HA Chapter 1: The Nurse's Role in Health Assessment Prep U questions

When assisting a client with health promotion, what must the nurse also nurture? A healthy environment Knowledge of the Healthy People 2020 indicators Family communication School/work attendance

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

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? Open the client's airway If the client is injured, protect the cervical spine Begin CPR Ensure that the client is safe

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.

In which situation should a nurse perform an emergency assessment of a client? Shortness of breath Broken arm Body rash Ear pain

An emergency assessment is a very rapid assessment performed in life threatening situations such as drowning, choking, or cardiac arrest. It is also 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. Shortness of breath requires an emergency assessment to promptly assess the client's ability to maintain an adequate airway. A broken arm, body rash, and ear pain require a focused assessment to gather information specific to the problem.

A new order for an antibiotic is received for a client. The nurse reviews the client's electronic medical record. The record states the client has no known allergies. What action should the nurse take? Administer the medication. Ask the client if they have allergies. Double-check in the admission notes for allergies. Hold the medication.

Ask the client if they have allergies. Once the nurse has reviewed the client's chart, the nurse should confirm (validate) the information with the client. The nurse should not assume all information is correct in the chart; validation of client data is essential in order to make valid nursing judgments. The nurse would not administer the medication until the client confirms that there are no allergies. Double-checking the admission notes for allergies will not validate that the client does not have allergies.

A client who underwent abdominal surgery this morning reports feeling weak and dizzy. The nurse also observed a decrease in urine output in the last hour. What action should the nurse take first? Assess the client. Administer IV fluids. Evaluate the outcome. Reevaluate the nursing plan.

Assess the client. Because the client is reporting new symptoms and there is a decrease in urine output, the nurse should first assess the client, then develop a plan, implement the plan (administer intravenous fluids), and evaluate the outcome.

what is the foundation of nursing practice? Planning Assessment Evaluation Intervention

Assessment

A client presents to the health care facility with reports of new onset of 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? Emergency Partial Comprehensive Focused

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

What are the areas of independent nursing practice? Select all that apply. Deciding which medications to administer to the client Deciding when physical procedures should be performed on a client Deciding what client teaching is necessary Deciding what diagnosis a client has Deciding when a client needs to be turned

Deciding when physical procedures should be performed on a client Deciding what client teaching is necessary Deciding when a client needs to be turned

A nurse is gathering subjective data. Which of the following would the nurse be most likely to assess? Feelings of happiness Posture Mood Behavior

Feelings of happiness 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, mood, and behavior are observable and considered objective data.

The nurse enters a client's room and sees that the client appears to be unresponsive. What action should the nurse take first? Call a code. Retrieve a code cart. Assess for a carotid pulse for 10 seconds. Gently shake the client and ask if the client is alright.

Gently shake the client and ask if the client is alright. The nurse needs more information before acting. An emergency assessment must be conducted. Basic life support protocols need to be followed and the first step is to assess responsiveness (ensuring that the client is in fact unresponsive and not, for example, sleeping). The following steps, as needed, are check pulse for 10 seconds, call for help (retrieve code cart), initiate rapid response (call a code).

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? Functional Focused Head-to-toe Body system

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

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? Inspection Therapeutic communication Interviewing Active listening

Inspection 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.

The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process? Each step is independent of the others. It is ongoing and continuous. It is used primarily in acute care settings. It involves independent nursing actions.

It is ongoing and continuous. Although the assessment phase of the nursing process precedes other phases in the formal nursing process, nurses are always aware that assessment is ongoing and continuous throughout all the phases of the nursing process. Therefore, the nursing process should be thought of as circular, not linear.

As a nurse becomes more proficient and comfortable in his or her role, what increases? Confidence and knowledge base Time management and confidence Knowledge base and expertise Expertise and time management

Knowledge base and expertise As the nurse becomes more proficient and comfortable in his or her role, the accountability does not decrease, but the knowledge base and expertise increase to foster confidence.

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. Obtain basic biographic data. Consult clinical resources explaining the client's diagnosis. Validate information with the client.

Review the client's medical record. 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 nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable? The client's age The unit's protocols The client's acuity The nurse's potential for liability

The client's acuity The frequency of ongoing assessment is determined by the acuity of the client. This factor is more important than the nurse's liability, the client's age, or the protocols of the unit.

Why is the nurse always reassessing the client for changes? To never make a mistake when providing care To always have the best nursing care plan To achieve the best results To update the nursing diagnosis

To achieve the best results The nurse or detective is always reassessing the client or case for changes in order to achieve the best results. Each relies on both the science and art of his or her respective profession.

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? collecting information regarding the client's health status stabilizing the client's physical condition developing an effective, respectful nurse-client relationship creating an environment that encourages client autonomy

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.

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed entry. exploratory. focused. comprehensive.

comprehensive. An initial comprehensive assessment involves collection of subjective data about the client's perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client's overall function) as well as objective data gathered during a step-by-step physical examination. Regardless of who collects the data, a total health assessment (subjective and objective data regarding functional health and body systems) is needed when the client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared.

