PrepU Chapter 1 Introduction to Health Assessment

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 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

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

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

Comprehensive

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 client has been admitted with new onset hypertension with a past medical history of asthma, type 2 diabetes, and hypercholesterolemia. After developing a nursing care plan, the nurse reports findings to the health care provider. After receiving medication orders from the health care provider, the nurse administers several medications for hypertension. What is the next best action of the nurse?

Evaluate patient outcome

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases?

Assessment

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

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

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 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.

-health care practices -personal medical history -number of pregnancies

What do nursing activities that promote health and prevent disease accomplish? (Select all that apply.)

-reduce the risk of disease -maintain optimal functioning -reinforce good habits

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?

A 50-year-old client newly diagnosed with diabetes

A nurse is conducting a health assessment. How will the information collected from the client be used?

As a basis for the nursing process

The nurse enters a client's room and sees that the client appears to be unresponsive. What action should the nurse take first?

Gently shake the client and ask if the client is alright

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

Healthy People 2030

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history?

Perform a physical examination

Program strategies consistent with a socioenvironmental approach to health and health promotion for nursing students would include:

Screening for occupationally induced physiological risk factors of disease

A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take?

Perform an emergency assessment

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?

Focused assessment

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

The nurse reviews data collected while completing a comprehensive assessment with a client. Which information should the nurse identify as being subjective data?

Follows a Kosher diet

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

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

Primary prevention

How do nurses facilitate the achievement of high-level wellness with a client?

Promoting health in the client

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason?

Reassess previously detected problems

An 80-year-old bed-bound client is admitted with altered mental status. The comprehensive nursing assessment reveals the following: ● bruising at different stages of healing ● decreased Body Mass Index indicating malnutrition ● stage 3 pressure ulcer on the coccyx ● cloudy urine with large amounts of bacteria The nurse considers priorities based on the data. Which of the following should be a priority concern for this client?

Suspected abuse

The nurse is completing an assessment on a new client at the community health clinic and would like to screen the client's cognitive ability. There are many resources that provide screening tools for nurses. Which agency would be most helpful in directing the nurse to a screening tool to assess the client's cognitive ability?

The Alzheimer's Association

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

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 -recent changes in the client's blood pressure readings

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?

Evaluation

How does a nurse decide what health-promotion activities are necessary for a particular client?

Nurses collaborate with clients to identify areas in which clients are willing to make changes

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