PrepU Chapter 1
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?
Airway
What are nurses able to detect through the health assessment?
Areas in need of health adjustments
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 data related to overall function
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
What is a required component of a health assessment?
Critical thinking
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?
Determine any changes from the baseline data
When doing an overall assessment of a patient, the nurse is able to utilize findings and do what?
Identify in what areas the patient needs the most care
A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?
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
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
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
A nurse has completed assessment of a patient with Alzheimer's disease and documentation of the information obtained from the client and now needs to analyze the data collected. Which nursing actions should be included in this phase of the nursing process? Select all that apply.
-Identification of collaborative problems -Formulation of nursing diagnosis(es) -Identification of the need for referrals
The result of a nursing assessment is the
formulation of nursing diagnoses.
What are the types of nursing assessments? (Select all that apply.)
-Emergency -Comprehensive -Focused
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
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
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
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 interventions
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.
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."