Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data PrepU

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 a. arrive at conclusions about the client's health. b. document any physical symptoms the client may have. c. contribute to the medical diagnosis. d. validate the data collected.

a. arrive at conclusions about the client's health. The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment data.

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

d. Areas in need of health adjustments Through the health assessment nurses are able to detect areas in need of health adjustments.

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

d. Nursing diagnosis Analysis of data or nursing diagnosis, is the second phase of the nursing process. Planning occurs after the data is analyzed. Evaluation is the final phase of the process. Implementation occurs after planning.

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

b. Asking the appropriate questions Knowing how to facilitate the nursing health assessment by asking appropriate questions to obtain more information assists the nurse to solve the mystery or create a nursing care plan.

The nurse is conducting a physical assessment of a new client. What data does the nurse collect that are measurable? a. Subjective b. Objective c. Affective d. Effective

b. Objective The physical assessment follows the history and focused interview, and includes objective data, which are measurable.

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.

b. focused or problem-oriented assessment. A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.

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

d. Empathy 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.

When assisting a client 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. A healthy environment In order to assist a client with health promotion, a healthy environment must also be nurtured.

What is the primary purpose of health assessment? a. To gather information about the health status of the client b. To make judgments about the client's lifestyle and behaviors that contribute to the client's illness c. To decide on the best way to manage a client's illness based on the nurse's own views and beliefs d. To help the physician diagnose illness without further testing

a. To gather information about the health status of the client Health assessment is "gathering information about the health status of the client, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings, and evaluating client care outcomes" (AACN, 2011). Health assessment is not making judgments about a client's lifestyle; it does not involve care based on the nurse's views and beliefs, nor does it help the physician diagnose illness without further testing.

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.

a. physiologic status. The physician performing a medical assessment focuses primarily on the client's physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.

What are the types of nursing assessments? (Select all that apply.) a. Physical b. Focused c. Mental d. Emergency e. Comprehensive

b. Focused d. Emergency e. Comprehensive Three types of nursing assessments are common: emergency, focused, and comprehensive. Physical and mental assessments are areas addressed in the various types of nursing assessments.

The client has a murmur. This is what type of data? a. Subjective b. Objective c. Focused d. Comprehensive

b. Objective Objective data includes data that is measurable. Subjective data is what the client states, feels or senses. Focused and comprehensive are types of assessments

The nurse is following a structured head-to-toe approach to identify changes in a client's body systems. Which component of the health assessment is the nurse completing with the client? a. Health history b. Physical examination c. Goal setting d. Planning care

b. Physical examination In the physical examination, the nurse uses a structured head-to-toe approach to identify changes in the client's body systems. The health history is when the nurse asks pertinent questions to gather data from the client and/or family. Goal setting and planning care are not parts of the health assessment.

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

c. Critical thinking Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems. Diagnostic reasoning is important in developing diagnostic statements, not in caring for multiple clients with complex care needs. Physical assessment is important in the building the foundation of the nursing care plan. The nursing care plan directs the care that will be provided for the individual client, but does not address the needs of caring for multiple clients.

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first a. discuss the client's symptoms with other team members. b. plan for potential laboratory procedures. c. review the client's health care record. d. determine potential health care resources.

c. review the client's health care record. Before actually meeting the client and beginning the nursing health assessment, it is helpful to review the client's medical record, if available. Knowing the client's basic biographical data (age, sex, religion, educational level, and occupation) is useful. The medical record provides background about chronic diseases and gives clues to how a present illness may impact the client's activities of daily living (ADL). An awareness of the client's previous and current health status provides valuable information to guide interactions with the client.

Revising the plan as needed occurs in what part of the nursing process? a. Assessment b. Diagnosis c. Planning d. Evaluation

d. Evaluation Evaluation assesses whether the outcome criteria have been met and revising the plan as necessary. Diagnosis occurs when the data has been analyzed and a professional judgement occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan.