Revising the plan as needed occurs in what part of the nursing process? Assessment Diagnosis Planning Evaluation

evaluation

A client is receiving a unit of packed red blood cells (PRBC). The client develops a low-grade temperature one (1) hour after the blood transfusion was initiated. What type of assessment should the nurse perform? ongoing or partial comprehensive emergency focused

focused Signs and symptoms of reactions to blood transfusion include fever, low blood pressure, increased heart rate, rashes, fluid overload, and back pain. Because a problem arose—the client developed a temperature—the nurse would perform a focused/problem-based assessment. Even though the nurse will continue to perform ongoing or partial assessment to determine if the client is improving, this is not the best action in this situation. A comprehensive assessment would have been performed on admission. Because a low-grade temperature is not life-threatening, the nurse would not conduct an emergency assessment.

The obstetric nurse is performing an initial assessment of a pregnant woman. Which subjective data will the nurse include in the assessment? Select all that apply. fundal height 28 cm (11 inches) health care practices personal medical history number of pregnancies elevated blood pressure

health care practices personal medical history number of pregnancies

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history? cluster the data document the findings determine a problem list perform a physical examination

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.

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? the client's ability to communicate verbally the nurse's ability to ask relevant questions the type and degree of physical issues the client is experiencing the rapport that exists between the nurse and the client

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.

Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern? "Do you have family who visit you regularly?" "What amount of cleaning have you been doing in the past?" "Have you tried to schedule a cleaning service?" "Are you friendly with your neighbors?"

"Do you have family who visit you regularly?" Asking if family visit regularly may provide a link to getting them to assist in cleaning the apartment.

The nurse is reviewing a client's health history and physical examination. Which of the following would the nurse identify as subjective data? Select all that apply. "I feel so tired sometimes" Weight—145 lb Lungs clear to auscultation Client complains of a headache "My father died of a heart attack" Pupils equal, round, and reactive to light

"I feel so tired sometimes" Client complains of a headache "My father died of a heart attack"

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? "Fortunately, assessment only needs to be done at the beginning of your stay." "I'll just need to evaluate you once more, at the end of your stay." "Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end." "I'm sorry, but assessment is ongoing and continuous."

"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.

A client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments? "Nurses focus on the diagnosis and treatment of diseases." "Both are the same and they serve to validate the information collected." "Nurses focus on the diagnosis of actual human responses to disease or life events." "The health care provider focuses on the treatment of human responses caused by diseases."

"Nurses focus on the diagnosis of actual human responses to disease or life events." The medical focus is on diagnoses and treatment of the disease. Nurses focus on diagnoses and treatment of the actual or potential human responses to disease or life events. The assessments are not the same and are not used to validate collected information.

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

"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. If 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.

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which client would the nurse most likely expect to facilitate a referral? An 80-year-old client who lives with her daughter A 50-year-old client newly diagnosed with diabetes An adult presenting for an influenza vaccination A teenager seeking information about contraception

A 50-year-old client newly diagnosed with diabetes During the comprehensive assessment, the nurse identifies problems that require the assistance of other health care professionals. A client who is newly diagnosed with diabetes would benefit from a referral to a diabetes education program. Assistance from other health care professionals would not necessarily be required for the older adult client, the client wanting a vaccination, or the teenager seeking information.

The nurse has been assigned the following clients. Which client requires a focused assessment? A client admitted yesterday with hyperthyroidism with a heart rate of 110 has maintained a heart rate in the 80s for the past 24 hours. A new admission with a history of congestive heart failure has 3+ pitting edema and shortness of breath with exertion. A client who underwent chest tube placement 2 hours prior with 250 mL output this past hour, an increase from 100 mL the hour before, reports feeling a little dizzy. A postoperative client who underwent a laparoscopic cholecystectomy is ready for discharge.

A client who underwent chest tube placement 2 hours prior with 250 mL output this past hour, an increase from 100 mL the hour before, reports feeling a little dizzy. Output from drains should taper, not increase or decrease suddenly. Increased output from a chest tube and a client reporting dizziness could mean the client is losing too much blood. The nurse should perform a focused assessment on this client. A client with hyperthyroidism who has maintained a normal heart rate for 24 hours would require ongoing assessment. A new admission would require a comprehensive assessment. A client ready for discharge would require an ongoing assessment.

The nurse is completing an admission database entry and must include priority nursing diagnoses for the plan of care. Which statement describes a nursing diagnosis? To diagnose the condition and particular illness of the client. A clinical judgment about client responses to health difficulties. The collection of subjective and objective data. Identification of realistic, client-centered goals.

A clinical judgment about client responses to health difficulties. Diagnosis is the clustering of data to make a judgment or statement about the client's difficulty or condition. NANDA International (NANDA-I, 2012) defines nursing diagnosis as "a clinical judgment about individual, family or community responses to actual or potential health difficulties/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable."

While assessing a client, the nurse notes that the client is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process? emotional social mental spiritual

A subdued affect would be part of the emotional assessment.

When making rounds, the RN should prioritize follow-up care for which client? An oncology client with a cough but no fever. A client who is receiving intravenous antibiotics for pneumonia. A client with strong, equal pedal pulses following catheterization. A client who is due for a routine shift assessment.

An oncology client with a cough but no fever. The nurse should prioritize care for the oncology client, because immunosuppression due to chemotherapy is a concern. The immunosuppressed client can still exhibit a respiratory infection without fever. The clients require routine assessments with no immediate concerns.

The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data? Family history Occupation Appearance History of present health concern

Appearance Appearance is something that can be directly observed by the nurse and is considered objective data. Present concern, family history, and occupation are considered subjective.

