PrepU Chapter 1 questions

When assisting a patient 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 healthy environment In order to assist a patient with health promotion, a healthy environment must also be nurtured.

When making rounds, the RN should prioritize follow-up care for which client? a) A client who is receiving intravenous antibiotics for pneumonia. b) A client with strong, equal pedal pulses following catheterization. c) A client who is due for a routine shift assessment. d) An oncology client with a cough but no fever.

An oncology client with a cough but no fever. Explanation: The nurse should prioritize care for the oncology client, because immunosuppression due to chemptherapy is a concern. The immunosuppressed client can still exhibit a respiratory infection without fever. The clients require routine assessments with no immediate concerns.

What are nurses able to detect through the health assessment? a) Areas that need in-hospital care b) Areas in need of health adjustments c) Areas that need referral to a specialist d) Areas that need continuous care

Areas in need of health adjustments

Revising the plan as needed occurs in what part of the nursing process? Assessment Diagnosis Planning Evaluation

Evaluation Evaluation assesses whether the outcome criteria have been met and revising the plan as necessary. Diagnosis occurs when the data has been analyzed and a professional judgement occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan.

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? Body systems Functional Focused Head to toe

Head to toe The head-to-toe method is efficient and provides more modesty for clients. The body systems and functional assessment does not address the modesty issue in the question. The focused assessment is not appropriate for the newly admitted client.

The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what? The client's cooperation How much time the nurse has The client's acuity Onset of current symptoms

The client's acuity Data that nurses collect during a physical assessment vary depending on a client's acuity (condition), health history, and current symptoms. The data collected during a physical assessment do not depend on how much time the nurse has, how cooperative the client is, or the onset of the current symptoms.

What is paramount in health promotion? (Select all that apply.) Working with the individual patient Demonstrating authority Emphasizing the risks of poor health practices Developing the nursing care plan Limiting the involvements of the patient's friends and family

Working with the individual patient Developing the nursing care plan Developing the nursing care plan and working with the individual patient are paramount in health promotion. Demonstrating authority, limiting the role of friends and family, and emphasizing negative consequences are inappropriate actions.

When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what? Assessment Diagnosis Planning Evaluation

diagnosis Diagnosis occurs when the data has been analyzed and a professional judgment occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan. Evaluation assesses whether the outcome criteria have been met.

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's a) physiologic status. b) holistic wellness status. c) developmental history. d) level of functioning.

physiologic status. Explanation: The physician performing a medical assessment focuses primarily on the client's physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.

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? "Are you friendly with your neighbors?" "What amount of cleaning have you been doing in the past?" "Have you tried to schedule a cleaning service?" "Do you have family who visit you regularly?"

"Do you have family who visit you regularly?" Asking if family visit regularly may provide a link to getting them to assist in cleaning the apartment.

A patient 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 patient? Breathing Circulation Airway Disability

Airway The emergency assessment involves a life-threatening or unstable situation, such as a patient in an ED who has experienced a traumatic injury. Staff members at the ED use triage to determine the level of urgency by considering assessments based on the mnemonic A, B, C, D, E: A—Airway; B—Breathing; C—Circulation; D—Disability; and E—Exposure.

How does a nurse best facilitate the nursing health assessment? Creating a nursing care plan Maintaining privacy Asking the appropriate questions Formulating a nursing diagnosis

Asking the appropriate questions Knowing how to facilitate the nursing health assessment by asking appropriate questions to obtain more information assists the nurse to solve the mystery or create a nursing care plan.

The nurse reviews information obtained from the admission's department about a client seeking medical care for a chronic problem. What should the nurse expect to complete when assessing this client? Select all that apply. Collect objective data Validate data Document data Collect subjective data Analyze outcome data

Collect objective data Validate data Document data Collect subjective data The assessment phase of the nursing process has four major steps: collect subjective data; collect objective data; validate data; and document data. Analyzing outcome data is performed during the evaluation phase of the nursing process.

A nurse performs a comprehensive assessment on a client. Which is included only in a comprehensive assessment? Circulatory assessment Assessment of the airway Complete health history Disability assessment

Complete health history The comprehensive assessment includes a complete health history and physical assessment. It is done annually on an outpatient basis, following admission to a hospital or long-term care facility, or as defined in a facility's standards of care in the acute care setting. Circulatory assessment, assessment of the airway, and disability assessment are part of an emergency assessment.

A client presents to the health care facility with reports of new onset of chest pain of three 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 perform for this client? Partial Focused Emergency Comprehensive

Comprehensive This client presents with a new problem and the nurse should perform a comprehensive assessment. Chest pain is an emergent problem but the client is has stable vital signs and no chest pain so an emergency assessment is not indicated at this time. A partial or focused assessment would not allow collection of enough data to properly complete diagnose the cause of a new problem.

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? Critical thinking Nursing care plan Physical assessment Diagnostic reasoning

Critical thinking Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems. Diagnostic reasoning is important in developing diagnostic statements, not in caring for multiple clients with complex care needs. Physical assessment is important in the building the foundation of the nursing care plan. The nursing care plan directs the care that will be provided for the individual client, but does not address the needs of caring for multiple clients.

