PrepU Questions Ch 1: The Nurse's Role in Health Assessment

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. A clinical judgement about client responses to health difficulties B. Identification of realistic, client-centered goals C. To diagnose the condition and particular illness of the client D. The collection of subjective and objective data

A. A clinical judgement about client responses to health difficulties

What are the primary frameworks used in conducting a health assessment? Select all that apply. A. Body systems B. Head to toe C. Functional D. Analytical E. Gordons

A. Body systems B. Head to toe C. Functional

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

A. Deciding what client teaching is necessary D. Deciding when a client needs to be turned E. Deciding when physical procedures should be performed on a client

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? A. Nursing intervention B. Nursing evaluation C. Nursing goal D. Nursing assessment

A. Nursing intervention

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. Transcribing medication orders onto the nurse's medication administration record C. Notifying the healthcare provider of a critical lab result 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

A young Hispanic woman brings her baby into the clinic for immunizations. What type of disease-prevention strategy is this? A. Primary prevention B. Secondary prevention C. Nursing prevention D. Teritary prevention

A. Primary prevention

An adult client is being admitted to the hospital for cardiac catheterization related to chest pain and shortness of breath on exertion. What kind of assessment is the admitting nurse going to perform? A. Emergency B. Comprehensive C. None, the cardiac catherization will provide all needed information D. Focused

A. emergency

What is a required component of a health assessment? A. Critical judgement B. Critical thinking C. Critical analysis D. Critical decision making

B. Critical thinking

A client on the orthopedic unit is being discharged at 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 that apply. A. How will the client drive? B. How will the client get home from the hospital? C. How will the client cook and eat? D. Who will be there to help the client with ADLs? E. How will the client use her left arm?

B. How will the client get home from the hospital? C. How will the client cook and eat? D. Who will be there to help the client with ADLs?

How does a nurse decide what health-promotion activities are necessary for a particular client? A. Nurses address areas associated with healthy behaviors only B. Nurses collaborate with clients to identify areas in which clients are willing to make changes C. Nurses assess areas in which clients are willing to make changes only D. Nurses construct their own theories to identify perceptions, barriers and positive outcomes

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

What are the components of the SBAR? Select all that apply. A. Biophysical test results B. Recommendation C. Referral D. Assessment E. Situation

B. Recommendation D. Assessment E. Situation

Why is it important for a new nurse, working on a step down unit, to know the standards of care for the facility in which the nurse is working? A. Standards of care instruct the nurse how to assess for cardiac event B. standards of care often set the time frame for assessing the clients on the unit C. Standards of care dictate how to handle clients who have experienced trauma D. Standards of care tell the nurse how to get a good evaluation

B. standards of care often set the time frame for assessing the clients on the unit

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

C. Critical thinking helps nurses work through the analysis, develop alternative and implement the best interventions

When making rounds, the RN should prioritizes following-up care for which unit? A. A client who is due for a routine shift assessment B. A client with strong, equal pedal pulses following catheterization C. A client who is receiving intravenous antibiotics for pneumonia D. An oncology client with a cough but no fever

D. An oncology client with a cough but no fever

As part of the nursing profession, nurses function as client advocates. What is one way in which a nurse advocates for the client? A. Assisting families to optimal states of client interaction B. Keeping the client free from disease C. Providing client teaching about the family history of disease D. Identifying the side effects of treatment

D. Identifying the side effects of treatment

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? A. If the client is injured, protect the cervical spine B. Begin CPR C. Ensure that the client is safe D. Open the client's airways

D. Open the client's airways

Nurses provide both direct and indirect care. What is an example of indirect care? A. Completing a nursing assessment B. Calculating medication dosage C. Adjusting an IV rate D. Participating in client care conference

D. Participating in client care conference

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

D. Primary

Four broad goals describe the role of professional nurse. Which is one of these goals? A. To prescribe medication B. To counsel the human responses to health or illness C. To diagnose illness D. To advocate for individuals, families, communities, and populations

D. To advocate for individuals, families, communities, and populations

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

D. To gather information about the health status of the patient