Ch.1: The Nurse's Role in Health Assessment

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

Diagnosis

While assessing a client, the nurse notes that the client is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process?

Emotional

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 nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation

Revising the plan as needed occurs in what part of the nursing process?

Evaluation

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

Which of the following is an example of a recent trend in nursing roles?

Gathering forensic evidence for a legal proceeding

The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply.

- Client complains of a headache - "My father died of a heart attack." - "I feel so tired sometimes."

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 subjective data - Validate data - Collect objective data - Document data

What are the areas of independent nursing practice? Select all that apply.

- Deciding what client teaching is necessary - Deciding when a client needs to be turned - Deciding when physical procedures should be performed on a client

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following?

Avoid biases and judgements

Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern?

"Do you have family who visit you regularly?"

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'm sorry, but assessment is ongoing and continuous."

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral?

A 50-year-old client newly diagnosed with diabetes

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?

Collect Subjective Data

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.

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

A nurse is preparing to interview a client who is a Seventh Day Adventist. The nurse does not agree with this religion's view of modern medicine. Reflection of the nurse on her personal feelings regarding this client and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation?

Formation of judgments that may interfere with the interview

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 2020

A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the client's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?

Making incorrect nursing judgments or diagnoses

The client has a murmur. This is what type of data?

Objective

The nurse is exhibiting critical thinking in which client care situation?

Performing a focused assessment on a client who is complaining of shortness of breath.

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?

Significantly impaired hearing

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 rapport that exists between the nurse and the client

The nurse prepares to collect objective data on a client new to a health clinic. What will the nurse use to collect this data?

- Ausculation - Palpation - Inspection - Percussion

When assisting a client with health promotion, what must the nurse also nurture?

A healthy environment

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?

Hospice

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?

Standards of care often set the time frame for assessing the clients on the unit

As a nurse becomes more proficient and comfortable in his or her role, what increases?

Knowledge base and expertise

A client has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this client?

Knowledge deficit

An instructor is describing a comprehensive nursing health assessment to a group of students. The instructor determines that the teaching was successful when the students identify which of the following as the overall purpose?

Make a clinical judgment

An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession?

Natural senses

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

Nurses provide both direct and indirect care. What is an example of indirect care?

Participating in a client care conference

A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas?

Physiologic, psychological, sociocultural, developmental, and spiritual data

A young Hispanic woman brings her baby into the clinic for immunizations. What type of disease-prevention strategy is this?

Primary prevention

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.

What are the components of the SBAR? Select all that apply.

Situation, Assessment, Recommendation

A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify?

The client's feelings of happiness

The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following?

The client's motivation for change

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 2020 indicator of responsible sexual behavior?

The importance of using a condom when engaging in sexual activity

What is the primary function of the health care team?

To decide the best overall care

What is the primary purpose of health assessment?

To gather information about the health status of the client

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?

Uses evidence-based techniques

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be:

Using reputable health-education strategies to reduce risk behaviors

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

as a basis for the nursing process

Consider the nurse's role in the health assessment of a client. What action will the nurse perform initially when admitting a client to a long-term care facility?

collecting information regarding the client's health status

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

comprehensive

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is

continuous

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

perform a physical examination

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

physiologic status.

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

primary prevention

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 of actual human responses to disease or life events."

A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client?

Airway

Before beginning a health assessment with a client, the nurse reviews Healthy People 2020 because:

It identifies risk factors, health issues, and diseases.

In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation?

Effect of health on functional status

An assessment that concentrates on patterns of role performance that all humans share is called what?

Functional

A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is "a bit sporadic." How should the nurse best respond to this assessment finding?

Identify a nursing diagnosis of Ineffective Health Maintenance.

Which skill does the nurse need to obtain subjective data during the initial comprehensive assessment?

Empathy

When the nurse is performing a physical examination on admission of a client to the medical unit, the client says the doctor already did an exam. The best response by the nurse would be

"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."

The 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 - Imporving one's quality of life - increasing the longevity of one's life

A nurse has received a report on a client who will soon be admitted to the medical unit from the emergency department. When preparing for the assessment phase of the nursing process, which of the following should the nurse do first?

Collect subjective data.

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

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?

Individual student interview and questionnaire

An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem?

Measure the client's blood glucose four times daily.

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

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?

Ongoing or partial

The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data?

Appearance

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?

Nursing Diagnosis

An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the first action of the nurse?

Open the client's airway

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

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?

Collect subjective and objective data related to overall function.

The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process?

It is ongoing and continuous.

A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?

Making incorrect nursing judgments or diagnoses

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?

Ongoing

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?

Recognize the need to reevaluate the client's plan of care.

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?

Determine any changes from the baseline data

The nurse is collecting data from a client. Which of the following best reflects objective data?

Apperance

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?

Ask the client about the most recent experiences of pain.

Which assessment finding should the nurse document as objective data?

Body Functions

During a health assessment, the client identifies having a 1 pack per day smoking habit. What should the nurse initially focus upon when approaching the client about the benefits of smoking cessation?

Determining whether the client wants to stop smoking

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?

Inspection

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

Which of the following is the best example of assessment in everyday life?

Measuring the remaining tread on a car tire to determine whether it is time to replace it

A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable?

The client's acuity