Chapter 1: The Nurse's Role in Health Assessment

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

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." 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.

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

Evaluation

Reflection of the nurse upon personal feelings 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 After reviewing the client's record, the nurse should remember to keep an open mind and to avoid premature judgments that may alter the ability to collect accurate data. Making a referral that the client may not want or performing unnecessary tests do not involve personal feelings.

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

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 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. This statement is suggestive of a nursing concern, which the nurse would characterize as a nursing diagnosis and follow up with education. Social work and occupational therapy are not relevant to this statement, and rechecking the client's glucose level does not address the problem at hand.

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

Knowledge deficit A knowledge deficit diagnosis is appropriate for any new diagnosis and/or medication.

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

Situation Assessment Recommendation One system by which nurses can communicate information and make referrals of clients to other health care providers (e.g., dieticians, speech therapists) is the SBAR (situation, background, assessment, recommendation) framework. Components of SBAR do not include biophysical test results or referral.

What is the primary function of the health care team?

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.

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

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.

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?

A clinical judgment about client responses to health difficulties. Diagnosis is the clustering of data to make a judgment or statement about the client'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 client, the nurse is able to utilize findings and do what?

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

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 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.

Why is the nurse always reassessing the client for changes?

To achieve the best results The nurse or detective is always reassessing the client or case for changes in order to achieve the best results. Each relies on both the science and art of his or her respective profession.

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 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.

The result of a nursing assessment is the

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.

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

Palpation Inspection Percussion Auscultation Objective data is obtained by general observation and through the use of the physical assessment techniques: palpation, inspection, percussion, and auscultation. Even though the medical record would be a source of objective data, the client is new to the health clinic and medical record data would not exist.

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 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

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

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 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 medical examination focus is on diagnosis and treatment of disease and the nursing examination focuses on the human response.

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. During assessment, subjective data are collected prior to objective data. This is followed by validation and then documentation of data.

What is the nurse's focus while conducting a health assessment with a client? (Select all that apply.)

Completing the health history. Conducting a physical examination. 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.

Which of the following statements best conveys the rationale for health promotion in a school setting?

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.

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 Early on, nurses relied on their natural senses to perform assessment. Early nursing assessment was based on observation of the client's face and body for changes indicating improvement or deterioration of the client's condition.

When planning a community program related to Healthy People 2020, the critical first step involves

defining the community To determine what is needed in a program, the community must first be defined to narrow the focus and plan specific interventions.

For which of the following clients should a nurse perform a focused assessment?

Client with 4-day history of sore throat and fever with enlarged lymph nodes 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 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 (emergency assessment). A client with diabetes has a chronic, ongoing health problem that needs reassessment and possibly a change in treatment (ongoing or partial assessment).

Which part of the nursing process includes the formulation of goals?

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

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 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.

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

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.

As part of the nursing profession, nurses function as client advocates. What is one way in which a nurse advocates for a client?

Identifying the side effects of treatment Nurses advocate for clients in many ways: keeping them safe, communicating their needs, identifying the side effects of treatment and finding better options, and helping clients to understand their diseases and treatments so that they can optimize self-care. Advocacy does not include teaching about a family's history of disease, assisting the family to optimal states of client interaction, or keeping the client disease free.

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. 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.

The nurse prepares to complete a holistic assessment of a client with a chronic health problem. Which areas will the nurse include in this assessment? Select all that apply.

Spiritual Physiologic Sociocultural Psychological Developmental The purpose of a nursing health assessment is to collect holistic data to determine a client's level of functioning and make professional clinical judgments. Holistic data includes spiritual, physiologic, sociocultural, psychological and developmental data. Recreational data is not specifically identified when completing a holistic assessment.

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

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.

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'?" 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.

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?

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.

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 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.

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 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 client's health status and current problems.

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 When performing critical thinking the nurse begins with identifying abnormal data and strengths and then clusters the data. Afterwards, inferences and drawn and problems identified. Possible nursing diagnoses are then determined before checking for defining characteristics of the diagnoses. Before documenting, the nurse confirms or rules out any nursing diagnoses inappropriate for the client's problems.

Student nurses are learning about evidence-based practice. What would they learn is the final step in this process?

Justifying the selection of interventions Evidence-based practice helps you solve common problems through these four steps: 1. Clearly identify the issue or difficulties based on an accurate analysis of current nursing knowledge and practice; 2. Search the literature for relevant research; 3. Evaluate the research evidence using established criteria regarding scientific merit; 4. Choose interventions and justify the selection with the most valid evidence.