What are the areas of independent nursing practice? Select all that apply. Deciding which medications to administer to the client Deciding when physical procedures should be performed on a client Deciding what client teaching is necessary Deciding what diagnosis a client has Deciding when a client needs to be turned

Deciding when physical procedures should be performed on a client Deciding what client teaching is necessary Deciding when a client needs to be turned Independent nursing interventions include client teaching, therapeutic communication, and physical procedures such as turning patients or assisting them with ambulation. The medications a client receives and the diagnosis of the client are medical decisions, not nursing decisions.

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 Sympathy Inspection Palpation

Empathy 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.

The nurse is performing a health assessment on a new client. While taking the detailed history, the nurse knows to include what? a) Functional status b) Only data involving the client complaint c) A focused assessment of the client complaint d) Family history for the past three generations

Functional status Explanation: A detailed history includes data on all systems, psychosocial and mental health, and functional status. Therefore, options B, C, and D are incorrect. Data must be included other than the client complaint. Family histories generally go back only to grandparents, not great-grandparents.

Which of the following is an example of a recent trend in nursing roles? a) Gathering forensic evidence for a legal proceeding b) Using auscultation to examine heart sounds c) Using palpation to assess the abdomen of a pregnant woman d) Performing visual inspection of a client's eyes to detect illness

Gathering forensic evidence for a legal proceeding Explanation: Forensic nursing is an example of one of the rapidly evolving roles of nursing that requires extensive focused assessments and the development of related nursing diagnoses. Auscultation, palpation, and inspection are all techniques that have been used by nurses for over 100 years. (less)

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? a) Focused b) Functional c) Head-to-toe d) Body system

Head-to-toe A head-to-toe assessment is the most organized system for gathering comprehensive physical data.

The nurse prepared to complete a comprehensive health assessment on a client in the community. What should the nurse expect to complete when performing this assessment? Select all that apply. Health history Wellness teaching Physical examination Outcome identification Medication administration

Health history Physical examination A comprehensive health assessing includes a health history and physical examination. Wellness teaching cannot be done until the client's needs are identified. Outcome identification is a part of planning. Medication administration is a part of implementation.

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.

Healthy child development is a critical health determinant because of its implications for lifelong health. The future implications of healthy child development coupled with the fact that children spend much time at school mean that schools are crucial settings for health promotion.

The nurse prepares to analyze a list of a client's health problems. In which order will the nurse complete critical thinking of these problems? Drag statements into the proper order.

Identify abnormal data and strengths Cluster the data Draw inferences and identify problems Propose possible nursing diagnoses Check for defining characteristics of the diagnoses Confirm or rule out nursing diagnoses

As a nurse becomes more proficient and comfortable in his or her role, what increases? Confidence and knowledge base Time management and confidence Knowledge base and expertise Expertise and time management

Knowledge base and expertise As the nurse becomes more proficient and comfortable in his or her role, the accountability does not decrease, but the knowledge base and expertise increase to foster confidence.

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 patient'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? Validating information that is already correct Making incorrect nursing judgments or diagnoses Interjection of the nurse's thoughts or feelings into the data Relying on objective and subjective information

Making incorrect nursing judgments or diagnoses Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the nursing process. Interjection of the nurse's thoughts or feelings may lead to bias or the withholding of information but would not necessarily result from a lack of a thorough and accurate assessment of a client. Nursing judgments should rely on both objective and subjective information; thus this is not an error. Validating information that is correct makes more work for the nurse but will not be prevented by a thorough and accurate assessment of a client.

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

Nursing diagnosis Analysis of data or nursing diagnosis, is the second phase of the nursing process. Planning occurs after the data is analyzed. Evaluation is the final phase of the process. Implementation occurs after planning.

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

Nursing intervention Nursing interventions are used to monitor health status; prevent, resolve, or control a problem; assist with ADLs; or promote optimum health and independence. Nursing goals are the client's desired outcomes. Nursing evaluation is deciding whether the nursing goals have been reached. Nursing assessment is an overview of the patient's health status and current problems.

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

Nursing process The nursing process serves as a framework for providing individualized care not only to individuals but also to families and communities. Diagnostic reasoning, critical thinking, and community care maps are not frameworks for providing individualized care to a community.

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

Ongoing Ongoing, follow-up or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline. An emergency assessment is a very rapid assessment performed in life-threatening situations such as drowning, choking, or cardiac arrest. It is used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. A focused assessment gathers information specific to the problem and does not cover any other areas. A comprehensive assessment is not necessary at this time because the client already has a documented problem.

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 lungs sounds to determine any changes from the baseline. What type of assessment is the nurse performing? a) Focused b) Comprehensive c) Partial d) Emergency

Partial Explanation: Ongoing or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline. An emergency assessment is a very rapid assessment performed in life threatening situations such as drowning, choking, or cardiac arrest. It is also used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. A focused assessment gathers information specific to the problem and does not cover any other areas. Comprehensive is not necessary at this time because the client already has a documented problem

The nurse is exhibiting critical thinking in which client care situation? Notifying the healthcare provider of a critical lab result. Performing a focused assessment on a client who is complaining of shortness of breath. Transcribing medication orders onto the nurse's medication administration record. 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. 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.

