Chapter 1
What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain? -Planning care to help minimize the client's pain -Teaching the client to draw knees to chest to help minimize the pain -Identifying pain management interventions with input from the client -Collecting data regarding the nature of the pain
Collecting data regarding the nature of the pain Explanation: 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 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? Evaluate whether outcomes of treatment are met Determine any changes from the baseline data Collect subjective data related to the client's overall health Perform a rapid assessment for prompt treatment
Determine any changes from the baseline data Explanation: 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. Evaluation is done after an intervention to determine if the outcomes have been achieved.
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? Sympathy Empathy Inspection Palpation
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
objective
Everything that you can observable and measure Posture, affect, behavior, inspection palpate, percussion, auscultation
An assessment that concentrates on patterns of role performance that all humans share is called what? Focused Functional Head-to-toe Body systems
Functional Explanation: A functional assessment focuses on the functional 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.
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?
Healthy People 2020 Explanation: 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.Healthy People 2020 organization standards of care the client's family history the client's past medical history
Which of the following statements best conveys the rationale for health promotion in a school setting? Health promotion in a school setting can yield improved health outcomes for the student's siblings and parents. Children younger than 13 years are some of the most common consumers of acute health care services. Children contract numerous communicable diseases in the school environment. 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.
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 Ambulatory care Critical care Public health
Hospice Explanation: 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.
A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is "a bit sporadic." How should the nurse best respond to this assessment finding? Identify a nursing diagnosis of Ineffective Health Maintenance. Reassess the client's blood glucose level. Identify a collaborative problem that should involve the occupational therapist. Make a referral to the unit's social work department.
Identify a nursing diagnosis of Ineffective Health Maintenance. Explanation: This statement is suggestive of a nursing concern, which the nurse would characterize as a nursing diagnosis and follow up with education. Social work and occupational therapy are not relevant to this statement, and rechecking the client's glucose level does not address the problem at hand.
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?
"I'm going to assess the client now so that I can begin formulating the care plan." Explanation: Each person needs a complete health assessment. Ideally this is done on admission, but extenuating circumstances may prohibit its completion in detail at this time. The sooner the health assessment is completed fully, the better the nurse knows the client, and more holistic care can be provided to ensure health promotion and quality of life. The assessment should not be postponed until after the consult. The family should be informed of the need for the assessment and asked to leave until it is completed, unless their input with the history is needed. While pain may complicate the assessment process, it is not advisable to wait until the client is pain free to complete the 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? "Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end." "Fortunately, assessment only needs to be done at the beginning of your stay." "I'm sorry, but assessment is ongoing and continuous." "I'll just need to evaluate you once more, at the end of your stay."
"I'm sorry, but assessment is ongoing and continuous." Explanation: 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 assisting a client with health promotion, what must the nurse also nurture? A healthy environment Knowledge of the Healthy People 2020 indicators School/work attendance Family communication
A healthy environment Explanation: In order to assist a client with health promotion, a healthy environment must also be nurtured.
The nurse is collecting data from a client. Which of the following best reflects objective data? Occupation Religion Appearance Age
Appearance Explanation: Appearance is something that can be directly observed by the nurse and is considered objective data. Religion and occupation are biographical data that are considered subjective. Age is considered to be subjective data because it is reported by the client. The nurse should assess whether the client appears to be their stated age.
What are nurses able to detect through the health assessment? Areas that need referral to a specialist Areas in need of health adjustments Areas that need continuous care Areas that need in-hospital care
Areas in need of health adjustments Explanation: Through the health assessment nurses are able to detect areas in need of health adjustments.
A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption? Collaborate with the physician who is treating the client. Review the client's medication administration record for analgesic use. Meet with the client's spouse and daughter to discuss the client's pain. Ask the client about the most recent experiences of pain.
Ask the client about the most recent experiences of pain. Explanation: Data are best validated by the client. Other sources are valid and useful, but the client is the ultimate source, especially in the case of subjective data.
How does a nurse best facilitate the nursing health assessment? Maintaining privacy Creating a nursing care plan Formulating a nursing diagnosis Asking the appropriate questions
Asking the appropriate questions Explanation: 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.
A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following?
Avoid biases and judgments Explanation: Once the nurse has gathered some basic data about a client, he or she needs to reflect on personal feelings to ensure keeping an open mind and avoiding premature judgments that may alter the ability to collect accurate data and maintain objectivity. The other listed actions may be necessary, but none is accomplished through reflection.
When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first? Collect objective data Collect subjective data Document the data Validate the data
Collec Subjective data Explanation: With assessment, subjective then objective data is collected. This is followed by validation and then documentation of data.
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? Review of literature and consultation with faculty Walk-through of education facility and faculty questionnaire Physical assessment and health history Individual student interview and questionnaire
Individual student interview and questionnaire Explanation: 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.
A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data? Therapeutic communication Inspection Active listening Interviewing
Inspection Explanation: Interviewing, therapeutic communication, caring, empathy, and listening skills are needed to obtain subjective data. Inspection, palpation, percussion, and auscultation are used to collect objective data.
Before beginning a health assessment with a client, the nurse reviews Healthy People 2020 because: It serves as a guide for the health assessment. It identifies risk factors, health issues, and diseases. It helps determine the client's plan of care. It lists specific interventions to address most client health problems.
It identifies risk factors, health issues, and diseases. Explanation: 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, targeting the next 10 years. Its overall goal is 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 does not help determine the client's plan of care. Healthy People 2020 does not serve as a guide for the health assessment nor does it list specific interventions to address specific health problems.
