N114 Chapter 1
A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan? Nursing process Diagnostic reasoning Critical thinking Community care map
A
Which of the following is an example of a recent trend in nursing roles? Gathering forensic evidence for a legal proceeding Using palpation to assess the abdomen of a pregnant woman Performing visual inspection of a client's eyes to detect illness Using auscultation to examine heart sounds
A
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? Breathing Airway Circulation Disability
B
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
B
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.
B
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
B
The nurse is following a structured head to toe approach to identify changes in a client's body systems. Which component of the health assessment is the nurse completing with the client? Health history Physical examination Goal setting Planning care
B
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
B
Which assessment finding should the nurse document as objective data? Biographical information Body functions Lifestyle practices Personal relationships
B
Which assessment finding should the nurse document as objective data? Biographical information Body functions Lifestyle practices Personal relationships
B
The purpose of a health assessment includes what? (Select all that apply.) Identifying the client's major disease process Collecting information about the health status of the client Clarifying the client's ability to pay for health care Evaluating client outcomes Synthesizing collected data
B, D, E
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.
C
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? Partial Focused Comprehensive Emergency
C
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? Initial Focused Ongoing Emergency
C
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
C
An assessment that concentrates on patterns of role performance that all humans share is called what? Head to toe Body systems Focused Functional
D; functional patterns that all humans share
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
A
When the nurse is performing a physical examination on admission of a client to the medical unit, the client says the doctor already did an exam. The best response by the nurse would be "the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease." "the doctor's and nurse's assessments are totally unrelated and are necessary so all forms are completed appropriately." "each assessment is important and the nurse and doctor will get together to determine what orders need to be written." "I know it seems repetitive but the doctor is trying to treat the reason you were admitted and I will focus more on getting everything ready for you to go home."
A
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.
A, E
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
B
The client has a murmur. This is what type of data? Subjective Objective Focused Comprehensive
B
The new graduate nurse asks the preceptor, "I keep hearing about learning to develop good critical thinking skills, but don't really understand what that is?" What is the best response by the preceptor? "Being open minded in order to provide professional nursing care." "A way of processing information using to formulate conclusions or diagnoses." "A way of problem solving so that you can transform from a novice to expert nurse." "A way to think so that you can solve problems."
B
The nurse collects data from a client with a nonproductive cough and labored respirations at a rate of 24/minute. What other data should the nurse collect before formulating an appropriate nursing diagnosis? history of illness status of breath sounds rash on face list of present medications
B
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
B
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? "The client has been ordered a nutritional consult; I do the health assessment right after that is finished." "I'll do the health assessment when the client's family leaves so that distractions will be minimal." "I'm going to assess the client now so that I can begin formulating the care plan." "The health assessment will be more thorough if I wait until the client is pain free."
C
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
C
When doing an overall assessment of a client, the nurse is able to utilize findings and do what? Identify what level of prevention the client is at Identify in what areas the client can educate his or her family Identify in what areas the client needs the most care Identify the client's medical diagnosis
C
A common error for beginning nurses who are formulating nursing diagnoses during data analysis is to include too much data about the client in the history. formulate too many nursing diagnoses for the client and family. obtain an insufficient number of cues and cluster patterns. quickly make a diagnosis without hypothesizing several diagnoses.
D
The nurse is exhibiting critical thinking in which client care situation? Transcribing medication orders onto the nurse's medication administration record. Notifying the healthcare provider of a critical lab result. Answering the client's call bell alarm while the nursing assistant is at lunch. Performing a focused assessment on a client who is complaining of shortness of breath.
D
The result of a nursing assessment is the prescription of treatment documentation of the need for a referral client's physiologic status formulation of nursing diagnoses.
D
The result of a nursing assessment is the prescription of treatment. documentation of the need for a referral. client's physiologic status. formulation of nursing diagnoses.
D
Using both verbal and nonverbal clues given by the client, what is the nurse constantly doing? Diagnosing Intervening where necessary Formulating a discharge plan Assessing
D
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
D
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed entry. focused. exploratory. comprehensive.
D
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed entry. exploratory. focused. comprehensive.
D
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
D
Which of the following is the best example of assessment in everyday life? Taking the dog for a walk in the park to get exercise Listening to a favorite song to relax in the evening Texting a friend to let her know that you made it home safely Measuring the remaining tread on a car tire to determine whether it is time to replace it
D
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.
D
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
A
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
A nurse has completed assessment of a client with Alzheimer's disease and documentation of the information obtained from the client and now needs to analyze the data collected. Which nursing actions should be included in this phase of the nursing process? Select all that apply. Identification of collaborative problems Assessment of the outcome of the care plan Identification of the need for referrals Formulation of nursing diagnosis(es) Development of a nursing care plan
A, C, D
The RN is implementing which level of intervention when administering immunizations at a pediatric clinic? Holistic Primary Secondary Tertiary
B
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
B
What is the foundation of nursing practice? Planning Assessment Evaluation Intervention
B
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."
C
A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse? Diagnostic reasoning Physical assessment Critical thinking Nursing care plan
C
A client asks why a health assessment needs to be done. What should the nurse respond to this client? "It serves as a tool to evaluate care provided." "It reduces the work load for the health care provider." "It is used to validate the findings from the health care provider's examination." "It determines your health status, risk factors and educational needs to develop a plan of care."
D
Revising the plan as needed occurs in what part of the nursing process? Assessment Diagnosis Planning Evaluation
D
A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use? Diagnostic reasoning Physical assessment skills Rationale American Nurses Association recommendations
A
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? Inspection Palpation Sympathy Empathy
D
Data collection occurs where in the nursing process? Assessment Diagnosis Planning Evaluation
A
In which situation should a nurse perform an emergency assessment of a client? Shortness of breath Broken arm Body rash Ear pain
A
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? physical environmental social well being developmental level
B
For which client should a nurse perform a focused assessment? Elevated blood pressure with no previous history of heart problems Four day history of sore throat and fever with enlarged lymph nodes Right upper abdominal pain that radiates into the groin area Diabetic with elevated blood sugars for the past two weeks
B
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
B
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."
D
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
D
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
D
The nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what? Focused Body systems Functional Head to toe
D
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
D
A nursing student demonstrates understanding of the different types of nursing diagnoses when choosing which of the following to be an actual diagnosis? impaired skin integrity readiness for enhanced skin integrity risk for infection risk for impaired skin integrity
A
After a health assessment the nurse determines that a client would benefit from health promotion interventions. Which item should the nurse refer to when determining the best actions for the client? Healthy People 2020 the client's family history organization standards of care the client's past medical history
A
Although the assessment phase of the nursing process precedes the other phases, the assessment phase is continuous. completed on admission. linear. performed only by nurses.
A
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
A
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
A
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.
A
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
B
The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action? Obtain an IV bag of the current solution and hang it. Discontinue the current solution and disconnect it from the client. Hang the IV solution the client's assigned nurse left on the pole. Review the client's prescribed medication orders.
D
A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment? Body systems Comprehensive Head to toe Emergency
A
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 To collect subjective data related to the client's overall health To perform a rapid assessment for prompt treatment To evaluate whether outcomes of treatment are met
A
A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? To establish a database against which subsequent assessments can be measured To establish rapport with the client and family To gather information for specialists to whom the client might be referred To quantify the degree of pain a client may be experiencing
A
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
A
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?" "Have you tried to schedule a cleaning service?" "Are you friendly with your neighbors?" "What amount of cleaning have you been doing in the past?"
A
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 judgments about the client. consult with the client's family members. review any past collaborative problems. analyze data that have already been collected.
A
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
B
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.
B
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
B