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 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.

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 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 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. 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.

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 The comprehensive health assessment focuses on how the client's health status affects the activities of daily living and how the client's activities and choices affect health status. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. In contrast, the physician performing a medical examination focuses primarily on the client's physiologic development status, with less focus on psychological, sociocultural, or spiritual well-being.

When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force?

Technology It is generally recognized that the depth and scope of nursing assessment have expanded significantly over the past several decades because of rapid advances in biomedical knowledge and technology and through the promotion of primary health care. The nurse's role in assessment is becoming increasingly diversified due to these advances. Sophisticated computerized information systems and informatics also are impacting the documentation and retrieval of assessment information.

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

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.

A nurse has documented the findings of a comprehensive assessment of a new client. What is the primary rationale that the nurse should identify for accurate and thorough documentation?

Assuring valid conclusions from analyzed data Documentation of assessment data is an important step in assessment because it forms the database for the entire nursing process and provides data for all other members of the health care team. Thorough and accurate documentation is vital to ensure valid conclusions are made when the data are analyzed in the second step of the nursing process. This rationale supersedes the other listed goals, although each is valid.

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?

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.

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 Smoking cessation requires a dramatic change in behavior. The client must be truly motivated in order for such a change to occur. The nurse should initially discuss with the client if smoking cessation is a goal that the client may have. If the client is interested in no longer smoking, the remaining options are less relevant. Explaining the detrimental effects of smoking, identifying smoking as a modifiable risk factor and educating the client to the various smoking cessation methods are beneficial when discussing the situation with a client who has not yet made the decision to stop smoking.

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

Empathy 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 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 After reviewing the client's record, the nurse should remember to keep an open mind and to avoid premature judgments that may alter the ability to collect accurate data. Making a referral that the client may not want, omitting pertinent data, or performing unnecessary tests does not involve personal feelings.

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?

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.

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 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 performing a health assessment on a community-dwelling client who is recovering from hip replacement surgery. Which of the following actions should the nurse prioritize during assessment?

Interpret the information about the client in context. The client must be viewed holistically. Many systems are operating to create the context in which the client exists and functions. The nurse sees an individual client, but accurate interpretation of what the nurse sees depends on perceiving the client in context. Culture, family, and community operate as systems interacting to form the context. Information does not normally need to be corroborated. The client's age is not the nurse's primary focus.

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

It identifies risk factors, health issues, and diseases. 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, targeting the next 10 years. Its overall goal is 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 does not help determine the client's plan of care. Healthy People 2020 does not serve as a guide for the health assessment nor does it list specific interventions to address specific health problems.

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 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 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 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?

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

Primary prevention Primary prevention involves strategies to prevent problems. Immunizations, health teaching, safety precautions, and nutrition counseling are examples. Secondary prevention is early diagnosis of health problems to prevent complications. Examples of secondary prevention would be blood pressure screenings, Pap smears, and TB skin test to name a few. Tertiary prevention is preventing complications of an existing disease and promoting health to the highest level. Examples of tertiary prevention would include diet instruction for clients with heart disease, and proper use of inhalers for clients with asthma or chronic respiratory diseases.

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. Before actually beginning the health assessment, the nurse should review the client's record. It provides basic biographic data and a background about chronic diseases. It also gives clues to how a present illness may impact the client's activities of daily living. Validating the information with the client occurs during the assessment. Consulting clinical resources is not an immediate priority.

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 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.

Four broad goals describe the role of a professional nurse. What is one of these goals?

To advocate for individuals, families, communities, and populations Four broad goals within nursing are (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. Nursing goals do not include diagnosing illness, counseling about human responses to health or illness, or prescribing medications.

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?

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.

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 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.

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 subdued affect would be part of the emotional assessment.

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 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.

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

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.

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 increasing the longevity of one's life Healthy People 2020 promotes a healthy lifestyle, disease prevention, improved quality of life, and length of a person's life. While important to the general wellness achieved by any individual, health care costs are not addressed by the Healthy People 2020 guidelines.

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 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.

The nurse is analyzing the data obtained from the following clients. Which client would the nurse expect to facilitate a referral?

A 50-year-old client newly diagnosed with diabetes During the comprehensive assessment, the nurse identifies problems that require the assistance of other health care professionals. A client who is newly diagnosed with diabetes would benefit from a referral to a diabetes education program. Assistance from other health care professionals would not be necessary for the older adult client, the child, or the teenager seeking information.