Nursing-210 chapter 1 quiz
A nursing instructor is trying to convince the class of the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors should stressed that will promote opportunities for nurses with advanced assessment skills? Select all that apply. A) Declining numbers of medical students due to rising costs and focus on primary care B) Growing aging population with complex comorbidities C) Declining health care needs of single parents D) Increasing impact of children and the homeless on communities E) Increasing complexity of acute care
A) Declining numbers of medical students due to rising costs and focus on primary care E) Increasing complexity of acute care B) Growing aging population with complex comorbidities D) Increasing impact of children and the homeless on communities Explanation: There is tremendous growth of the nursing role in the managed care environment. The most marketable nurses will continue to be those with strong assessment and client teaching abilities, as well as those who are technologically savvy. The following factors will continue to promote opportunities for nurses with advanced assessment skills: 1) rising educational costs and focus on primary care that affect the numbers and availability of medical students; 2) increasing complexity of acute care; 3) growing aging population with complex comorbidities; 4) expanding health care needs of single parents; 5) increasing impact of children and the homeless on communities; 6) intensifying mental health issues; 7) expanding health service networks; and 8) increasing reimbursement for health promotion and preventive care services.
When doing an overall assessment of a client, the nurse is able to utilize findings and do what? A) Identify in what areas the client can educate his or her family B) Identify what level of prevention the client is at C) Identify in what areas the client needs the most care D) Identify the client's medical diagnosis
A) Identify in what areas the client needs the most care Explanation: During the overall assessment of the client, the nurse is able to utilize the findings and decide which areas the client is in need of the most care and which levels of prevention are necessary.
The nurse is exhibiting critical thinking in which client care situation? A) Performing a focused assessment on a client who is complaining of shortness of breath. B) Notifying the healthcare provider of a critical lab result. C) Transcribing medication orders onto the nurse's medication administration record. D) Answering the client's call bell alarm while the nursing assistant is at lunch.
A) Performing a focused assessment on a client who is complaining of shortness of breath. Explanation: The nurse investigating a client problem by performing a focused assessment is exhibiting critical thinking. Transcribing orders, calling a healthcare provider, and answering a call bell are not examples of critical thinking that entail outcome-directed thinking based on the nursing process.
Following completion of the comprehensive health assessment, the nurse periodically performs a partial assessment primarily for which reason? A) Reassess previously detected problems B) Determine the need for crisis intervention C) Provide information for the client's record D) Address areas previously omitted
A) Reassess previously detected problems Explanation: A periodic partial assessment consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on his or her health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes from the baseline data. In addition, a brief reassessment of the client's normal body system or holistic health patterns is performed whenever the nurse or another health care professional has an encounter with the client.
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment? A) Evaluate whether outcomes of treatment are met B) Determine any changes from the baseline data C) Perform a rapid assessment for prompt treatment D) Collect subjective data related to the client's overall health
B) Determine any changes from the baseline data Explanation: Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment. Evaluation is done after an intervention to determine if the outcomes have been achieved.
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? A) Palpation B) Empathy C) Sympathy D) Inspection
B) Empathy Explanation: Empathy is an intuitive awareness of what the client is going through; it helps the nurse to be effective in providing for the client's needs while remaining compassionately detached. Inspection and palpation are skills that help the nurse in collecting objective data of the client's physical characteristics. Sympathy is a feeling that would make the nurse as emotionally distraught as the client; this hampers the ability of the nurse to provide client care.
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? A) Implementation B) Evaluation C) Diagnosis D) Assessment
B) Evaluation Explanation: 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.
During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is A) secondary prevention B) primary prevention C) tertiary prevention
B) primary prevention Explanation: Exercise and healthy eating improve wellness and help protect from disease and disability, which is primary prevention.
How does a nurse decide what health-promotion activities are necessary for a particular client? A) Nurses assess areas in which clients are willing to make changes only B) Nurses construct their own theories to identify perceptions, barriers, and positive outcomes C) Nurses collaborate with clients to identify areas in which clients are willing to make changes D) Nurses address areas associated with healthy behaviors only
C) Nurses collaborate with clients to identify areas in which clients are willing to make changes Explanation: 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.
A nurse on the hospital's subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice? A) The focused assessment should be done before the physical exam. B) The focused assessment is done after gathering subjective data. C) The focused assessment addresses a particular client problem. D) The focused assessment replaces the comprehensive database.
