Chapter 01: The Nurse's Role in Health Assessment
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 Standards of care tell the nurse how to get a good evaluation Standards of care instruct the nurse how to assess for a cardiac event Standards of care dictate how to handle clients who have experienced trauma
Standards of care often set the time frame for assessing the clients on the unit Clients in intensive care settings have vital signs and a focused assessment hourly. A facility's standards of care often prescribe such time frames, so it is important for the nurse to identify those standards for the unit and facility in which the nurse is working. Standards of care do not dictate how to handle a trauma client; they do not instruct the nurse how to assess for a cardiac event or tell the nurse how to get a good evaluation.
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 nurse's potential for liability The client's acuity The client's age The unit's protocols
The client's acuity The frequency of ongoing assessment is determined by the acuity of the client. This factor is more important than the nurse's liability, the client's age, or the protocols of the unit.
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's holistic wellness status. physiologic 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.
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 client's ability to communicate verbally the rapport that exists between the nurse and the client the type and degree of physical issues the client is experiencing the nurse's ability to ask relevant questions
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.
A nurse analyzes the data obtained from an initial assessment of a new client: weight gain of 15 lbs in 3 months, intolerance to cold, constipation, and lethargy. The nurse determines the client may have hypothyroidism and develops several nursing diagnoses with interventions to address the client concerns. Which action should the nurse take next? Evaluate outcomes. Reassess the client. Implement interventions. Cluster cues.
Implement interventions. Because the nurse has already assessed the client, analyzed the data, clustered the client cues, identified client concerns, and developed a plan with interventions, the next step in the nursing process would be to implement the interventions. The nurse would reassess the client after the interventions were implemented and evaluate the outcomes.
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? Provide the client with a bedtime protein snack. Encourage the client to increase oral fluid intake. Assist the client with personal hygiene. Measure the client's blood glucose four times daily.
Measure the client's blood glucose four times daily. Collaborative problems, such as changes in blood glucose, are certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems by implementing both physician- and nurse-prescribed interventions to reduce further complications. Nutrition (oral fluids, bedtime snack) and hygiene are most often considered to be independent nursing concerns.
How does a nurse best facilitate the nursing health assessment? Maintaining privacy Creating a nursing care plan 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.
A nurse is gathering subjective data. Which of the following would the nurse be most likely to assess? Posture Behavior Feelings of happiness Mood
Feelings of happiness Subjective data are sensations, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Happiness is a feeling and therefore subjective. Posture, mood, and behavior are observable and considered objective data.
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? U.S. Preventive Services Task Force Healthy People 2020 Pender Health Promotion Model Health Belief Model
Health Belief Model 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.
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? Asks unlicensed staff to measure vital signs Focuses on the system that caused the hospitalization Follows the ABC approach Uses evidence-based technique
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
What is the primary function of the health care team? To guide the client's care throughout times of crisis To develop an individual focus for each member To decide the best overall care To work together to obtain maximum coverage
To decide the best overall care The health care team meets to collaborate on clients 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 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? significantly impaired hearing greatly concerned about cost of services widowed 2 years ago lives alone
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.
Which of the following client situations would the nurse interpret as requiring an emergency assessment? A client who took a drug overdose A client who wants a pregnancy test A client with severe sunburn A client needing an employment physical
A client who took a drug overdose An emergency assessment is a rapid assessment performed in life-threatening situations to make an immediate diagnosis to provide prompt treatment. A drug overdose is a life-threatening situation. A severe sunburn, employment physical, and pregnancy testing would not be considered life-threatening situations.
Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first? Perform a comprehensive head-to-toe assessment. Alert the critical assessment team. Notify the health care provider. Conduct a focused assessment.
Conduct a focused assessment. Because a comprehensive assessment had already been conducted, the nurse would perform a focused assessment based on the observed neurological changes. The nurse would need to obtain more information before alerting the critical assessment team or contacting the health care provider; some actions would include completing the physical neurological exam, checking blood glucose, checking for changes in medications that may have contributed to the change in mental status, and reviewing the a.m. labs for abnormal sodium level.
An assessment that concentrates on patterns of role performance that all humans share is called what? Head-to-toe Focused Body systems Functional
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.
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 Walk-through of education facility and faculty questionnaire Review of literature and consultation with faculty Individual student interview and 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.
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 The client's medical comorbidities The client's prognosis for recovery The client's learning style
The client's motivation for change 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. As a result, implementation of this model should begin with an appraisal of the client's motivation to change. This consideration would precede the other listed variables, although each may affect care.
A 38-year-old client has been admitted to the emergency department (ED) with reports of abdominal pain and vomiting for the past 6 hours. Which type of assessment will the nurse complete on this client? comprehensive assessment emergency assessment ongoing assessment focused assessment
focused assessment A focused assessment may occur in all health care settings. It is smaller in scope than a comprehensive assessment, but more in depth related to the problem being presented. It usually involves one or two body systems. Data gathered and analyzed will determine the cause of the client's report. A comprehensive assessment includes the collection of objective data (data gathered during a step-by-step physical examination) and subjective data (the client's perception of the health of all body parts or systems, past health history, family history, lifestyle and health practices, including overall functioning). An emergency assessment is a very rapid assessment performed in life-threatening situations. In such situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment.
The nurse notes that an intervention provided to a client for a specific health problem was not effective. The nurse continues to monitor and care for the client. Which type of assessment is the nurse performing? ongoing or partial assessment focused or problem oriented emergency initial comprehensive
ongoing or partial assessment The nurse continues to assess the client, monitoring client progress and outcomes. Client problems that were initially assessed will be reassessed to evaluate for improvement or deterioration (change of condition). A comprehensive assessment occurs prior to an ongoing or partial assessment. An ongoing or partial assessment is completed by the nurse after a comprehensive database has been established. A focused or problem-oriented assessment is performed when a specific problem has been identified, which is not indicated in the client scenario. An emergency assessment would be performed during life-threatening situations, which is not indicated in the client scenario.
A nurse is performing a focused assessment on a client admitted with symptoms of meningitis who underwent a lumbar puncture this morning and is now reporting a headache and photophobia. The nurse identifies clear drainage on the dressing and redness and swelling around the site. The nurse documents which of the following objective findings in the chart? Select all that apply. photophobia clear drainage on dressing headache swelling redness around the site
swelling redness around the site clear drainage on dressing Objective data are referred to as signs that can be observed and measured, for example, skin color, posture, heart rate, and blood pressure. Swelling, redness around the site, and drainage on the dressing can all be observed and measured. Subjective data are referred to as what the client reports but the nurse cannot measure. The nurse may be able to observe that the client looks uncomfortable from a headache and obtain a pain rating scale but neither a headache nor photophobia cannot be directly observed or measured.