Student nurses are learning about evidence-based practice. What would they learn is the final step in this process? Justifying the selection of interventions Identifying the issue or problem based on an analysis of current nursing knowledge and practice Evaluating research evidence using their own criteria Searching the literature for research
Justifying the selection of interventions Explanation: Evidence-based practice helps you solve common problems through these four steps: 1. Clearly identify the issue or difficulties based on an accurate analysis of current nursing knowledge and practice; 2. Search the literature for relevant research; 3. Evaluate the research evidence using established criteria regarding scientific merit; 4. Choose interventions and justify the selection with the most valid evidence.
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? Validating information that is already correct Interjection of the nurse's thoughts or feelings into the data Relying on objective and subjective information Making incorrect nursing judgments or diagnoses
Making incorrect nursing judgments or diagnoses Explanation: 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. Injection of the nurse's thoughts or feeling may lead to bias or the withholding of information. Nursing judgments should rely on both objective and subjective information. Validating information that is correct makes more work for the nurse but will not lead to inaccurate judgments
An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem? Provide the client with a bedtime protein snack. Encourage the client to increase oral fluid intake. Measure the client's blood glucose four times daily. Assist the client with personal hygiene.
Measure the client's blood glucose four times daily. Explanation: Collaborative problems, such as changes in blood glucose, are certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems by implementing both physician- and nurse-prescribed interventions to reduce further complications. Nutrition (oral fluids, bedtime snack) and hygiene are most often considered to be independent nursing concerns.
Which of the following is the best example of holistic data collection by a nurse? Performing an x-ray, ECG, exercise stress test, and complete blood count Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings Measuring blood glucose level, cholesterol level, blood pressure, and resting heart rate Assessing the client's range of arm motion, auscultating for heart sounds, testing for pupil dilation, and conducting a vision test SUBMIT ANSWER
Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings. Explanation: 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.
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 goal Nursing intervention Nursing assessment Nursing evaluation
Nursing intervention Explanation: 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.
he client has a murmur. This is what type of data?
Objective Explanation: Objective data includes data that is measurable. Subjective data is what the client states, feels or senses. Focused and comprehensive are types of assessments
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? Emergency Initial comprehensive Focused or problem-oriented Ongoing or partial
Ongoing or partial Explanation: 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.
Subjective
Patient set: can not see. Interview, therapeutic communication , caring, empathy, listening, sensation, feelings, perceptions, desires, preferences, beliefs, idea
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? Focuses primarily on the client's physiologic development status Focuses only on the client's psychological, sociocultural, and spiritual well-being Involves the client's musculoskeletal system and activities of daily living Physiologic, psychological, sociocultural, developmental, and spiritual data
Physiologic, psychological, sociocultural, developmental, and spiritual data Explanation: 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.
The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first? Review the client's medical record. Consult clinical resources explaining the client's diagnosis. Validate information with the client. Obtain basic biographic data.
Review the client's medical record. Explanation: Before actually beginning the health assessment, the nurse should review the client's record. It provides basic biographic data and a background about chronic diseases. It also gives clues to how a present illness may impact the client's activities of daily living. Validating the information with the client occurs during the assessment. Consulting clinical resources is not an immediate priority.
A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify? The client's affect The client's posture The client's behavior The client's feelings of happiness
The client's feelings of happiness Explanation: Subjective data are sensations, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Happiness is a feeling and therefore subjective. Posture, affect, and behavior are observable and are thus considered objective data.
The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following? The client's medical comorbidities The client's learning style The client's motivation for change The client's prognosis for recovery
The client's motivation for change Explanation: The Health Belief Model is based on three concepts: the existence of sufficient motivation, the belief that one is susceptible or vulnerable to a serious problem, and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. As a result, implementation of this model should begin with an appraisal of the client's motivation to change. This consideration would precede the other listed variables, although each may affect care.
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? Assessment Diagnosis Evaluation Implementation
The evaluation Explanation: The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and the nursing care plan needs to be revised. The assessment stage involves collecting subjective and objective data. The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment. The implementation phase involves carrying out the plan to meet the determined outcome criteria.
The nurse reviews information obtained from the admission's department about a client seeking medical care for a chronic problem. What should the nurse expect to complete when assessing this client? Select all that apply. Collect objective data Collect subjective data Analyze outcome data Document data Validate data
Validate data Document data Collect objective data Collect subjective data Explanation: The assessment phase of the nursing process has four major steps: collect subjective data; collect objective data; validate data; and document data. Analyzing outcome data is performed during the evaluation phase of the nursing process.
A nurse is conducting a health assessment. How will the information collected from the client be used? to facilitate nurse-client caring as a basis for the nursing process to illustrate nursing competence as one component of medical care
as a basis for the nursing process Explanation: Health assessment is an integral component of nursing care and is the basis of the nursing process. Health assessments by nurses are used to plan, implement, and evaluate teaching and care. Nursing assessment is different from other types of healthcare provider assessments, as it is a holistic collection of information about a client's level of health.
To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next check for the presence of defining characteristics. draw inferences and identify problems. cluster the data collected. document conclusions.
check for the presence of defining characteristics. Explanation: To arrive at nursing diagnoses, collaborative problems, or referral, you must go through the steps of data analysis. This process requires diagnostic reasoning skills, often called critical thinking. The process can be divided into seven major steps: 1. Identify abnormal data and strengths. 2. Cluster the data. 3. Draw inferences and identify problems. 4. Propose possible nursing diagnoses. 5. Check for defining characteristics of those diagnoses. 6. Confirm or rule out nursing diagnoses. 7. Document conclusions.
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? creating an environment that encourages client autonomy collecting information regarding the client's health status stabilizing the client's physical condition developing an effective, respectful nurse-client relationship
collecting information regarding the client's health status Explanation: 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 medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's physiologic status. holistic wellness status. developmental history. level of functioning.
physiologic status. Explanation: 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.