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

d. perform a physical examination The health assessment includes a health history and physical examination. After completing the health history, the nurse should complete the physical examination. Clustering data and determining a problem list would occur after the physical examination is complete. Documentation of the findings would occur while conducting the health history and after completing the physical examination.

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

c. Head-to-toe A head-to-toe or comprehensive assessment is the most organized system for gathering comprehensive physical data.

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

a. Nursing intervention Nursing interventions are used to monitor health status; prevent, resolve, or control a problem; assist with ADLs; or promote optimum health and independence. Nursing goals are the client's desired outcomes. Nursing evaluation is deciding whether the nursing goals have been reached. Nursing assessment is an overview of the client's health status and current problems.

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? a. To establish a database against which subsequent assessments can be measured b. To establish rapport with the client and family c. To gather information for specialists to whom the client might be referred d. To quantify the degree of pain a client may be experiencing

a. To establish a database against which subsequent assessments can be measured A health assessment is performed to gain further insight into the current condition and to establish a database that subsequent assessments can be measured against.

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.

d. Healthy child development is a critical health determinant because of its implications for lifelong health. 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.

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? a. Interjection of the nurse's thoughts or feelings into the data b. Making incorrect nursing judgments or diagnoses c. Relying on objective and subjective information d. Validating information that is already correct

b. Making incorrect nursing judgments or diagnoses Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the nursing process. Interjection of the nurse's thoughts or feelings may lead to bias or the withholding of information but would not necessarily result from a lack of a thorough and accurate assessment of a client. Nursing judgments should rely on both objective and subjective information; thus this is not an error. Validating information that is correct makes more work for the nurse but will not be prevented by a thorough and accurate assessment of a client.

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

b. The client's acuity Data that nurses collect during a physical assessment vary depending on a client's acuity (condition), health history, and current symptoms. The data collected during a physical assessment do not depend on how much time the nurse has, how cooperative the client is, or the onset of the current symptoms.

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 client's care throughout times of crisis d. To develop an individual focus for each member

b. To decide the best overall care The health care team meets to collaborate on clients and decide the best overall care. This occurs throughout the lifespan, from the inception of life until death. The health care team is a partnership. The group includes the nurse, physician, nutritionist, social worker, physical therapist, occupational therapist, speech therapist, and/or dentist. They all work together on the same team for the benefit of the client.

A nurse is assessing the social and spiritual needs of a client who is terminally ill with pancreatic cancer and living at home. This nurse most likely works in which of the following settings? a. Public health b. Ambulatory care c. Critical care d. Hospice

d. Hospice Current focus on managed care and internal case management has had a dramatic impact on the assessment role of the nurse. Hospice nurses assess the needs of the terminally ill clients and their families. Ambulatory care nurses assess and screen clients to determine the need for physician referrals. Public health nurses assess the needs of communities, and school nurses monitor the growth and health of children. Critical care outreach nurses need enhanced assessment skills to safely assess critically ill clients who are outside the structured intensive care environment.

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

d. the rapport that exists between the nurse and the client The amount of success that nurse has in discovering the reason behind the client's crying is heavily dependent upon the relationship (rapport) that exists between the nurse and the client. It is this mutual respect and trust that allows the nurse to enter into conversations that would otherwise be off limits. The remaining options have the potential to affect the conversation, but the conversation will not likely occur without the presence of an effective nurse-client relationship.

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? a. Emergency b. Ongoing c. Focused d. Comprehensive

b. Ongoing Ongoing, follow-up or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline. An emergency assessment is a very rapid assessment performed in life-threatening situations such as drowning, choking, or cardiac arrest. It is used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. A focused assessment gathers information specific to the problem and does not cover any other areas. A comprehensive assessment is not necessary at this time because the client already has a documented problem.

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

c. Collecting data regarding the nature of the pain The nurse's initial role in health assessment is to collect data. Teaching would occur later in the process. Planning care and identifying interventions are parts of the nursing process and not the health assessment.

