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

A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data?

The client's range of motion in her right arm

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 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 nursing instructor is trying to convince the class of the importance of assessment kills in nursing. In discussing the future of the nursing profession, which factors should stressed that will promote opportunities for nurses with advannced assessment skills? Select all that apply.

1. Declining numbers of medical students due to rising costs and focus on primary care 2. Increasing complexity oof acute care 3. Growing aging population with complex comorbidities 4. Increasing impact of children and the homeless on communities

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.

1. Identification of collaborative problems 2. Identification of the need for referrals 3. Formulation of nursing diagnosis(es)

Which actions should a nurse perform before beginning the initial shift assessment of a client? Select all that apply.

1. Revise nursing care plans to reflect improvemnts in the clients conditions 2. Check the clients status with the nurse of the pervious shift 3. Review the client's record before meeting the client.

Which assessment finding should the nurse document as objective data?

Body functions

For which of the following clients should a nurse perform a focused assessment?

Client with a 4-day history of ssore throat and fever with enlarged lymph nodes

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?

Collct subjectibe and objective data related to overall function.

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 chhest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse perform for this client?

Comprehensive

A client presents to the health care facility with reports of new onset of the 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

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently unnderwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?

Empathy

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

A nurse is preparing to interview a client who is a Seventh Day Adventist. The nurse does not agree with this religion's view of modern medicine. Reflection of the nurse on her personal feelings regarding this patient and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation?

Formation of judgments that may interfere with the interview

For which client should a nurse perform a focused assessment?

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

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

Gathering forensic evidence for a legal proceeding

A nurse is working with an obese man who has type 2 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 lan that the nurse has helped himm create is feasible and would be effective in helping him meet his health goal. The nurse is using which of the following tools or resources in assessment of this client?

Health Belief Model

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?

Hospice

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 patient'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 judgements 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 clientt 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

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

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 lungs sounds to determine any changes from the baseline. What type of assessment is the nurse performing?

Ongoing or Partial Assessment

A nurse recommends that a client comes 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

A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client hould focus on collection of data in which of these areas?

Physiologic, psychological, sociocultural, developmental, and spiritual data.

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

Shortness of breath

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