What are nurses able to detect through the health assessment? Areas that need continuous care Areas that need in-hospital care Areas that need referral to a specialist Areas in need of health adjustments

Areas in need of health adjustments 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? Review the client's medication administration record for analgesic use. Ask the client about the most recent experiences of pain. Meet with the client's spouse and daughter to discuss the client's pain. Collaborate with the physician who is treating the client.

Ask the client about the most recent experiences of pain. 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 Asking the appropriate questions Formulating a nursing diagnosis Creating a nursing care plan

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.

A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse? Assess the nasogastric tube for proper functioning. Intervene by pulling out the nasogastric tube. Evaluate output in an hour. Develop a plan of care.

Assess the nasogastric tube for proper functioning. Drainage should taper off gradually, not increase or decrease abruptly. The nurse needs to assess proper functioning of the nasogastric tube. The nurse should not intervene before assessing the tube. The nurse should not wait another hour to evaluate output. The nurse does not have enough information to develop a plan.

A nurse has documented the findings of a comprehensive assessment of a new client. What is the primary rationale that the nurse should identify for accurate and thorough documentation? Guaranteeing a continual assessment process Identifying abnormal data Assuring valid conclusions from analyzed data Allowing for drawing inferences and identifying problems

Assuring valid conclusions from analyzed data Documentation of assessment data is an important step in assessment because it forms the database for the entire nursing process and provides data for all other members of the health care team. Thorough and accurate documentation is vital to ensure valid conclusions are made when the data are analyzed in the second step of the nursing process. This rationale supersedes the other listed goals, although each is valid.

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? Determine if pertinent data has been omitted Identify the need for referral Avoid biases and judgments Construct a plan of care

Avoid biases and judgments 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.

Which assessment finding should the nurse document as objective data? Biographical information Body functions Lifestyle practices Personal relationships

Body functions Subjective data is what the client tells the nurse. Objective data is what the nurse assesses or observes when performing care of a client.

For which of the following clients should a nurse perform a focused assessment? Client with elevated blood pressure with no previous history of heart problems Client with 4-day history of sore throat and fever with enlarged lymph nodes Client with right upper abdominal pain that radiates into the groin area Diabetic with elevated blood sugars for the past 2 weeks

Client with 4-day history of sore throat and fever with enlarged lymph nodes A client with a sore throat and fever with enlarged lymph nodes requires only a focused assessment by the nurse. A focused assessment consists of a thorough assessment of a particular client problem. An elevated blood pressure with no previous history of heart problems requires an initial comprehensive assessment. Right upper abdominal pain that radiates into the groin area is an emergency situation and the nurse should collect only the data necessary to make a quick diagnosis for immediate treatment (emergency assessment). A client with diabetes has a chronic, ongoing health problem that needs reassessment and possibly a change in treatment (ongoing or partial assessment).

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? Perform a musculoskeletal examination. Collect subjective and objective data related to overall function. Take anthropometric measurements. Obtain a 24-hour diet recall.

Collect subjective and objective data related to overall function. The nurse is responsible for collecting subjective and objective data related to the client's overall function. The physical therapist performs a musculoskeletal examination. A dietitian may take anthropometric measurements in addition to a subjective nutritional assessment, such as a 24-hour diet recall.

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first? Collect objective data Validate the data Collect subjective data Document the data

Collect subjective data

A nurse has received a report on a client who will soon be admitted to the medical unit from the emergency department. When preparing for the assessment phase of the nursing process, which of the following should the nurse do first? Collect objective data. Validate important data. Collect subjective data. Document the data.

Collect subjective data. During assessment, subjective data are collected prior to objective data. This is followed by validation and then documentation of data.

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain? Teaching the client to draw knees to chest to help minimize the pain Planning care to help minimize the client's pain Collecting data regarding the nature of the pain Identifying pain management interventions with input from the client

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.

What is the nurse's focus while conducting a health assessment with a client? (Select all that apply.) Completing the health history. Interpreting findings. Formulating a plan of care Implementing a plan of care. Conducting a physical examination.

Completing the health history. Conducting a physical examination. A health assessment is comprised of the taking the client's health history then followed by a physical examination. Interpreting findings, formulating a plan of care, and implementing a plan of care are steps within the nursing process that use the data identified by the health assessment.

The nurse notices a large number of positions available for employment in managed care. Which are reasons for the growth in nursing opportunities in this care environment? Select all that apply. Complex acute care Aging of baby boomer generation Expanding health service networks Uncontrollable costs for health care Expanding health needs of single parents

Complex acute care Aging of baby boomer generation Expanding health service networks Expanding health needs of single parents

Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first? Perform a comprehensive head-to-toe assessment. Conduct a focused assessment. Notify the health care provider. Alert the critical assessment team.

Conduct a focused assessment. Because a comprehensive assessment had already been conducted, the nurse would perform a focused assessment based on the observed neurological changes. The nurse would need to obtain more information before alerting the critical assessment team or contacting the health care provider; some actions would include completing the physical neurological exam, checking blood glucose, checking for changes in medications that may have contributed to the change in mental status, and reviewing the a.m. labs for abnormal sodium level.