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? Involves the client's musculoskeletal system and activities of daily living Focuses primarily on the client's physiologic development status Physiologic, psychological, sociocultural, developmental, and spiritual data Focuses only on the client's psychological, sociocultural, and spiritual well-being

Physiologic, psychological, sociocultural, developmental, and spiritual data A nursing health assessment includes physiologic, psychological, sociocultural, developmental, and spiritual data. Medical health assessment focuses primarily on the client's physiologic development status. The assessment by a physical therapist focuses mainly on the client's musculoskeletal system and activities of daily living.

A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan? a) Nursing process b) Diagnostic reasoning c) Critical thinking d) Community care map

The nursing process -serves as a framework for providing individualized care not only to individuals but also to families and communities. Diagnostic reasoning, critical thinking, and community care maps are not frameworks for providing individualized care to a community. Therefore, options B, C, and D are incorrect.

Why is the nurse always reassessing the patient for changes? To never make a mistake when providing care To always have the best nursing care plan To achieve the best results To update the nursing diagnosis

To achieve the best results

What is the primary function of the health care team? To decide the best overall care To develop an individual focus for each member To work together to obtain maximum coverage To guide the patient's care throughout times of crisis

To decide the best overall care The health care team meets to collaborate on patients and decide the best overall care. This occurs throughout the lifespan, from the inception of life until death. The health care team is a partnership. The group includes the nurse, physician, nutritionist, social worker, physical therapist, occupational therapist, speech therapist, and/or dentist. They all work together on the same team for the benefit of the patient.

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 collect subjective data related to the client's overall health To perform a rapid assessment for prompt treatment To determine any changes from the baseline data To evaluate whether outcomes of treatment are met

To determine any changes from the baseline data 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 (emergency assessment). Evaluation is done after an intervention to determine whether the outcomes have been achieved.

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to a) validate the data collected. b) contribute to the medical diagnosis. c) arrive at conclusions about the client's health. d) document any physical symptoms the client may have.

arrive at conclusions about the client's health. Explanation: The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment data.

The nurse recognizes the value of the Healthy People 2020 guidelines when creating a plan of care that addresses which client-centered goals? Select all that apply living a healthy lifestyle disease prevention improving one's quality of life providing affordable health care services increasing the longevity of one's life

living a healthy lifestyle disease prevention improving one's quality of life increasing the longevity of one's life

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's a) level of functioning. b) holistic wellness status. c) developmental history. d) physiologic status.

physiologic status The physician performing a medical assessment focuses primarily on the client's physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.

The nurse is completing an admission database entry and must include priority nursing diagnoses for the plan of care. Which statement describes a nursing diagnosis? To diagnose the condition and particular illness of the client. A clinical judgment about client responses to health difficulties. The collection of subjective and objective data. Identification of realistic, client-centered goals.

A clinical judgment about client responses to health difficulties. Diagnosis is the clustering of data to make a judgment or statement about the patient's difficulty or condition. NANDA International (NANDA-I, 2012) defines nursing diagnosis as "a clinical judgment about individual, family or community responses to actual or potential health difficulties/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable."

The RN is completing an admission database and must include priority nursing diagnoses for the plan of care. Which statement describes the purpose of nursing diagnosis? a) To diagnose the condition and particular illness of the client. b) Identification of realistic, client-centered goals. c) A clinical judgment about client responses to health difficulties. d) The collection of subjective and objective data.

A clinical judgment about client responses to health difficulties. Explanation: Diagnosis is the clustering of data to make a judgment or statement about the patient's difficulty or condition. NANDA International (NANDA-I, 2012) defines nursing diagnosis as "a clinical judgment about individual, family or community responses to actual or potential health difficulties/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

When doing an overall assessment of a patient, the nurse is able to utilize findings and do what? a) Identify the patient's medical diagnosis b) Identify in what areas the patient can educate his or her family c) Identify what level of prevention the patient is at d) Identify in what areas the patient needs the most care

Identify in what areas the patient needs the most care Explanation: During the overall assessment of the patient, the nurse is able to utilize the findings and decide which areas the patient is in need of the most care and which levels of prevention are necessary.

The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what? a) The client's acuity b) The client's cooperation c) Onset of current symptoms d) How much time the nurse has

The client's acuity Explanation: Data that nurses collect during a physical assessment vary depending on a client's acuity, health history, and current symptoms. The data collected during a physical assessment do not depend on how much time the nurse has, how cooperative the client is, or the onset of the current symptoms

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history? document the findings perform a physical examination cluster the data determine a problem list

perform a physical examination The health assessment includes a health history and physical examination. After completing the health history, the nurse should complete the physical examination. Clustering data and determining a problem list would occur after the physical examination is complete. Documentation of the findings would occur while conducting the health history and after completing the physical examination.

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'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 client has been ordered a nutritional consult; I do the health assessment right after that is finished." "The health assessment will be more thorough if I wait until the client is pain free."

"I'm going to assess the client now so that I can begin formulating the care plan." 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 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? "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." "Fortunately, assessment only needs to be done at the beginning of your stay."

"I'm sorry, but assessment is ongoing and continuous." Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ongoing and continuous throughout all the phases of the nursing process.

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."

"Nurses focus on the diagnosis of actual human responses to disease or life events." The medical focus is on diagnoses and treatment of the disease. Nurses focus on diagnoses and treatment of the actual or potential human responses to disease or life events. The assessments are not the same and are not used to validate collected information.

