Fundamentals of Nursing: Collecting and Analyzing Data
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
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
The nurse is preparing to conduct a health assessment with a patient. What will be the nurse's initial role when caring for this patient?
Collecting data
What is a required component of a health assessment?
Critical thinking
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 judgments or diagnoses
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
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
The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?
Primary
The purpose of a health assessment includes what?
Synthesizing collected data, Collecting information about the health status of the client, Evaluating client outcomes
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
comprehensive
Although the assessment phase of the nursing process precedes the other phases, the assessment phase is
continuous
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?
critical thinking
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
physiologic status.
To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first
review the client's health care record.
Reflection of the nurse upon personal feelings 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
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
As a nurse becomes more proficient and comfortable in his or her role, what increases?
Knowledge base and expertise
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
When answering questions about health during a presentation at a women's club luncheon, the nurse emphasizes that prevention of disease is multifaceted but is connected directly to
a healthy lifestyle
In which situation should a nurse perform an emergency assessment of a client?
shortness of breath
The nurse tells a newly admitted patient that she is going to do a health assessment to help in planning care and educational needs during the patient's hospital stay. Before the physical examination, the nurse should first
take a complete health history
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
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
What are nurses able to detect through the health assessment?
Areas in need of health adjustments
To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be:
Using reputable health-education strategies to reduce risk behaviours
The result of a nursing assessment is the
formulation of nursing diagnoses.
The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable?
objective
An assessment that concentrates on patterns of role performance that all humans share is called what?
Functional
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?
Identification of collaborative problems, Identification of the need for referrals, Formulation of nursing diagnosis(es)
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?
empathy
