Health Assessment Missed PrepU Questions cha 1

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 unit's protocols The client's age The nurse's potential for liability The client's acuity

The client's acuity. key word: "creating a plan of nursing care" acuity is seeing or understanding things clearly

Why is the nurse always reassessing the client for changes?

To achieve the best results The nurse, like a detective, is always reassessing the patient and their case for changes in order to achieve the best results.

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?

Uses evidence-based techniques. evidence-based assessment - collection of data about the individual's health state - subjective data - objective data - database - diagnostic reasoning

A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time?

emergency. A patient who presents with a new problem of a serious or critical nature would require an emergency assessment to determine the patient's current status. A focused assessment is completed on a patient who has already had a comprehensive examination and is being seen for a follow-up visit.

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. A focused assessment is completed on a patient who has already had a comprehensive examination and is being seen for a follow-up visit. A patient who presents with a new problem of a serious or critical nature would require an emergency assessment to determine the patient's current status.

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?

ongoing or partial assessment.

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?

Conduct a focused assessment.

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?

Evaluate an outcome.

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 - Emotional health is the ability to handle life and its challenges that may arise. The ability to be resilient and use coping mechanisms effectively, including strong relationships with others, are recognized.

A client requires soft wrist restraints. What assessments should the nurse perform to ensure the client's safety? Select all that apply. hydration status skin integrity elimination circulation gait

- hydration status - skin integrity - elimination - circulation Learning about the patient's physical, emotional, social, financial, occupational, environmental, intellectual, and spiritual beliefs and issues contributes to a well-rounded history.

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

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?

Comprehensive However, if this patient is now stable and the acute condition has subsided, the nurse needs to complete a comprehensive health assessment to evaluate all body systems to better decide which system is contributing to the patient's current problem

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

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.

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?

Nursing diagnosis. A medical diagnosis refers to the disease process and illness. This diagnosis is at the discretion of the physician. In contrast, the focus of the nursing analysis is on the patient's response to the medical condition or disease.

A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?

Nursing process. nursing process - The ability of the nurse to extrapolate the findings, prioritize them, and finally formulate and implement the plan of care is the overall goal.

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

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should consult with the client's family members. analyze data that have already been collected. avoid premature judgments about the client. review any past collaborative problems

avoid premature judgments about the client. - The care plan is evaluated periodically, and changes are made to update the plan. The nurse, like a detective, is always reassessing the patient and their case for changes in order to achieve the best results.

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?

focused - A focused assessment is completed on a patient who has already had a comprehensive examination and is being seen for a follow-up visit.

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 Key words: "has been admitted" & "with reports of ... past 6 hours" - A focused assessment is completed on a patient who has already had a comprehensive examination and is being seen for a follow-up visit.

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

physiologic status. An example is the medical diagnosis of hypertension; the physician focuses on figuring out the etiology of the disease and how to treat the high blood pressure using medical or surgical interventions. The nurse focuses on how to treat the patient's potential responses, such as fear of the diagnosis, risk of falling related to the potential for fainting, lack of knowledge regarding new medications, and the need for education about lifestyle changes involving diet and exercise.

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.

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment?

Establish a baseline for the comparison of future health changes. key word: "new to the clinic"

A client who was alert and oriented at the start of the shift is now presenting with diaphoresis, confusion, and lethargy. The client received NPH 20 units insulin sliding scale (Lispro/ Humalog). Based on this information, what type of assessment should the nurse perform on the client?

focused - A focused assessment is completed on a patient who has already had a comprehensive examination and is being seen for a follow-up visit.