-10)

When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what? A) Assessment B) Diagnosis C) Planning D) Evaluation

Diagnosis Ref: (ch.1 pg. 9)

The result of a nursing assessment is the A) Prescription of treatment B) Documentation of the need for a referral C) Client's physiologic status D) Formulation of nursing diagnoses

Formulation of nursing diagnoses Ref: (ch.1 pg.8-9)

An assessment that concentrates on patterns of role performance that all humans share is called what? A) Head-to-toe B) Body systems C) Focused D) Functional

Functional Ref: (ch.1 pg.6)

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? A) Planning B) Evaluation C) Implementation D) Nursing diagnosis

Nursing diagnosis Ref: (ch.1 pg. 8-9)

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? A) Initial B) Focused C) Ongoing D) Emergency

Ongoing Ref: (ch.1 pg.6)

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? A) Initial comprehensive B) Ongoing or partial C) Focused or problem-oriented D) Emergency

Ongoing or partial Ref: (ch.1 pg.6)

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history? A) Cluster the data B) Document the findings C) Determine a problem list D) Perform a physical examination

Perform a physical examination Ref: (ch.1 pg. 5)

The nurse is exhibiting critical thinking in which client care situation? A) Transcribing medication orders onto the nurse's medication administration record B) Notifying the healthcare provider of a critical lab result C) Answering the client's call bell alarm while the nursing assistant is at lunch D) Performing a focused assessment on a client who is complaining of shortness of breath

Performing a focused assessment on a client who is complaining of shortness of breath Ref: (ch.1 pg.6)

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? A) lives alone B) significantly impaired hearing C) widowed 2 years ago D) greatly concerned about cost of services

Significantly impaired hearing

The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what? A)How much time the nurse has B) The client's acuity C) The client's cooperation D) Onset of current symptoms

The client's acuity Explanation: Data that nurses collect during a physical assessment vary depending on a client's acuity (condition), health history, and current symptoms. Ref: (ch.1 pg. 6)

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? A) "Nurses focus on the diagnosis and treatment of diseases." B) "Both are the same and they serve to validate the information collected." C) "Nurses focus on the diagnosis of actual human responses to disease or life events." D) "The health care provider focuses on the treatment of human responses caused by diseases."

"Nurses focuses on the diagnosis of actual human responses to disease or life events." Ref: (ch.1 pg. 2)

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) To diagnose the condition and particular illness of the client B) A clinical judgement about client responses to health difficulties C) The collection of subjective and objective data D) Identification of realistic, client-centered goals

A clinical judgement about client responses to health difficulties Ref: (ch.1 pg. 9)

When assisting a patient with health promotion, what must the nurse also nurture? A) A healthy environment B) Knowledge of the Healthy People 2020 indicators C) Family communication D) School/work attendance

A healthy environment Explanation: In order to assist a patient with health promotion, a healthy environment must also be nurtured. Ref: (ch.1 pg.5)

A patient 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 patient? A) Breathing B) Airway C) Circulation D) Disability

Airway Ref: (ch.1 pg. 6-7)

How does a nurse best facilitate the nursing health assessment? A) Maintaining privacy B) Asking the appropriate questions C) Formulating a nursing diagnosis D) Creating a nursing care plan

Asking the appropriate questions Ref: (ch.1 pg.10)

Using both verbal and nonverbal clues given by the patient, what is the nurse constantly doing? A) Diagnosing B) Intervening where necessary C) Formulating a discharge plan D) Assessing

Assessing Ref: (ch.1 pg. 3-4)

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should A) Analyze data that have already been collected B) Review any past collaborative problems C) Avoid premature judgments about the client D) Consult with the client's family members

Avoid premature judgments about the client Ref: (ch.1 pg.7)

Which assessment finding should the nurse document as objective data? A) Biographical information B) Body functions C) Lifestyle practices D) Personal relationships

Body functions Ref: (ch.1 pg.8)

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain? A) Teaching the client to draw knees to chest to help minimize the pain B) Planning care to help minimize the client's pain C) Collecting data regarding the nature of the pain D) Identifying pain management interventions with input from the client

Collecting data regarding the nature of the pain Ref: (ch.1 pg 7)

What are the types of nursing assessments? (Select all that apply.) A) Physical B) Focused C) Mental D) Emergency E) Comprehensive

