Health Assessment : Chapter 1

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

Primary

Diagnostic reasoning is a seven-step process of _____________________; the nurse gathers and clusters data, draws inferences, and develops nursing diagnoses.

critical thinking

The three major frameworks to organize assessment findings include the functional assessment based on Gordon's functional patterns, the systematic ___________ assessment, and body systems assessment.

head-to-toe

There are 10 areas of focus in the U.S. Department of Health and Human Services Healthy People 2020 which provides strategies based on health promotion and ___________ reduction strategies.

risk

Health assessment is the first step of the nursing process and includes the health assessment, which is _______________ data, and the physical assessment, which is ______________ data.

subjective, objective

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

A

What are the 5 components of the nursing process?

1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation

A community health nurse is assessing an older adult client in their home. When the nurse is gathering subjective data, which of the following would the nurse identify? A) The client's feelings of happiness B) The client's posture C) The client's affect D) The client's behavior

A

When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what? A)Assessment B) Diagnosis C) Planning D) Evaluation

B) Diagnosis

A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time? A) focused B) emergency C) comprehensive D) ongoing or partial

B) emergency

The nurse is reviewing a client's health history and physical examination. Which of the following would the nurse identify as subjective data? Select all that apply. A) Weight—145 lb B) Lungs clear to auscultation C) "My father died of a heart attack" D) Client complains of a headache E)Pupils equal, round, and reactive to light F) "I feel so tired sometimes"

C, D, F

What are nurses able to detect through the health assessment? A) Areas that need referral to a specialist B) Areas that need continuous care C) Areas that need in-hospital care D) Areas in need of health adjustments

D) Areas in need of health adjustments

A nurse on the subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice? A) The focused assessment replaces the comprehensive database. B) The focused assessment should be done before the physical exam. C)The focused assessment is done after gathering subjective data. D) The focused assessment addresses a particular client problem.

D) particular client problem

A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next? A) Cluster client cues. B) Implement an intervention. C) Identify client concerns. D) Evaluate outcome.

D) Evaluate Outcome

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

D) comprehensive

A client who underwent abdominal surgery this morning reports feeling weak and dizzy. The nurse also observed a decrease in urine output in the last hour. What action should the nurse take first? A) Reevaluate the nursing plan. B) Administer IV fluids. C) Assess the client. D) Evaluate the outcome.

C) Assess the client

Which of the following is the best example of holistic data collection by a nurse? A) Measuring blood glucose level, cholesterol level, blood pressure, and resting heart rate B) Assessing the client's range of arm motion, auscultating for heart sounds, testing for pupil dilation, and conducting a vision test C)Performing an x-ray, ECG, exercise stress test, and complete blood count D)Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings

D