A client presents to the health care facility with reports of new onset of chest pain of three 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 perform for this client? a. Emergency b. Partial c. Comprehensive d. Focused

c. Comprehensive This client presents with a new problem and the nurse should perform a comprehensive assessment. Chest pain is an emergent problem but the client is has stable vital signs and no chest pain so an emergency assessment is not indicated at this time. A partial or focused assessment would not allow collection of enough data to properly complete diagnose the cause of a new problem.

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

c. Ongoing An ongoing or client assessment occurs after the comprehensive database is established. It is a mini overview of the client's body systems. The initial assessment was completed upon admission. A focused assessment is completed when the database for a client already exists and the client is experiencing a specific problem. An emergency assessment is completed in a life-threatening situation.

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? a. Healthy People 2020 b. the client's family history c. organization standards of care d. the client's past medical history

a. Healthy People 2020 Healthy People 2020 is a framework that identifies risk factors, health issues, and diseases of concern in the United States. The goals and objectives serve to improve the health of individuals and communities with the overall goal to increase quality of life by creating guidelines for a healthy lifestyle as well as educating people and cultivating an awareness that will assist in the elimination of health disparities. Healthy People 2020 promotes health and disease prevention as it improves the quality and length of a person's life. The client's family history or past medical history will not help identify health promotion interventions. The organization's standards of care are generalized and do not identify health promotion interventions.

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."

d. "I'm sorry, but assessment is ongoing and continuous." Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ongoing and continuous throughout all the phases of the nursing process.

When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what? a. Assessment b. Diagnosis c. Planning d. Evaluation

b. Diagnosis Diagnosis occurs when the data has been analyzed and a professional judgment occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan. Evaluation assesses whether the outcome criteria have been met.

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? a. "What do you mean by 'a little dizzy'?" b. "Do you often feel dizzy?" c. "Have you ever been dizzy enough to fall?" d. "Can you remember when you first started to feel dizzy?"

a. "What do you mean by 'a little dizzy'?" Listening and understanding a client is key to discovering a client's needs. As more details are acquired and collated, actual health risks emerge. The nurse should first clarify what the client means by the statement. It is only then that the nurse can determine is a health risk exists. While knowing the details of when the symptom started, how often it occurs, and if falling has occurred is important, clarification of what the client means is the initial focus of the nurse.

A nurse has completed assessment of a client 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. a. Identification of collaborative problems b. Assessment of the outcome of the care plan c. Identification of the need for referrals d. Formulation of nursing diagnosis(es) e. Development of a nursing care plan

a. Identification of collaborative problems c. Identification of the need for referrals d. Formulation of nursing diagnosis(es) The second phase of the nursing process is to identify collaborative problems and the need for referrals as well as formulate nursing diagnoses, for which the nurse must go through the steps of data analysis. Planning is the third phase of the nursing process, which involves development of a nursing care plan and assessment of the outcome of the care plan, based on the nursing diagnosis obtained in the second phase of the nursing process.

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? a. Open the client's airway b. If the client is injured, protect the cervical spine c. Begin CPR d. Ensure that the client is safe

a. Open the client's airway All life-threatening problems identified during the initial assessment require the initiation of critical interventions. The nurse opens the client's airway; assists the client's breathing; provides assistance with circulation (CPR if needed); if the client is injured, protects the cervical spine; ensures that the disoriented or suicidal client is safe; and provides pain management and sedation. The client has assessments and critical interventions performed simultaneously as life-threatening problems are treated.

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

a. Physiologic, psychological, sociocultural, developmental, and spiritual data A nursing health assessment includes physiologic, psychological, sociocultural, developmental, and spiritual data. Medical health assessment focuses primarily on the client's physiologic development status. The assessment by a physical therapist focuses mainly on the client's musculoskeletal system and activities of daily living.

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

a. To determine any changes from the baseline data Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment (emergency assessment). Evaluation is done after an intervention to determine whether the outcomes have been achieved.