During a health assessment, the client identifies having a 1 pack per day smoking habit. What should the nurse initially focus upon when approaching the client about the benefits of smoking cessation? Determining whether the client wants to stop smoking Educating the client on the detrimental effects smoking has on the entire body. Identifying smoking as a modifiable risk factor for the client. Sharing with the client that there are various smoking cessation methods available.

Determining whether the client wants to stop smoking Smoking cessation requires a dramatic change in behavior. The client must be truly motivated in order for such a change to occur. The nurse should initially discuss with the client if smoking cessation is a goal that the client may have. If the client is interested in no longer smoking, the remaining options are less relevant. Explaining the detrimental effects of smoking, identifying smoking as a modifiable risk factor and educating the client to the various smoking cessation methods are beneficial when discussing the situation with a client who has not yet made the decision to stop smoking.

The nurse reviews the laboratory values of a client and observes a decrease in the client's hematocrit and hemoglobin since admission. The nurse reviews the client's vital sign trend since admission and sees the BP has been decreasing as well. What is the best action of the nurse? Analyze the data. Evaluate outcomes. Implement interventions. Develop a nursing diagnosis.

Develop a nursing diagnosis. The nurse has already clustered and analyzed the data, identified a client concern (possible blood loss causing a decrease in blood pressure), and should now develop a nursing diagnosis (for example, hypotension). After developing a nursing diagnosis, the nurse would develop a plan including interventions, implement the plan, and evaluate the outcomes.

The nurse performs an assessment on a newly admitted client. Data analysis reveals temperature 100.9 F (38.3 C), BP 82/58 mm Hg, 02 Saturation 91% RA, productive cough, lethargy, diaphoresis, WBC 15,000 mm3, Hemoglobin 9 g/dL, Hematocrit 29%. What action should the nurse take next? Develop diagnosis. Implement interventions. Develop a plan of care. Evaluate outcomes.

Develop diagnosis. According to the nursing process, once data have been collected, the nurse analyzes the data and develops nursing diagnoses. Once nursing diagnoses (actual and potential) are developed, the nurse plans interventions to improve outcomes. The interventions are then implemented and outcomes are evaluated. Reference:

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

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.

In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation? Current physiologic status Effect of health on functional status Past medical history Motivation for adherence to treatment

Effect of health on functional status The comprehensive health assessment focuses on how the client's health status affects the activities of daily living and how the client's activities and choices affect health status. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. In addition, the nurse assesses how clients interact within their family and community, and how the clients' health status affects the family and community. In contrast, the physician performing a medical examination focuses primarily on the client's physiologic development status, with less focus on psychological, sociocultural, or spiritual well-being.

An adult client is being admitted to the hospital for a cardiac catheterization related to chest pain and shortness of breath on exertion. What kind of assessment is the admitting nurse going to perform? Focused Comprehensive None, the cardiac catheterization will provide all needed information Emergency

Emergency The emergency assessment involves a life-threatening or unstable situation, such as a client in an emergency department (ED) who has experienced trauma. Focused and comprehensive assessments are not used in a life-threatening situation. The cardiac catheterization alone will not be sufficient.

The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg, O2 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process? Develop a nursing diagnosis. Implement an intervention. Evaluate an outcome. Perform an assessment.

Evaluate an outcome. The nurse has already assessed the client, analyzed the data, determined the client was hyperthermic (nursing diagnosis), and administered a medication (implemented an intervention); therefore, the next step is to evaluate the client's response.

A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next? Cluster client cues. Evaluate outcome. Identify client concerns. Implement an intervention.

Evaluate outcome. Because the nurse implemented an intervention (in this case, applied oxygen), the nurse would next evaluate the effectiveness of the intervention. The first step in the nursing process is gathering data (objective and subjective) and then validating and documenting the data. The second step is analyzing the data, clustering client cues to identify client concerns and prioritize client concerns (diagnosis). The third step is developing a plan with interventions. In the fourth step the nurse implements the interventions, and in the last step the nurse evaluates the effectiveness of the interventions.

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 Implementation Evaluation

Evaluation 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.

A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify? Expansion of health care networks Decrease in client participation in care The shrinking cost of medical care Public mistrust of physicians

Expansion of health care networks Opportunities for nurses with advanced assessment skills will be enhanced by the expansion of health service networks, increasing complexity of acute care, growing aging population with complex morbidities, expanding health care needs of single parents, increasing impact of children and homeless on communities, intensifying mental health issues, and increasing reimbursement for health care promotion and preventive services. Public mistrust of physicians is not a noted phenomenon.

A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? Comprehensive assessment Ongoing assessment Focused assessment Emergency assessment

Focused assessment The nurse would most likely perform a focused assessment, which is done when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A comprehensive assessment is completed for this client when he or she first visited the office. An ongoing assessment is completed to evaluate problems identified earlier, to determine any changes. This would be the type of assessment done when the client returns after receiving treatment for current complaints. An emergency assessment is done if the client presented with with a life-threatening complaint or problem.

The nurse reviews data collected while completing a comprehensive assessment with a client. Which information should the nurse identify as being subjective data? Skin warm and dry Follows a Kosher diet Heart rate 72 and regular Hemoglobin level 9.9 mg/dL

Follows a Kosher diet Subjective data includes information that is elicited and confirmed by the client. It cannot be measured. Objective data is that which can be measured or directly observed such as skin texture and temperature, heart rate, and hemoglobin level.

