306 Week 1 Chapter 1,3,4

While interviewing an adult client about the client's stress "levels and coping responses, an appropriate question by the nurse s Do you feel stress at work?" "How often do you feel stressed?" "Is stress a problem in your life?" "How do you manage your stress?"

"How do you manage your stress?" To investigate the amount of stress clients perceive they are under and how they cope with it, ask questions that address what events cause stress for the client and how they usually respond. In addition, find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive.

A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history?

"What is your major health concern at this time?"

A community health nurse provides information to a patient with newly diagnosed multiple sclerosis for a support group at the local hospital for patients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following?

A referral

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

Data collection occurs where in the nursing process?

Assessment

A client reports pain as being 7 on a scale from 1 to 10. In which area of the symptom should the nurse document this information? Characteristic Onset Location Duration

Characteristic

While assessing a patient, the nurse is asking questions that help the nurse perceive and communicate an understanding of what the patient is feeling. What is this called? Sympathy Caring Therapeutic communication Empathy

Empathy Empathy is feeling what a patient feels from the patient's perspective. You keep the focus on the patient: this allows the patient to express himself or herself completely.

A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the

Focused assessment

A client with a foot wound returns to the outpatient wound clinic for a weekly appointment and treatment. Which type of assessment should the nurse complete with this client? Follow-up Comprehensive Problem-oriented Focused

Follow-up

Learning about the effects of the illness does what for the nurse and the patient?

Gives them the opportunity to create a complete and congruent picture of the proble

During the assessment interview, the client made numerous statements that suggested his life generally exists in a state of harmony and balance. The nurse would document this as which type of nursing diagnosis?

Health promotion diagnosis A health promotion diagnosis indicates that the client has the opportunity for enhancement of a health state. The client is in a state of harmony and balance. An actual diagnosis would be used for a stated health problem. A risk diagnosis is used when a client does not currently have a problem but is at high risk for developing it. A collaborative problem is one that requires both medical and nursing interventions.

In the closing phase of the interview process, the nurse analyzes the data collected for what priority reason?

Identifying the primary problems or patterns of concern

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 client admitted to the health care facility for new onset of abdominal pain expresses to nurse that they were treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

Past health history

The nurse would document driving with car seatbelt fastened, bicycling with properly-fitted helmet, and installing a smoke detector in a vacation home in the client's health history under which of the following?

Personal and social history Health-maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety are components of the client's personal and social history.

The patient is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the patient, the nurse is obtaining what other type of data from the patient?

Primary Subjective data given by the patient are considered primary data. Charts and family are sources of secondary data, while objective data are based upon tests, vital signs, and examinations. At present, no data are called tertiary.

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?

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.

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?

Secondary

The nurse is assessing an older adult client a hospice unit. The client cannot speak or communicate, but the client's daughter is there and answers all the questions as best as she can. What type of data source is the daughter?

Secondary

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is Holistic Primary Secondary Tertiary

Secondary 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 documenting clinical data after an assessment of the patient's neck, what might you write in the physical assessment?

Thyroid isthmus barely palpable, lobes not felt Explanation: An example of documentation from the assessment of a patient's neck is: Neck supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt.

While interviewing a patient, the nurse asks, "What happens when you have low blood glucose?" This type of response to the patient is used for what purpose? To promote objectivity To restate what the patient has said To summarize the conversation To clarify

To clarify Another way to clarify is to ask, "What happens when you get low blood sugar?" Such questions prompt patients to identify other symptoms or give more information so that you can better understand the situation.

Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients? Select all that apply.

Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally Do not use facial expressions such as rolling the eyes or looking bored or disgusted Make sure that dress and appearance are professional

A nurse is conducting a health assessment. How will the information collected from the patient be used?

as a basis for the nursing process

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus? sleep-rest coping-stress-tolerance activity-exercise self-perception/self-concept

coping-stress-tolerance

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 The environment influences conditions to promote health. Physical health is the way the body works and adapts. Social well-being identifies relationships that support health. Developmental level focuses on thinking, problem solving, and decision making.

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 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 Body system Functional Focused

head to toe

During the interview process, the nurse obtains what type of data from the client? Primary Secondary Objective Oral

primary Nurses collect primary data from clients themselves. Secondary data come from family and medical records. Objective data are data observed. Oral data is a form of data obtained through conversation.