During a health assessment, a client shares, "I get a little dizzy when I get up from my chair too quickly." Which question will the nurse ask the client first when attempting to identify client needs and potential health risks? "What do you mean by 'a little dizzy'?" Can you remember when you first started to feel dizzy?" "Have you ever been dizzy enough to fall?" "Do you often feel dizzy?"

"What do you mean by 'a little dizzy'?" Listening and understanding a client is key to discovering a client's needs. As more details are acquired and collated, actual health risks emerge. The nurse should first clarify what the client means by the statement. If is only then that the nurse can determine is a health risk exists. While knowing the details of when the symptom started, how often it occurs, and if falling has occurred is important, clarification of what the client means is the initial focus of the nurse.

When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient says the doctor already did an exam. The best response by the nurse would be a) "the doctor's and nurse's assessments are totally unrelated and are necessary so all forms are completed appropriately." b) "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." c) "the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease." d) "each assessment is important and the nurse and doctor will get together to determine what orders need to be written."

"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease." Explanation: The medical examination focus is on diagnosis and treatment of disease and the nursing examination focuses on the human response.

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

Areas in need of health adjustments Through the health assessment nurses are able to detect areas in need of health adjustments.

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain? Planning care to help minimize the client's pain Identifying pain management interventions with input from the client Collecting data regarding the nature of the pain Teaching the client to draw knees to chest to help minimize the pain

Collecting data regarding the nature of the pain The nurse's initial role in health assessment is to collect data. Teaching would occur later in the process. Planning care and identifying interventions are parts of the nursing process and not the health assessment.

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

Collecting information about the health status of the client Evaluating client outcomes Synthesizing collected data Health assessment is "gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings and evaluating patient care outcomes" (AACN, 2008). While the nurse may elicit financial information and information about disease processes during a health assessment, the purposes of the activity are not to identify the patient's major disease process or ability to pay.

What is one way nurses use critical thinking in regard to the nursing process? a) Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions b) Nurses do not need to think critically; they just need to follow the doctor's orders c) Critical thinking allows nurses to make decisions regarding client care without involving the client in decisions d) Critical thinking helps nurses decide which parts of the nursing process are not needed in regard to a particular client

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions Correct Explanation: Critical thinking in nursing entails purposeful, outcome-directed (results-oriented) thinking; is driven by client, family, and community needs; is based on the nursing process, evidence-based thinking, and the scientific method; requires specific knowledge, skills, and experience; is guided by professional standards and codes of ethics; and is constantly reevaluating, self-correcting, and striving to improve. Critical thinking does not decide which parts of the nursing process are not needed in caring for a particular client.

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? Rationale American Nurses Association recommendations Physical assessment skills Diagnostic reasoning

Diagnostic Nurses use diagnostic reasoning and critical thinking to formulate diagnostic statements. Rationale, ANA recommendations, and physical assessment skills are not part of formulating diagnostic statements. Rationale supports the nursing interventions of the nursing care plan. The American Nurses Association does not have recommendations regarding formulation of diagnostic statements for the care plan. Physical assessment skills are important in the assessment step of the nursing process, not the formulation of the diagnostic statements.

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? a) Physical assessment skills b) American Nurses Association recommendations c) Diagnostic reasoning d) Rationale

Diagnostic reasoning Explanation: Nurses use diagnostic reasoning and critical thinking to formulate diagnostic statements. Rationale, ANA recommendations, and physical assessment skills are not part of formulating diagnostic statements. Rationale supports the nursing interventions of the nursing care plan. The American Nurses Association does not have recommendations regarding formulation of diagnostic statements for the care plan. Physical assessment skills are important in the assessment step of the nursing process, not the formulation of the diagnostic statements

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? Focused Comprehensive None, the cardiac catheterization will provide all needed information Emergency

Emergency 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.

Which skill does the nurse need to obtain subjective data during the initial comprehensive assessment? a) Sympathy b) Observation c) Inspection d) Empathy

Empathy Explanation: Empathy is an intuitive awareness of what the client is going through; it helps the nurse to become effective in providing for the client's needs while remaining compassionately detached. Inspection and observation are skills that help the nurse in collecting objective data of the client's physical characteristics. Sympathy is a feeling that makes 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 whether the client has achieved the outcome criteria of the treatment? a) Implementation b) Diagnosis c) Evaluation d) Assessment

Evaluation The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and whether 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

For which client should a nurse perform a focused assessment? a) Elevated blood pressure with no previous history of heart problems b) Diabetic with elevated blood sugars for the past two weeks c) Right upper abdominal pain that radiates into the groin area d) Four-day history of sore throat and fever with enlarged lymph nodes

Four-day history of sore throat and fever with enlarged lymph nodes Explanation: A client with a sore throat and fever with enlarged lymph nodes requires only a focused assessment by the nurse. A focused assessment consists of a thorough assessment of a particular client problem. An elevated blood pressure with no previous history of heart problems requires an initial or comprehensive assessment. Right upper abdominal pain that radiates into the groin area is an emergency situation and the nurse should collect only the data necessary to make a quick diagnosis for immediate treatment. A client with diabetes has a chronic, ongoing health problem that needs reassessment and possibly a change in treatment.