An assessment that concentrates on patterns of role performance that all humans share is called what? Head-to-toe Body systems Focused Functional

Functional 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.

Which of the following is an example of a recent trend in nursing roles? Gathering forensic evidence for a legal proceeding Using auscultation to examine heart sounds Using palpation to assess the abdomen of a pregnant woman Performing visual inspection of a client's eyes to detect illness

Gathering forensic evidence for a legal proceeding Forensic nursing is an example of one of the rapidly evolving roles of nursing that requires extensive focused assessments and the development of related nursing diagnoses. Auscultation, palpation, and inspection are all techniques that have been used by nurses for over 100 years.

The nurse prepared to complete a comprehensive health assessment on a client in the community. What should the nurse expect to complete when performing this assessment? Select all that apply. Health history Wellness teaching Physical examination Outcome identification Medication administration

Health history Physical examination A comprehensive health assessing includes a health history and physical examination. Wellness teaching cannot be done until the client's needs are identified. Outcome identification is a part of planning. Medication administration is a part of implementation.

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. 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 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. Identify a collaborative problem that should involve the occupational therapist. Make a referral to the unit's social work department. Reassess the client's blood glucose level.

Identify a nursing diagnosis of Ineffective Health Maintenance. 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.

The nurse prepares to analyze a list of a client's health problems. In which order will the nurse complete critical thinking of these problems? Drag statements into the proper order. Cluster the data. Identify abnormal data and strengths. Draw inferences and identify problems. Propose possible nursing diagnoses. Check for defining characteristics of the diagnoses. Confirm or rule out nursing diagnoses.

Identify abnormal data and strengths. Cluster the data. Draw inferences and identify problems. Propose possible nursing diagnoses. Check for defining characteristics of the diagnoses. Confirm or rule out nursing diagnoses. When performing data analysis, the nurse begins by identifying abnormal data and strengths and then clusters the data. Then inferences are drawn and problems identified. Possible nursing diagnoses are then determined before the nurse checks for their defining characteristics. Before documenting, the nurse confirms the nursing diagnoses, ruling out any that are inappropriate for the client's problems.

As part of the nursing profession, nurses function as client advocates. What is one way in which a nurse advocates for a client? Identifying the side effects of treatment Providing client teaching about the family history of disease Assisting families to optimal states of client interaction Keeping the client disease free

Identifying the side effects of treatment Nurses advocate for clients in many ways: keeping them safe, communicating their needs, identifying the side effects of treatment and finding better options, and helping clients to understand their diseases and treatments so that they can optimize self-care. Advocacy does not include teaching about a family's history of disease, assisting the family to optimal states of client interaction, or keeping the client disease free.

A nurse analyzes the data obtained from an initial assessment of a new client: weight gain of 15 lbs in 3 months, intolerance to cold, constipation, and lethargy. The nurse determines the client may have hypothyroidism and develops several nursing diagnoses with interventions to address the client concerns. Which action should the nurse take next? Implement interventions. Reassess the client. Evaluate outcomes. Cluster cues.

Implement interventions. Because the nurse has already assessed the client, analyzed the data, clustered the client cues, identified client concerns, and developed a plan with interventions, the next step in the nursing process would be to implement the interventions. The nurse would reassess the client after the interventions were implemented and evaluate the outcomes.

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? Physical assessment and health history Individual student interview and questionnaire Review of literature and consultation with faculty Walk-through of education facility and faculty questionnaire

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.

The nurse is performing a health assessment on a community-dwelling client who is recovering from hip replacement surgery. Which of the following actions should the nurse prioritize during assessment? Focus the assessment on the client as a member of her age group. Interpret the information about the client in context. Corroborate the client's statements with trusted sources. Gather information from a variety of sources.

Interpret the information about the client in context. The client must be viewed holistically. Many systems are operating to create the context in which the client exists and functions. The nurse sees an individual client, but accurate interpretation of what the nurse sees depends on perceiving the client in context. Culture, family, and community operate as systems interacting to form the context. Information does not normally need to be corroborated. The client's age is not the nurse's primary focus.

Before beginning a health assessment with a client, the nurse reviews Healthy People 2030 because of which of the following reasons? It helps determine the client's plan of care. It serves as a guide for the health assessment. It identifies heath indicators, appropriate interventions, and resources. It addresses most client health problems.

It identifies heath indicators, appropriate interventions, and resources. Healthy People 2030 is a framework that identifies heath indicators, appropriate interventions, and resources 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 2030 does not help determine every client's plan of care. Healthy People 2030 does not serve as a guide for the health assessment nor does it list specific interventions to address specific health problems. Instead, Healthy People 2030 indicators pertinent to individuals are determined as the nurse completes the health assessment on each patient.

Student nurses are learning about evidence-based practice. What would they learn is the final step in this process? Searching the literature for research Evaluating research evidence using their own criteria Identifying the issue or problem based on an analysis of current nursing knowledge and practice Justifying the selection of interventions

Justifying the selection of interventions 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 client has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this client? Knowledge deficit Ineffective coping Nutrition: less than body requirements Acute pain

Knowledge deficit A knowledge deficit diagnosis is appropriate for any new diagnosis and/or medication.

