Holistic Assessment PrepU questions
A nurse is conducting a review of systems with a client and is asking about his ears. The nurse asks, "Do you have any problems with your ears or your hearing?" The client stares blankly at the nurse a moment and then says, "I'm sorry—could you repeat that?" The nurse repeats the question, to which the client replies, "No." The nurse then asks, "Do you ever experience any trouble hearing or any ringing, buzzing, or earaches?" The client responds, "No." What should the nurse record under "Ears" in the review of systems section of the client's health history?
"denies any trouble hearing or any ringing, buzzing, or earaches"
A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?
"what other symptoms occurred during the spell?"
When assisting a client with health promotion, what must the nurse also nurture?
A healthy environment
A nurse is interviewing an adult client who had a miscarriage 3 weeks ago. The woman is crying and is having difficulty talking. The nurse moves closer and places a hand on the woman's hand. What type of communication is this?
Active listening
A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client?
Airway
What are nurses able to detect through the health assessment?
Areas in need of health adjustments
A nurse collects data about a client's family health history. Which family member's health problems should the nurse include when documenting this information in the database?
As many maternal and paternal relatives as the client can recall
How does a nurse best facilitate the nursing health assessment?
Asking the appropriate questions
Data collection occurs where in the nursing process?
Assessment
The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should
Avoid premature judgements about the client
Which assessment finding should the nurse document as objective data?
Body functions
During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?
Chief complaint
What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain?
Collecting data regarding the nature of the pain
The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus?
Coping-stress-tolerance
When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what?
Diagnosis
During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?
Environmental
A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?
Evaluation
Revising the plan as needed occurs in what part of the nursing process?
Evaluation
An assessment that concentrates on patterns of role performance that all humans share is called what?
Functional
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 is working with an obese man who has type II diabetes mellitus. After interviewing this client, the nurse has established that he is aware of the seriousness and risks of his conditions, is motivated to make lifestyle changes to improve his health, and believes that following the diet and exercise plan that the nurse has helped him create is feasible and would be effective in helping him meet his health goals. The nurse is using which of the following tools or resources in assessment of this client?
Health Belief Model
While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is
How do you manage your stress?
When doing an overall assessment of a client, the nurse is able to utilize findings and do what?
Identify in what areas the client needs the most care
A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information?
Lifestyle and health practices profile
Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data?
Maintain a professional distance during assessment
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?
Making incorrect nursing judgments or diagnoses
Which of the following is the best example of holistic data collection by a nurse?
Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings
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
After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?
Ongoing
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?
Ongoing or partial
The nurse is reviewing the medical record before meeting a new client. In which phase of the interview process is the nurse working?
Pre-interview/Pre-introduction
The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?
Primary
During a health history a client recalls the date when being first diagnosed with hypertension. Which term should the nurse use to categorize the quality of the client's data?
Reliable
A nurse is working with a client who has AIDS. Which of the following is an example of subjective data that might be gathered for this client?
The client's pain level
A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data?
The client's range of motion in her right arm
The result of a nursing assessment is the
The formulation of nursing diagnoses
What is the primary function of the health care team?
To decide the best overall care
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment?
To determine any changes from the baseline data
During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?
Working
The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?
ask the client to repeat the statement or question
The principle of confidentiality is of paramount importance in the nurse-client relationship. When should you inform the client of with whom his or her information will be shared?
at the beginning of the interview
A nurse who may be shy in social situations may exhibit excellent therapeutic communication by what? Select all that apply.
communicating nonverbally through facial expression using touch using silence
A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?
create a genogram
What are the nursing goals for the introductory phase of the nurse-client interview? (Select all that apply.)
establishing a trusting, respectful rapport with the client agreeing upon the agenda for the interview
The nurse is planning to interview a client who is being treated for depression. When the nurse enters the examination room, the client is sitting on the table with shoulders slumped. The nurse should plan to approach this client by
expressing interest in a neutral manner
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)
focused or problem-oriented assessment
Learning about the effects of the illness does what for the nurse and the client?
gives them the opportunity to create a complete and congruent picture of the problem
A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice?
health maintenance
A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?
health maintenance
Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms and to generate and test diagnostic hypotheses?
open-ended questions to encourage the client to tell his or her story
A client's spouse answers the interview questions and will not leave the examination room. What should the nurse suspect be occurring with the client?
physical abuse
A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client?
provide simple and organized information
A student nurse is conducting her first client interview. The student suddenly draws a blank on what to ask the client next. What is a useful interview technique for the student to use at this point?
summarization
While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose?
to clarify
The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to
use very basic lay terminology
A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?
"I'm going to assess the client now so that I can begin formulating the care plan"
A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time?
"What diseases did you have as a child?"
A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?
"can you tell me about your sleep problem from when it started until now?"
A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?
Empathy
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?
Individual student interview and questionnaire
The nurse is exhibiting critical thinking in which client care situation?
Performing a focused assessment on a client who is complaining of shortness of breath
A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?
Personal health history
For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have
knowledge of his or her own thoughts and feelings about these issues.
An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?
last surgery date validated by adult daughter