The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students know that this type of information is assessed in what type of assessment? Body systems Head to toe Functional Focused

Functional A functional assessment focuses on the patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs (Gordon, 1987). The body systems, the focused nor the head to toe assessment addresses the holistic needs of the client. The roles and relationships of the client would not be included in these assessment

An assessment that concentrates on patterns of role performance that all humans share is called what? Functional Focused Head-to-toe Body systems

Functional A functional assessment focuses on the functional patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs.

Which of the following is an example of a recent trend in nursing roles? Gathering forensic evidence for a legal proceeding Using auscultation to examine heart sounds Using palpation to assess the abdomen of a pregnant woman Performing visual inspection of a client's eyes to detect illness

Gathering forensic evidence for a legal proceeding Forensic nursing is an example of one of the rapidly evolving roles of nursing that requires extensive focused assessments and the development of related nursing diagnoses. Auscultation, palpation, and inspection are all techniques that have been used by nurses for over 100 years.

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? a) U.S. Preventive Services Task Force b) Healthy People 2020 c) Health Belief Model d) Pender Health Promotion Model

Health Belief Model Explanation: The Health Belief Model is based on three concepts: the existence of sufficient motivation; the belief that one is susceptible or vulnerable to a serious problem; and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. The Pender Health Promotion Model proposes that individual characteristics and experiences affect behavior-specific cognitions and affect, which in turn yield the level of commitment to a plan. Healthy People 2020 is a model developed by the U.S. Department of Health and Human Services that focuses on increasing the life span and improving the quality of health for Americans. The U.S. Preventive Services Task Force (USPSTF) determines risk versus benefit in screenings

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

Healthy People 2020 Healthy People 2020 is a framework that identifies risk factors, health issues, and diseases of concern in the United States. The goals and objectives serve to improve the health of individuals and communities with the overall goal to increase quality of life by creating guidelines for a healthy lifestyle as well as educating people and cultivating an awareness that will assist in the elimination of health disparities. Healthy People 2020 promotes health and disease prevention as it improves the quality and length of a person's life. The client's family history or past medical history will not help identify health promotion interventions. The organization's standards of care are generalized and do not identify health promotion interventions.

Which of the following statements best conveys the rationale for health promotion in a school setting? a) Children younger than 13 years are some of the most common consumers of acute health care services. b) Healthy child development is a critical health determinant because of its implications for lifelong health. c) Children contract numerous communicable diseases in the school environment. d) Health promotion in a school setting can yield improved health outcomes for the student's siblings and parents.

Healthy child development is a critical health determinant because of its implications for lifelong health. Explanation: The future implications of healthy child development coupled with the fact that children spend much time at school mean that schools are crucial settings for health promotion

A nurse is assessing the social and spiritual needs of a client who is terminally ill with pancreatic cancer and living at home. This nurse most likely works in which of the following settings? a) Critical care b) Public health c) Hospice d) Ambulatory care

Hospice Explanation: Current focus on managed care and internal case management has had a dramatic impact on the assessment role of the nurse. Hospice nurses assess the needs of the terminally ill clients and their families. Ambulatory care nurses assess and screen clients to determine the need for physician referrals. Public health nurses assess the needs of communities, and school nurses monitor the growth and health of children. Critical care outreach nurses need enhanced assessment skills to safely assess critically ill clients who are outside the structured intensive care environment.

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

Individual student interview and questionnaire Key to any health promotion activity is a thorough assessment of the context and particular needs of the participants. This could be best determined by asking the students what would be more effective than a physical assessment, literature review, tour of the facility, or questionnaire of the faculty members.

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 Assessing the client's range of arm motion, auscultating for heart sounds, testing for pupil dilation, and conducting a vision test Measuring blood glucose level, cholesterol level, blood pressure, and resting heart rate Performing an x-ray, ECG, exercise stress test, and complete blood count

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings 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 clien'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.

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 collaborate with clients to identify areas in which clients are willing to make changes c) Nurses construct their own theories to identify perceptions, barriers, and positive outcomes d) Nurses address areas associated with healthy behaviors only

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 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 Focused or problem-oriented Ongoing or partial Emergency

Ongoing or partial An ongoing, follow-up or partial assessment of the client consists of data collection that occurs after the comprehensive database is established. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data. In addition, a brief reassessment of the client's body systems and holistic health patterns is performed to detect any new problems. An initial comprehensive assessment involves collection of subjective data about the client's perception of own health of all body parts or systems, past health history, family history, and lifestyle and health practices. A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern and consists of a thorough assessment of a particular client problem, and does not cover areas not related to the problem. An emergency assessment is a very rapid assessment performed in life-threatening situations.

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? Ensure that the client is safe Begin CPR Open the client's airway If the client is injured, protect the cervical spine

Open the client's airway All life-threatening problems identified during the initial assessment require the initiation of critical interventions. The nurse opens the client's airway; assists the client's breathing; provides assistance with circulation (CPR if needed); if the client is injured, protects the cervical spine; ensures that the disoriented or suicidal client is safe; and provides pain management and sedation. The client has assessments and critical interventions performed simultaneously as life-threatening problems are treated.