An instructor is describing a comprehensive nursing health assessment to a group of students. The instructor determines that the teaching was successful when the students identify which of the following as the overall purpose? Collect large quantities of data Assist the physician Validate previous data Make a clinical judgment

Make a clinical judgment The purpose of a nursing health assessment is to collect subjective and objective data to determine a client's overall level of functioning to make a professional clinical judgment.

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

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.

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? Encourage the client to increase oral fluid intake. Provide the client with a bedtime protein snack. Assist the client with personal hygiene. Measure the client's blood glucose four times daily.

Measure the client's blood glucose four times daily. 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? Measuring blood glucose level, cholesterol level, blood pressure, and resting heart rate Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings Performing an x-ray, ECG, exercise stress test, and complete blood count Assessing the client's range of arm motion, auscultating for heart sounds, testing for pupil dilation, and conducting a vision test

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.

An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession? Natural senses Biomedical knowledge Simple technology Critical pathways

Natural senses Early on, nurses relied on their natural senses to perform assessment. Early nursing assessment was based on observation of the client's face and body for changes indicating improvement or deterioration of the client's condition.

How does a nurse decide what health-promotion activities are necessary for a particular client? Nurses address areas associated with healthy behaviors only Nurses collaborate with clients to identify areas in which clients are willing to make changes Nurses assess areas in which clients are willing to make changes only Nurses construct their own theories to identify perceptions, barriers, and positive outcomes

Nurses collaborate with clients to identify areas in which clients are willing to make changes Rather than addressing all areas associated with healthy behaviors and overwhelming clients, nurses collaborate with them to identify areas in which clients are willing to make changes. When caring for a client, a nurse does not address healthy behaviors only; nurses do not address only areas where clients are willing to make changes, nor do they construct their own theories to identify perceptions, barriers, and positive outcomes.

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? Planning Evaluation Implementation Nursing diagnosis

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.

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 Nursing goal Nursing evaluation Nursing assessment

Nursing intervention

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? Emergency Ongoing Focused Comprehensive

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.

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? Initial comprehensive Ongoing or partial Focused or problem-oriented Emergency

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 nurse prepares to collect objective data on a client new to a health clinic. What will the nurse use to collect this data? Select all that apply Palpation Inspection Percussion Auscultation The medical record

Palpation Inspection Percussion Auscultation Objective data is obtained by general observation and through the use of the physical assessment techniques: palpation, inspection, percussion, and auscultation. Even though the medical record would be a source of objective data, the client is new to the health clinic and medical record data would not exist.

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? Physiologic, psychological, sociocultural, developmental, and spiritual data Focuses primarily on the client's physiologic development status Involves the client's musculoskeletal system and activities of daily living Focuses only on the client's psychological, sociocultural, and spiritual well-being

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 client admitted with reports of nausea and vomiting has not reported any vomiting in the last 6 hours. What initial response should the nurse have regarding this assessment information and its effect on the client's nursing plan of care? Request that the health care team revise the plan of care. Notify the primary health care provider of the change in the client's health status . Recognize the need to reevaluate the client's plan of care. Monitor the client frequently for other changes in health status.

Recognize the need to reevaluate the client's plan of care. The health assessment allows data to be collected that is specific to the client and his or her nursing care needs. Initially, the nurse must be aware that any change to the client's health status may require an change to this plan of care. If changes are required, the health care team will be asked to consider and recommend them. Monitoring the client for changes is always considered a nursing responsibility. Notifying the primary health care provider is not directly related to the nursing plan of care.

What are the components of the SBAR? Select all that apply. Situation Biophysical test results Assessment Referral Recommendation

Situation Assessment Recommendation One system by which nurses can communicate information and make referrals of clients to other health care providers (e.g., dieticians, speech therapists) is the SBAR (situation, background, assessment, recommendation) framework. Components of SBAR do not include biophysical test results or referral.

Why is it important for a new nurse, working on a step-down unit, to know the standards of care for the facility in which the nurse is working? Standards of care often set the time frame for assessing the clients on the unit Standards of care dictate how to handle clients who have experienced trauma Standards of care instruct the nurse how to assess for a cardiac event Standards of care tell the nurse how to get a good evaluation

Standards of care often set the time frame for assessing the clients on the unit Clients in intensive care settings have vital signs and a focused assessment hourly. A facility's standards of care often prescribe such time frames, so it is important for the nurse to identify those standards for the unit and facility in which the nurse is working. Standards of care do not dictate how to handle a trauma client; they do not instruct the nurse how to assess for a cardiac event or tell the nurse how to get a good evaluation.

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 motivation for change The client's medical comorbidities The client's learning style The client's prognosis for recovery

The client's motivation for change 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.

During a health assessment, the nurse learns that an adolescent is sexually active. What information can the nurse provide the client in order to support the Healthy People 2030 indicator of responsible sexual behavior? The importance of using a condom when engaging in sexual activity The importance of abstaining from sexual activity unless in a monogamous relationship The need for frequent diagnostic testing for sexually transmitted infections The need to reduce the percentage of adolescents who are HIV positive

The importance of using a condom when engaging in sexual activity An objective to support the Healthy People 2030 indicator of responsible sexual behavior is to increase the proportion of sexually active persons who use condoms. The nurse should instruct the client about condom use with sexual activity. The objectives of Healthy People 2030 do not include promoting sexual abstinence. While diagnostic testing and reducing the percentage of adolescents diagnosed with HIV may be worthwhile goals, they are not identified as such by Healthy People 2030.