C) The focused assessment addresses a particular client problem. Explanation: A focused assessment gathers specific data for a particular client problem usually discovered during the physical exam. This assessment "focuses" on the particular problem only and does not cover areas unrelated to the problem.
The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply. A) "My father died of a heart attack." B) Weight: 145 lbs C) Lungs clear to auscultation D) "I feel so tired sometimes." E) Pupils equal, round, and reactive to light F) Client complains of a headache
D) "I feel so tired sometimes." F) Client complains of a headache A) "My father died of a heart attack." Explanation: Subjective data include information obtained from the client through interviewing and therapeutic communication skills and are sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Feeling tired, complaints of a headache, and the statement about the client's father dying of a heart attack reflect subjective information. Weight, lung sounds, and pupil reaction are examples of objective data.
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? A) "I'll do the health assessment when the client's family leaves so that distractions will be minimal." B) "The client has been ordered a nutritional consult; I do the health assessment right after that is finished." C) "The health assessment will be more thorough if I wait until the client is pain free." D) "I'm going to assess the client now so that I can begin formulating the care plan."
D) "I'm going to assess the client now so that I can begin formulating the care plan." Explanation: Each person needs a complete health assessment. Ideally this is done on admission, but extenuating circumstances may prohibit its completion in detail at this time. The sooner the health assessment is completed fully, the better the nurse knows the client, and more holistic care can be provided to ensure health promotion and quality of life. The assessment should not be postponed until after the consult. The family should be informed of the need for the assessment and asked to leave until it is completed, unless their input with the history is needed. While pain may complicate the assessment process, it is not advisable to wait until the client is pain free to complete the assessment.
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? A) Construct a plan of care B) Determine if pertinent data has been omitted C) Identify the need for referral D) Avoid biases and judgments
D) Avoid biases and judgments Explanation: 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? A) Lifestyle practices B) Personal relationships C) Biographical information D) Body functions
D) Body functions Explanation: Subjective data is what the client tells the nurse. Objective data is what the nurse assesses or observes when performing care of a client.
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? A) Perform a musculoskeletal examination B) Obtain a 24-hour diet recall C) Take anthropometric measurements D) Collect subjective data related to overall function
D) Collect subjective data related to overall function Explanation: The nurse is responsible for collecting subjective data related to the client's overall function. The physical therapist performs a musculoskeletal examination. A dietician may take anthropometric measurements in addition to a subjective nutritional assessment.
A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment? A) Admissions clerk B) Diagnostic technician C) Gastroenterologist D) ED nurse
D) ED nurse Explanation: The nurse typically collects the subjective data, especially those related to the client's overall function. However, depending on the setting, other members of the health care team may participate in various parts of the objective data collection. Referral to a medical specialist would not take place at this early stage of assessment.
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? A) Comprehensive B) None, the cardiac catheterization will provide all needed information C) Focused D) Emergency
D) Emergency Explanation: 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.
Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of A) the Department of Health and Human Services B) the three levels of preventative care C) the nursing process D) Healthy People 2020
D) Healthy People 2020 Explanation: Healthy People 2020 is a government project intended to increase the quality of life for people in the United States.
Which of the following is the best example of holistic data collection by a nurse? A) Measuring blood glucose level, cholesterol level, blood pressure, and resting heart rate B) Performing an x-ray, ECG, exercise stress test, and complete blood count C) Assessing the client's range of arm motion, auscultating for heart sounds, testing for pupil dilation, and conducting a vision test D) Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings
D) Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings Explanation: 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.
Which of the following is the best example of assessment in everyday life? A) Listening to a favorite song to relax in the evening B) Taking the dog for a walk in the park to get exercise C) Texting a friend to let her know that you made it home safely D) Measuring the remaining tread on a car tire to determine whether it is time to replace it
D) Measuring the remaining tread on a car tire to determine whether it is time to replace it Explanation: As a professional nurse, you will constantly observe situations and collect information to make nursing judgments. This occurs no matter what the setting: hospital, clinic, home, community, or long-term care. You conduct many informal assessments every day. For example, when you get up in the morning, you check the weather and determine what would be the most appropriate clothing to wear. Measuring the remaining tread on a car tire to determine whether it is time to replace it is an example of assessment, as it involves gathering information (the height of the tire tread) to make a decision (whether to buy new tires). The other answers do not involve gathering information to make a decision.