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? Monitor the client frequently for other changes in health status. 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.

Recognize the need to reevaluate the client's plan of care. The health assessment allows data to be collected that is specific to the client and his or her nursing care needs. Initially, the nurse must be aware that any change to the client's health status may require an change to this plan of care. If changes are required, the health care team will be asked to consider and recommend them. Monitoring the client for changes is always considered a nursing responsibility. Notifying the primary health care provider is not directly related to the nursing plan of care.

The nurse plans to follow the Health Belief Model when identifying a client's care needs. On what will the nurse focus when using this model? Select all that apply. Behavioral outcomes Sufficient motivation Individual characteristics Making a change would be beneficial Belief of being susceptible to a health problem

Sufficient motivation Making a change would be beneficial Belief of being susceptible to a health problem The Health Belief Model is based on three concepts: the client has sufficient motivation; the client is susceptible to a health problem; and making a change will be beneficial to improve health. Behavioral outcomes and individual characteristics are focuses of the Health Promotion Model.

A nurse is trying to decide whether to recommend that a pregnant client be screened for HIV. Which of the following resources would best help in this decision? a) Health Belief Model b) Pender Health Promotion Model c) Healthy People 2020 d) U.S. Preventive Services Task Force

The U.S. Preventive Services Task Force (USPSTF) determines risk versus benefit in screenings. The Health Belief Model is based on three concepts: the existence of sufficient motivation; the belief that one is susceptible or vulnerable to a serious problem; and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. The Pender Health Promotion Model proposes that individual characteristics and experiences affect behavior-specific cognitions and affect, which in turn yield the level of commitment to a plan. Healthy People 2020 is a model developed by the U.S. Department of Health and Human Services that focuses on increasing the life span and improving the quality of health for Americans

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

To establish a database against which subsequent assessments can be measured

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? a) To establish a database against which subsequent assessments can be measured b) To establish rapport with the client and family c) To gather information for specialists to whom the client might be referred d) To quantify the degree of pain a client may be experiencing

To establish a database against which subsequent assessments can be measured Other purposes of health assessment are to gain further insight into the current condition and to establish a database that subsequent assessments can be measured against. Therefore, options B, C, and D are incorrect.

What is the primary purpose of health assessment? To help the physician diagnose illness without further testing To decide on the best way to manage a client's illness based on the nurse's own views and beliefs To gather information about the health status of the client To make judgments about the client's lifestyle and behaviors that contribute to the patient's illness

To gather information about the health status of the client Health assessment is "gathering information about the health status of the client, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings, and evaluating client care outcomes" (AACN, 2011). Health assessment is not making judgments about a client's lifestyle; it does not involve care based on the nurse's views and beliefs, nor does it help the physician diagnose illness without further testing.

What is one of the broad goals within nursing? To promote self-care To form broad nursing diagnoses To treat human responses To provide cost effective care

To treat human responses Four broad goals are within nursing: (1) to promote health (state of optimal functioning or well-being with physical, social, and mental components); (2) to prevent illness; (3) to treat human responses to health or illness; and (4) to advocate for individuals, families, communities, and populations. The other options listed are not broad goals. Nursing, focuses on promoting health; while cost-effective care is strived for, is not a part of the broad goal, therefore, this is not a broad goal within nursing. Nursing looks to develop specific nursing diagnoses, not broad. Promoting self-care is important, but does not correctly answer the question.

What is one of the broad goals within nursing? a) To promote self-care b) To treat human responses c) To address mental health issues d) To form broad nursing diagnoses

To treat human responses Four broad goals are within nursing: (1) to promote health (state of optimal functioning or well-being with physical, social, and mental components); (2) to prevent illness; (3) to treat human responses to health or illness; and (4) to advocate for individuals, families, communities, and populations. The other options listed are not broad goals. Nursing, along with other disciplines address mental health issues, therefore, this is not a broad goal within nursing. Nursing looks to develop specific nursing diagnoses, not broad. Promoting self-care is important, but does not correctly answer the question

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

Uses evidence-based techniques To accomplish pertinent and comprehensive data collection the nurse uses appropriate evidence-based assessment techniques and instruments when collecting data. The ABC approach may not be necessary. Although measure vital signs can be delegated to unlicensed staff, this does not ensure that the data will guide the identification of appropriate interventions. Focusing on one system may be appropriate in specific situations however the admission assessment should include all body systems

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be: Ascertaining past and current use of health care services Determining client stress levels related to lifestyle choices Using reputable health-education strategies to reduce risk behaviours Understanding the health problems that clients experience in everyday life

Using reputable health-education strategies to reduce risk behaviours A central component of health promotion involves helping clients to develop personal health practices and to enhance coping skills, which are results of health education that emphasizes client knowledge for directing choices and actions. While the other given factors may hold significance for many individuals, they are not as salient as health education.

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to document any physical symptoms the client may have. arrive at conclusions about the client's health. contribute to the medical diagnosis. validate the data collected.

arrive at conclusions about the client's health. The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment 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 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.

avoid premature judgments about the client. After reviewing the record or discussing the client's status with others, remember to keep an open mind and to avoid premature judgments that may alter your ability to collect accurate data. Validate information with the client and be prepared to collect additional data.