Emergency, Focused, Comprehensive Ref: (ch.1 pg. 5)

For which client should a nurse perform a focused assessment? A) Elevated blood pressure with no previous history of heart problems B) Four-day history of sore throat and fever with enlarged lymph nodes C) Right upper abdominal pain that radiates into the groin area D) Diabetic with elevated blood sugars for the past two weeks

Four-day history of sore throat and fever with enlarged lymph nodes Ref: (ch.1 pg. 6-7)

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? A) Functional B) Focused C) Head-to-toe D) Body system

Head-to-toe Explanation: A head-to-toe or comprehensive assessment is the most organized system for gathering comprehensive physical data. Ref: (ch.1 pg.5-6)

When doing an overall assessment of a patient, the nurse is able to utilize findings and do what? A) Identify what level of prevention the patients is at B) Identify in what areas the patients can educate his or her family C) Identify in what areas the patient needs most care D) Identify the patient's medical diagnosis

Identify in what areas the patient needs the most care Ref: (ch.1 pg. 6)

Which of the following is the best example of holistic data collection by a nurse? A) Measuring blood glucose level, cholesterol level, blood pressure, and resting heart rate B) Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking his condition affects family gatherings C) Performing an x-ray, ECG, exercise stress test, and complete blood count D) Assessing the client's range of arm motion, auscultating for heart sounds, testing for pupil dilation, and conducting a vision test

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings Ref: (ch.1 pg.4)

The client has a murmur. This is what type of data? A) Subjective B) Objective C) Focused D) Comprehensive

Objective Ref: (ch.1 pg.8)

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's A) Physiologic status B) Holistic wellness status C) Developmental history D) Level of functioning

Physiologic status Ref: (ch.1 pg.4)

What is the primary function of the health care team? A) To work together to obtain maximum coverage B) To decide the best overall care C) To guide the patient's care throughout times of crisis D) To develop an individual focus for each member

To decide the best overall care Ref: (ch.1 pg. 5)

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? A) To determine any changes from the baseline data B) To collect subjective data related to the client's overall health C) To perform a rapid assessment for prompt treatment D) To evaluate whether outcomes of treatment are met

To determine any changes from the baseline data Ref: (ch 1 pg 6)

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) A) ongoing or partial assessment B) focused or problem-oriented assessment C) emergency assessment D) initial comprehensive assessment

focused or problem-oriented assessment Ref: (ch.1 pg.6-7)

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? A) Body systems B) Functional C) Focused D) Head to toe

Head to toe Explanation: The head-to-toe method is efficient and provides more modesty for clients. The body systems and functional assessment does not address the modesty issue in the question. The focused assessment is not appropriate for the newly admitted client. Ref: (ch.1 pg.5)

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? A) Physiologic, psychological, sociocultural, developmental, and spiritual data B) Focuses primarily on the client's physiologic development status C) Involves the client's musculoskeletal system and activities of daily living D) Focuses only on the client's psychological, sociocultural, and spiritual well-being

Physiologic, psychological, sociocultural, developmental, and spiritual data Ref: (ch.1 pg.4)

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? A) Physical B) Environmental C) Social well-being D) Developmental level

Environmental Ref: (ch.1 pg.7-8)

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? A) "The client has been ordered a nutritional consult; I do the health assessment right after that is finished." B) "I'll do the health assessment when the client's family leaves so that distractions will be minimal." C) "I'm going to assess the client now so that I can begin formulating the care plan." D) "The health assessment will be more thorough if I wait until the client is pain free."

"I'm going to assess the client now so that I can begin formulating the care plan."

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? A) Collecting information regarding the client's health status B) Stabilizing the client's physical condition C) Developing an effective, respectful nurse-client relationship D) Creating an environment that encourages client autonomy

Collecting information regarding the client's health status Ref: (ch.1 pg. 4)

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? A) Emergency B) Partial C) Comprehensive D) Focused

Comprehensive Ref: (ch.1 pg.5-6)

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? A) Assessment B) Diagnosis C) Implementation D) Evaluation

Evaluation Ref: (ch.1 pg 4)

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? A) Body systems B) Head to toe C) Functional D) Focused

Functional Explanation: A functional assessment focuses on the patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs (Gordon, 1987). The body systems, the focused nor the head to toe assessment addresses the holistic needs of the client. The roles and relationships of the client would not be included in these assessment Ref: (ch.1 pg.5)