Four broad goals describe the role of a professional nurse. What is one of these goals? To diagnose illness To counsel about human responses to health or illness To advocate for individuals, families, communities, and populations To prescribe medication

To advocate for individuals, families, communities, and populations Four broad goals within nursing are (1) to promote health (state of optimal functioning or well-being with physical, social, and mental components); (2) to prevent illness; (3) to treat human responses to health or illness; and (4) to advocate for individuals, families, communities, and populations. Nursing goals do not include diagnosing illness, counseling about human responses to health or illness, or prescribing medications.

What is the primary function of the health care team? To work together to obtain maximum coverage To decide the best overall care To guide the client's care throughout times of crisis To develop an individual focus for each member

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 trying to decide whether to recommend that a pregnant client be screened for HIV. Which of the following resources would best help in this decision? Pender Health Promotion Model Health Belief Model Healthy People 2030 U.S. Preventive Services Task Force

U.S. Preventive Services Task Force The U.S. Preventive Services Task Force (USPSTF) determines risk versus benefit in screenings. 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. The Pender Health Promotion Model proposes that individual characteristics and experiences affect behavior-specific cognitions and affect, which in turn yield the level of commitment to a plan. Healthy People 2030 is a model developed by the U.S. Department of Health and Human Services that focuses on increasing the life span and improving the quality of health for Americans.

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? Follows the ABC approach Uses evidence-based techniques Asks unlicensed staff to measure vital signs Focuses on the system that caused the hospitalization

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

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be: Ascertaining past and current use of health care services Determining client stress levels related to lifestyle choices Using reputable health-education strategies to reduce risk behaviors Understanding the health problems that clients experience in everyday life

Using reputable health-education strategies to reduce risk behaviors A central component of health promotion involves helping clients to develop personal health practices and to enhance coping skills, which are results of health education that emphasizes client knowledge for directing choices and actions. While the other given factors may hold significance for many individuals, they are not as salient as health education.

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. Validate data Document data Collect objective data Analyze outcome data Collect subjective data

Validate data Document data Collect objective data Collect subjective data 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.

The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next? Leave the inhalers with the client to self-administer. Validate that the client understands how to use the inhalers. Ask the client if they need any assistance with the inhalers. Provide privacy for the client to administer the inhaler

Validate that the client understands how to use the inhalers. The nurse should not assume that the client knows how to administer their medications. The nurse should always validate information, for example, that the client knows how to properly administer the inhalers. If the nurse does not validate that the client knows how to properly administer medication, the treatment may be ineffective.

The nurse working in the emergency room has been assigned the following clients. Which client requires an ongoing assessment? a client admitted with acute atrial fibrillation who has a heart rate of 150 bpm and irregular heart rhythm a client admitted with a leg fracture who is reporting sudden shortness of breath and a rash a newly admitted client who was involved in a motor vehicle incident with a head injury and reports a headache of 3 on a scale of 1-10 a client admitted 2 days ago with exacerbation of chronic obstructive pulmonary disease with an oxygen saturation of 90% on 2L nasal cannula who reports ease of breathing

a client admitted 2 days ago with exacerbation of chronic obstructive pulmonary disease with an oxygen saturation of 90% on 2L nasal cannula who reports ease of breathing A client with improvement of symptoms would need ongoing assessments. Because it can be life-threatening for the client to have an irregular, fast heart rate (atrial fibrillation) of 150 BPM, an emergency assessment should be conducted for that client. The client with large bone fractures with sudden shortness of breath would require an emergency assessment; this client is at high risk for fat emboli, which could cause pulmonary embolism or stroke, and fat embolism syndrome, which can cause multi-organ failure if not treated in a timely manner. A newly admitted client would require a comprehensive assessment.

After performing a comprehensive assessment on a client, the nurse notes the following. Which part of the nursing process is the nurse performing? Nursing Notes: ● Client reports pain in bilateral lower extremities when walking short distances, relieved with rest. ● Pulses are weak, barely palpable in bilateral lower extremities. ● Bilateral feet are cool to touch ● Total cholesterol > 200. ● Client smokes two packs of cigarettes daily for past 20 years. documentation of subjective assessment findings development of priority nursing diagnosis analysis of assessment findings implementation of interventions

analysis of assessment findings The nurse is analyzing the findings by clustering the cues collected during assessment to determine if a client concern (nursing problem) exists. The notes contain both subjective and objective information related to peripheral arterial disease. The nurse would develop a problem-based plan based on these cues of impaired tissue perfusion and develop and implement interventions to improve the client's circulation. Documentation of the subjective assessment findings occurs during assessment. Once the assessment findings are analyzed, priority nursing diagnoses will be developed and interventions implemented.

A nurse is conducting a health assessment. How will the information collected from the client be used? as a basis for the nursing process to illustrate nursing competence to facilitate nurse-client caring as one component of medical care

as a basis for the nursing process 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.

When planning a community program related to Healthy People 2030, the critical first step involves defining the community assessing the community formulating questions to ask community leaders planning an introductory program for the community

defining the community To determine what is needed in a program, the community must first be defined to narrow the focus and plan specific interventions.