Which actions should a nurse perform before beginning the initial shift assessment of a client? Select all that apply a) Gather assessment tools after meeting the client b) Determine knowledge of self-care based on age, education, and experience c) Revise nursing care plans to reflect improvements in the clients condition d) Review the client's record before meeting the client e) Check the client's status with the nurse of the previous shift

c) Revise nursing care plans to reflect improvements in the clients condition d) Review the client's record before meeting the client e) Check the client's status with the nurse of the previous shift

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next cluster the data collected. draw inferences and identify problems. document conclusions. check for the presence of defining characteristics.

check for the presence of defining characteristics. To arrive at nursing diagnoses, collaborative problems, or referral, you must go through the steps of data analysis. This process requires diagnostic reasoning skills, often called critical thinking. The process can be divided into seven major steps: 1. Identify abnormal data and strengths. 2. Cluster the data. 3. Draw inferences and identify problems. 4. Propose possible nursing diagnoses. 5. Check for defining characteristics of those diagnoses. 6. Confirm or rule out nursing diagnoses. 7. Document conclusions.

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next a) draw inferences and identify problems. b) document conclusions. c) check for the presence of defining characteristics. d) cluster the data collected.

check for the presence of defining characteristics. Explanation: To arrive at nursing diagnoses, collaborative problems, or referral, you must go through the steps of data analysis. This process requires diagnostic reasoning skills, often called critical thinking. The process can be divided into seven major steps: 1. Identify abnormal data and strengths. 2. Cluster the data. 3. Draw inferences and identify problems. 4. Propose possible nursing diagnoses. 5. Check for defining characteristics of those diagnoses. 6. Confirm or rule out nursing diagnoses. 7. Document conclusions

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? creating an environment that encourages client autonomy stabilizing the client's physical condition collecting information regarding the client's health status developing an effective, respectful nurse-client relationship

collecting information regarding the client's health status Regardless of the care setting, the nurse's initial role in health assessment is to collect data. While all the remaining options are relevant to quality client care, they are not associated directly with the nurse's role concerning health assessment.

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? a) Comprehensive b) Partial c) Focused d) Emergency

comprehensive Explanation: This client presents with a new problem, for which the nurse should perform a comprehensive assessment. Chest pain is an emergent problem, but the client has stable vital signs and no chest pain; an emergency assessment thus is not indicated at this time. A partial or focused assessment would not allow collection of enough data to properly diagnose the cause of a new problem.

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed comprehensive. exploratory. focused. entry.

comprehensive. An initial comprehensive assessment involves collection of subjective data about the client's perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client's overall function) as well as objective data gathered during a step-by-step physical examination. Regardless of who collects the data, a total health assessment (subjective and objective data regarding functional health and body systems) is needed when the client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared.

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) Take anthropometric measurements c) Obtain a 24-hour diet recall d) Collect subjective data related to overall function

d) Collect subjective data related to overall function 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.

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

emergency 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.

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) emergency assessment. focused or problem-oriented assessment. initial comprehensive assessment. ongoing or partial assessment.

focused or problem-oriented assessment. A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.

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) a) focused or problem-oriented assessment. b) ongoing or partial assessment. c) emergency assessment. d) initial comprehensive assessment.

focused or problem-oriented assessment. Explanation: A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.

The result of a nursing assessment is the client's physiologic status. documentation of the need for a referral. prescription of treatment. formulation of nursing diagnoses.

formulation of nursing diagnoses. Analysis of data (often called nursing diagnosis) is the second phase of the nursing process. Analysis of the collected data goes hand in hand with the rationale for performing a nursing assessment. The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment data.

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? a) Focused b) Emergency c) Ongoing d) Comprehensive

ongoing Ongoing or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline. An emergency assessment is a very rapid assessment performed in life-threatening situations such as drowning, choking, or cardiac arrest. It is used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. A focused assessment gathers information specific to the problem and does not cover any other areas. A comprehensive assessment is not necessary at this time because the client already has a documented problem

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.

physiologic status. The physician performing a medical assessment focuses primarily on the client's physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic? Primary Tertiary Secondary Holistic

primary Primary prevention involves strategies aimed at preventing problems. Immunizations, health teaching, safety precautions, and nutrition counseling are examples. • Secondary prevention includes the early diagnosis of health problems and prompts treatment to prevent complications. Vision screening, Pap smears, BP screening, hearing testing, scoliosis screening, and tuberculin skin testing are examples. [SCREENING IS SECONDARY!]• Tertiary prevention focuses on preventing complications of an existing disease and promoting health to the highest level. Diet teaching for patients with diabetes, inhaler teaching for patients with lung disease, and exercise programs for those who have had myocardial infarction are examples. A holistic approach to health care may be applied to all levels of interventions but is not a "level" of intervention itself.

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first plan for potential laboratory procedures. discuss the client's symptoms with other team members. review the client's health care record. determine potential health care resources.

review the client's health care record. Before actually meeting the client and beginning the nursing health assessment, it is helpful to review the client's medical record, if available. Knowing the client's basic biographical data (age, sex, religion, educational level, and occupation) is useful. The medical record provides background about chronic diseases and gives clues to how a present illness may impact the client's activities of daily living (ADL). An awareness of the client's previous and current health status provides valuable information to guide interactions with the client.