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? A) Pender Health Promotion Model B) Health Belief Model C) Healthy People 2020 D) U.S. Preventive Services Task Force

Health Belief Model Ref: (ch.1 pg.5)

Which of the following statements best conveys the rationale for health promotion in a school setting? A) Health promotion in a school setting can yield improved health outcomes for the student's siblings and parents B) Children younger than 13 years are some of the most common consumers of acute health care services C) Children contract numerous communicable diseases in the school environment D) Healthy child development is a critical health determinant because of its implications for lifelong health

Healthy child development is a critical health determinant because of its implications for lifelong health Explanation: The future implications of healthy child development coupled with the fact that children spend much time at school mean that schools are crucial settings for health promotion. Ref: (ch.1 pg.3)

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? A) Physical assessment and health history B) Individual student interview and questionnaire C) Review of literature and consultation with faculty D) Walk-through of education faculty questionnaire

Individual student interview and questionnaire

Which of the following is the best example of assessment in everyday life? A) Taking the dog for a walk in the park to get exercise B) Listening to a favorite song to relax in the evening C) Texting a friend to let her know you made it home safely D) Measuring the remaining tread on a car tire to determine whether it is time to replace it

Measuring the remaining tread on a car tire to determine whether it is time to replace it Explanation: As a professional nurse, you will constantly observe situations and collect information to make nursing judgments. This occurs no matter what the setting: hospital, clinic, home, community, or long-term care. You conduct many informal assessments every day. For example, when you get up in the morning, you check the weather and determine what would be the most appropriate clothing to wear. Measuring the remaining tread on a car tire to determine whether it is time to replace it is an example of assessment, as it involves gathering information (the height of the tire tread) to make a decision (whether to buy new tires). The other answers do not involve gathering information to make a decision. Ref: (ch.1 pg 1)

How does a nurse decide what health-promotion activities are necessary for a particular client? A) Nurse addresses areas associated with healthy behaviors only B) Nurses collaborate with clients to identify areas in which clients are willing to make changes C) Nurses assess areas in which clients are willing to make changes only D) Nurses construct their own theories to identify perceptions, barriers, and positive outcomes

Nurses collaborate with clients to identify areas in which clients are willing to make changes Explanation: Rather than addressing all areas associated with healthy behaviors and overwhelming clients, nurses collaborate with them to identify areas in which clients are willing to make changes. Ref: (ch.1 pg 5)

A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan? A) Nursing process B) Diagnostic reasoning C) Critical thinking D) Community care map

Nursing process Ref: (ch.1 pg.2)

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic? A) Holistic B) Primary C) Secondary D) Tertiary

Primary Explanation: 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, BP screening, hearing testing, scoliosis screening, and tuberculin skin testing are examples. • Tertiary prevention focuses on preventing complications of an existing disease and promoting health to the highest level. Diet teaching for patients with diabetes, inhaler teaching for patients with lung disease, and 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.

When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient says the doctor already did an exam. The best response by the nurse would be A) "the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease." B) "the doctor's and nurse's assessments are totally unrelated and are necessary so all forms are completed appropriately." C) "each assessment is important and the nurse and doctor will get together to determine what orders need to be written" D) "I know it seems repetitive but the doctor is trying to treat the reason you were admitted and I will focus more on getting everything ready for you to go home."

The doctor focuses more on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease. Ref: (ch.1 pg 2)

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? A) the client's ability to communicate verbally B) the nurse's ability to ask relevant questions C) the type and degree of physical issues the client is experiencing D) the rapport that exists between the nurse and the client

The rapport that exists between the nurse and the client Ref: (ch.1 pg.7)

Why is the nurse always reassessing the patient for changes? A) To never make a mistake when providing care B) To always have the best nursing care plan C) To achieve the best results D) To update the nursing diagnosis

To achieve the best results Explanation: The nurse or detective is always reassessing the patient or case for changes in order to achieve the best results. Each relies on both the science and art of his or her respective profession. Ref: (ch.1 pg.6)

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? A) Follows the ABC approach B) Uses evidence-based techniques C) Asks unlicensed staff to measure vital signs D) Focuses on the system that caused the hospitalization

Uses evidence-based techniques Ref: (ch.1 pg. 2)