When the nurse collects objective data, which finding requires immediate follow-up? cerumen in the ear acne lesions on the face and upper chest moist nasal mucosa enlarged lymph node in the neck

enlarged lymph node in the neck Objective data may be obtained by direct observation or physical examination using the four examination techniques of inspection, auscultation, palpation, and percussion. Cerumen in the ear (ear wax) is a normal objective finding during a physical examination and does not require immediate attention. Acne lesions on the face and upper chest may be a chronic condition and do not require immediate attention. Moist nasal mucosa is a common finding and does not require immediate attention. Usually lymph nodes are small, distinct, and mobile. An enlarged lymph node suggests inflammation and requires an immediate follow-up with a reexamination of the area where it drains.

Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next? assessment diagnosis planning evaluation

evaluation Because the nurse administered the insulin, the effectiveness of the insulin needs to be evaluated. The nurse already assessed the client, diagnosed the client with hyperglycemia, and implemented a plan to treat the hyperglycemia.

A 38-year-old client has been admitted to the emergency department (ED) with reports of abdominal pain and vomiting for the past 6 hours. Which type of assessment will the nurse complete on this client? focused assessment comprehensive assessment emergency assessment ongoing assessment

focused assessment A focused assessment may occur in all health care settings. It is smaller in scope than a comprehensive assessment, but more in depth related to the problem being presented. It usually involves one or two body systems. Data gathered and analyzed will determine the cause of the client's report. A comprehensive assessment includes the collection of objective data (data gathered during a step-by-step physical examination) and subjective data (the client's perception of the health of all body parts or systems, past health history, family history, lifestyle and health practices, including overall functioning). An emergency assessment is a very rapid assessment performed in life-threatening situations. In such situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment.

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) ongoing or partial assessment. focused or problem-oriented assessment. emergency assessment. initial comprehensive assessment.

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.

The nurse is conducting a health assessment on a client presenting to the emergency room with a critical condition. The nurse should initially ask questions regarding which topic(s) during the initial assessment? Select all that apply. medications allergies adverse reactions lifestyle changes stress at work

medications allergies adverse reactions The nurse should ask a client in critical condition brought into the emergency department about topics concerning the event, including medications, allergies, and adverse reactions. When a client has a professional relationship with the nurse and has had a thorough health assessment at the initial meeting, the nurse may explore other assessment topics such as lifestyle changes and stress at work. The thorough health history would be completed when the client was stable and able to answer further questions.

The nurse notes that an intervention provided to a client for a specific health problem was not effective. The nurse continues to monitor and care for the client. Which type of assessment is the nurse performing? initial comprehensive focused or problem oriented emergency ongoing or partial assessment

ongoing or partial assessment The nurse continues to assess the client, monitoring client progress and outcomes. Client problems that were initially assessed will be reassessed to evaluate for improvement or deterioration (change of condition). A comprehensive assessment occurs prior to an ongoing or partial assessment. An ongoing or partial assessment is completed by the nurse after a comprehensive database has been established. A focused or problem-oriented assessment is performed when a specific problem has been identified, which is not indicated in the client scenario. An emergency assessment would be performed during life-threatening situations, which is not indicated in the client scenario.

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. 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.

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

primary prevention Exercise and healthy eating improve wellness and help protect from disease and disability, which is primary prevention.

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? lives alone significantly impaired hearing widowed 2 years ago greatly concerned about cost of services

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.

A nurse is performing a focused assessment on a client admitted with symptoms of meningitis who underwent a lumbar puncture this morning and is now reporting a headache and photophobia. The nurse identifies clear drainage on the dressing and redness and swelling around the site. The nurse documents which of the following objective findings in the chart? Select all that apply. headache swelling photophobia redness around the site clear drainage on dressing

swelling redness around the site clear drainage on dressing

The nurse discusses ear plugs for a client with low tone deafness when working in a noisy environment. The nurse is utilizing tertiary prevention primary prevention secondary prevention

tertiary prevention Tertiary prevention decreases the effects of a disease and prevents additional loss. Ear plugs will help decrease further hearing loss.

The nurse is assigned the following clients. Which client requires an emergency assessment? the client who underwent a hysterectomy yesterday and is now reporting shortness of breath and has decreased oxygen saturations the client admitted with small bowel obstruction who underwent surgery this morning and is now reporting incisional pain 7 out of 10 the client admitted with a fractured arm who reports some numbness and tingling in the fingers the client admitted with chest pain yesterday who now denies pain after nitroglycerin administration

the client who underwent a hysterectomy yesterday and is now reporting shortness of breath and has decreased oxygen saturations A client reporting difficulty breathing and who has decreased saturations requires an emergency assessment. This client might be suffering from a pulmonary embolism. Pain after surgery is common; this client would require a focused assessment. Some tingling and numbness in the fingers is common after a cast is placed; this client needs a focused assessment. The nurse would conduct an ongoing/partial assessment on a client with chest pain that has been relieved.

The nurse is gathering objective information from the medical record of a newly admitted client to the medical-surgical unit of an acute care facility. Which of the following data would the nurse consider as a priority in assessing the client? Select all that apply. the client's medical diagnosis recent abnormal laboratory findings the client's recent divorce the client's tonsillectomy 45 years ago recent changes in the client's blood pressure readings

the client's medical diagnosis recent abnormal laboratory findings recent changes in the client's blood pressure readings