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

a. collecting information regarding the client's health status Regardless of the care setting, the nurse's initial role in health assessment is to collect data. While all the remaining options are relevant to quality client care, they are not associated directly with the nurse's role concerning health assessment.

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 facility and faculty questionnaire

b. Individual student interview and questionnaire Key to any health promotion activity is a thorough assessment of the context and particular needs of the participants. This could be best determined by asking the students what would be more effective than a physical assessment, literature review, tour of the facility, or questionnaire of the faculty members.

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 the client how 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

b. Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings The purpose of a nursing health assessment is to collect holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. Thus the nurse performs holistic data collection. The mind, body, and spirit are considered to be interdependent factors that affect a person's level of health. The nurse, in particular, focuses on how the client's health status affects his activities of daily living and how the client's activities of daily living affect his health. For example, a client with asthma may have to avoid extreme temperatures and may not be able to enjoy recreational camping. If this client walks to work in a smoggy environment, it may adversely affect his asthma. The other answers pertain only to the physiologic functioning of the client and not the other aspects.

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

b. Ongoing or partial An ongoing, follow-up or partial assessment of the client consists of data collection that occurs after the comprehensive database is established. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data. In addition, a brief reassessment of the client's body systems and holistic health patterns is performed to detect any new problems. An initial comprehensive assessment involves collection of subjective data about the client's perception of own health of all body parts or systems, past health history, family history, and lifestyle and health practices. A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern and consists of a thorough assessment of a particular client problem, and does not cover areas not related to the problem. An emergency assessment is a very rapid assessment performed in life-threatening situations.

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic? a. Holistic b. Primary c. Secondary d. Tertiary

b. Primary 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 clients with diabetes, inhaler teaching for clients 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 nurse plans to follow the Health Belief Model when identifying a client's care needs. On what will the nurse focus when using this model? Select all that apply. a. Behavioral outcomes b. Sufficient motivation c. Individual characteristics d. Making a change would be beneficial e. Belief of being susceptible to a health problem

b. Sufficient motivation d. Making a change would be beneficial e. Belief of being susceptible to a health problem The Health Belief Model is based on three concepts: the client has sufficient motivation; the client is susceptible to a health problem; and making a change will be beneficial to improve health. Behavioral outcomes and individual characteristics are focuses of the Health Promotion Model.

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

b. Uses evidence-based techniques To accomplish pertinent and comprehensive data collection the nurse uses appropriate evidence-based assessment techniques and instruments when collecting data. The ABC approach may not be necessary. Although measure vital signs can be delegated to unlicensed staff, this does not ensure that the data will guide the identification of appropriate interventions. Focusing on one system may be appropriate in specific situations however the admission assessment should include all body systems

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

b. significantly impaired hearing As a nurse, it is vital to sift through all the client information and make decisions on what information will impact client safety and quality of care. The ability to identify what is important on a daily basis for each individual client is paramount for nursing care. Of the data provided, the client's impaired hearing poses the greatest safety risk and has the greatest impact on the client's quality of life and so has priority. While the other options could be potential factors related to quality of life and safety, the nurse will need to assess them further.

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.

c. avoid premature judgments about the client. After reviewing the record or discussing the client's status with others, remember to keep an open mind and to avoid premature judgments that may alter your ability to collect accurate data. Validate information with the client and be prepared to collect additional data.

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? a. Rationale b. American Nurses Association recommendations c. Physical assessment skills d. Diagnostic reasoning

d. Diagnostic reasoning Nurses use diagnostic reasoning and critical thinking to formulate diagnostic statements. Rationale, ANA recommendations, and physical assessment skills are not part of formulating diagnostic statements. Rationale supports the nursing interventions of the nursing care plan. The American Nurses Association does not have recommendations regarding formulation of diagnostic statements for the care plan. Physical assessment skills are important in the assessment step of the nursing process, not the formulation of the diagnostic statements.

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 that you made it home safely d. Measuring the remaining tread on a car tire to determine whether it is time to replace it

d. Measuring the remaining tread on a car tire to determine whether it is time to replace it 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.