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

significantly impaired hearing As a nurse, it is vital to sift through all the client information and make decisions on what information will impact client safety and quality of care. The ability to identify what is important on a daily basis for each individual client is paramount for nursing care. Of the data provided, the client's impaired hearing poses the greatest safety risk and has the greatest impact on the client's quality of life and so has priority. While the other options could be potential factors related to quality of life and safety, the nurse will need to assess them further.

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 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 the client's ability to communicate verbally

the rapport that exists between the nurse and the client The amount of success that nurse has in discovering the reason behind the client's crying is heavily dependent upon the relationship (rapport) that exists between the nurse and the client. It is this mutual respect and trust that allows the nurse to enter into conversations that would otherwise be off limits. The remaining options have the potential to affect the conversation, but the conversation will not likely occur without the presence of an effective nurse-client relationship.

The purpose of a health assessment includes what? (Select all that apply.) a) Collecting information about the health status of the client b) Evaluating client outcomes c) Clarifying the client's ability to pay for health care d) Synthesizing collected data e) Identifying the client's major disease process

• Collecting information about the health status of the client • Evaluating client outcomes • Synthesizing collected data Explanation: Health assessment is "gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings and evaluating patient care outcomes" (AACN, 2008). While the nurse may elicit financial information and information about disease processes during a health assessment, the purposes of the activity are not to identify the patient's major disease process or ability to pay

What is the nurse's focus while conducting a health assessment with a client? (Select all that apply.) a) Interpreting findings. b) Conducting a physical examination. c) Completing the health history. d) Implementing a plan of care. e) Formulating a plan of care

• Completing the health history. • Conducting a physical examination. Explanation: A health assessment is comprised of the taking the client's health history then followed by a physical examination. Interpreting findings, formulating a plan of care, and implementing a plan of care are steps within the nursing process that use the data identified by the health assessment.

What are the areas of independent nursing practice? Select all that apply. a) Deciding when a client needs to be turned b) Deciding what client teaching is necessary c) Deciding when physical procedures should be performed on a client d) Deciding what diagnosis a client has e) Deciding which medications to administer to the client

• Deciding when physical procedures should be performed on a client • Deciding what client teaching is necessary • Deciding when a client needs to be turned Explanation: Independent nursing interventions include client teaching, therapeutic communication, and physical procedures such as turning patients or assisting them with ambulation. The medications a client receives and the diagnosis of the client are medical decisions, not nursing decisions

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) Increasing impact of children and the homeless on communities b) Growing aging population with complex comorbidities c) Increasing complexity of acute care d) Declining numbers of medical students due to rising costs and focus on primary care e) Declining health care needs of single parents

• Declining numbers of medical students due to rising costs and focus on primary care • Increasing complexity of acute care • Growing aging population with complex comorbidities • 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

A nurse has completed assessment of a patient 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. a) Development of a nursing care plan b) Identification of collaborative problems c) Assessment of the outcome of the care plan d) Identification of the need for referrals e) Formulation of nursing diagnosis(es)

• Identification of collaborative problems • Identification of the need for referrals • Formulation of nursing diagnosis(es) Explanation: The second phase of the nursing process is to identify collaborative problems and the need for referrals as well as formulate nursing diagnoses, for which the nurse must go through the steps of data analysis. Planning is the third phase of the nursing process, which involves development of a nursing care plan and assessment of the outcome of the care plan, based on the nursing diagnosis obtained in the second phase of the nursing process.

After assessment and documentation of the information obtained from the client, the nurse needs to analyze the data collected. Which nursing actions depend on accurate analysis of data during this phase of the nursing process? Select all that apply. a) Formulation of nursing diagnosis/es b) Identification of the need for referrals c) Identification of collaborative problems d) Assessment of the outcome of the care plan e) Development of a nursing care plan

• Identification of collaborative problems • Identification of the need for referrals • Formulation of nursing diagnosis/es Explanation: The second phase of the nursing process is to identify collaborative problems and the need for referrals, and formulate nursing diagnosis/es, for which the nurse must go through the steps of data analysis. Planning is the third phase of the nursing process which involves development of a nursing care plan, and assessment of the outcome of the care plan, based on the nursing diagnosis obtained in the second phase of the nursing process

A client on the orthopedic unit is being discharged home. The client is elderly and has a broken right humerus; the client is right handed. The client's closest family member lives 50 miles away. What should the nurse consider before discharging the client? Select all the apply. (select all that apply.) a) How will the client drive? b) How will the client cook and eat? c) How will the client use her left arm? d) How will the client get home from the hospital? e) Who will be there to help the client with ADLs?

• Who will be there to help the client with ADLs? • How will the client get home from the hospital? • How will the client cook and eat? Explanation: Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems. The nurse would not be focused on the client's left arm or driving

What is paramount in health promotion? (Select all that apply.) a) Developing the nursing care plan b) Emphasizing the risks of poor health practices c) Working with the individual patient d) Limiting the involvements of the patient's friends and family e) Demonstrating authority

• Working with the individual patient • Developing the nursing care plan Explanation: Developing the nursing care plan and working with the individual patient are paramount in health promotion. Demonstrating authority, limiting the role of friends and family, and emphasizing negative consequences are inappropriate actions