Health Assessment; PrepU Ch. 1-5; 7, 10

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?

The focused assessment addresses a particular client problem.

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 2030 indicator of responsible sexual behavior?

The importance of using a condom when engaging in sexual activity

The nurse suspects that a female client has an alcohol use disorder. When completing the AUDIT-C screening tool, which response requires further follow-up by the nurse?

"On the weekends I will go out and have about six to seven drinks with friends."

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

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

Appearance

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?

emergency

A victim of a house fire is admitted for possible inhalation injuries. During the admission process, which type of assessment should the nurse complete?

emergency

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 client with a long history of congestive heart failure is admitted with difficulty breathing. Assessment reveals the following: 5-lb weight gain in 1 week, 4+ pitting pedal edema, crackles ½ way up bilateral lungs; vital signs: blood pressure 140/90, heart rate 100 bounding, oxygen saturation 90% while the client is on 2 liters nasal cannula. Orders to manage the client's fluid overload are obtained and the client is now stable. What health history information should the nurse obtain in order to prevent future exacerbations and hospitalizations? Select the best option.

"Are you able to purchase your prescriptions?"

The nurse is performing a health assessment with a client who presented to the emergency department after falling as a result of feeling dizzy. Which questions demonstrates that the nurse understands the initial purpose of effectively conducting a health assessment? Select all that apply.

"Are you experiencing any pain at this time?" "Are you feeling dizzy now?" "Do you know what your blood pressure is usually?"

The nurse is preparing to assess a female client's activities related to health promotion and maintenance. Which question would provide the most objective and thorough data?

"Could you describe how you perform self-breast exams?"

A client complains of knee pain on the nurse's arrival in the room. What should the nurse's first sentence be after greeting the client?

"Could you please describe what happened?"

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

"How do you manage your stress?"

A client states, "My wife died two months ago today." Which of the following responses would be most appropriate?

"How does that make you feel?"

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.

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

A client with a long history of back pain is scheduled for back surgery. The nurse obtains the client's health history. Which of the following statements by the client requires further investigation?

"I take medication to thin my blood."

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?

"I'm going to assess the client now so that I can begin formulating the care plan."

A 60-year-old woman with a bunion will undergo surgery later today. The client tells the nurse in the surgical daycare admitting department, "I'm sure I've been asked these questions before. Can't we just focus on my foot and not all these other topics?" How should the nurse best explain the rationale for obtaining a health history?

"We want to make sure your nursing care matches your needs as closely as possible."

Which of the following questions would be most important for the nurse to ask first when obtaining the health history?

"What is your major health concern at this time?"

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?

"What other symptoms occurred during the spell?"

The nurse is questioning a 19-year-old client about personal relationships with family members or significant others in order to assess problems and potential support from the client's family of origin. Which question would be the best question for the nurse to ask?

"Who is the most important person in your life?"

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

A 45-year-old man with chest pain and diaphoresis for 1 hour

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

A 50-year-old client newly diagnosed with diabetes

The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use?

After assessing for cigarette use

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

A new order for an antibiotic is received for a client. The nurse reviews the client's electronic medical record. The record states the client has no known allergies. What action should the nurse take?

Ask the client if they have allergies.

A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000.The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse?

Assess the nasogastric tube for proper functioning.

Data collection occurs where in the nursing process?

Assessment

The principle of confidentiality is of paramount importance in the nurse-client relationship. When should you inform the client of with whom his or her information will be shared?

At the beginning of the interview

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 judgments

During an interview, how can the nurse best assist the client as the client tells their story?

Avoid interrupting the client.

When conducting the health assessment, the nurse interacts with the client in a caring manner. How would the nurse demonstrate caring to the client? Select all that apply.

Being nonjudgmental Showing respect to the client Valuing the client unconditionally

Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client did not want to wait. The nurse has heard about this client many times from colleagues and is aware that she is very talkative. Which of the following is a helpful technique to improve the quality of the interview for both provider and client?

Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed.

A client reports pain as being 7 on a scale from 1 to 10. In which area of the symptom should the nurse document this information?

Characteristic

A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative?

Circle with a cross

While conducting a comprehensive assessment the nurse decides to add questions about physical abuse. Which finding caused the nurse to make this clinical determination? (Select all answer choices that apply)

Client waited several weeks before seeking treatment Past history of injuries or accidents Spouse has a history of alcohol abuse Injuries are inconsistent with the client's report

During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?

environmental

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 data related to overall function

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?

Conduct a focused assessment.

While gathering data for the family history portion of the health history, what would you ask about?

Coronary artery disease

A nurse completes an initial assessment and discusses findings with the client. What is the next best action of the nurse?

Develop a plan of care with the client

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

Diagnosis

The second standard within the Nursing Scope and Standards of Practice states that the nurse analyzes assessment data to determine the diagnoses or issues. Which activities will the nurse perform when complying with the expectations of the second standard? Select all that apply.

Documents the diagnoses Derives the diagnosis based on assessment data Validates the diagnoses with the client, family, and other health care providers

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

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 is preparing to assess a client who is new to the clinic. When beginning the collection of the client's data, which of the following actions should the nurse prioritize?

Establishing a trusting relationship

A client has been admitted with new onset hypertension with a past medical history of asthma, type 2 diabetes, and hypercholesterolemia. After developing a nursing care plan, the nurse reports findings to the health care provider. After receiving medication orders from the health care provider, the nurse administers several medications for hypertension. What is the nextbest action of the nurse?

Evaluate patient outcome.

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

A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify?

Expansion of health care networks

A client with a foot wound returns to the outpatient wound clinic for a weekly appointment and treatment. Which type of assessment should the nurse complete with this client?

Follow-up

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

A graduate nurse working on a medical-surgical unit is admitting a client who does not speak English. No interpreters are available. The client's spouse is present and speaks English. What should the nurse remember about the use of interpreters when communicating with clients?

Friends and family who are unfamiliar with medical terminology may misinterpret information

Learning about the effects of the illness does what for the nurse and the client?

Gives them the opportunity to create a complete and congruent picture of the problem

The nurse is teaching the client how to self-administer insulin. Which functional health pattern does this nursing intervention address?

Health perception-health management

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?

Implement interventions.

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

Before beginning a health assessment with a client, the nurse reviews Healthy People 2030 because of which of the following reasons?

It identifies heath indicators, appropriate interventions, and resources.

Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data?

Maintain a professional distance during assessment.

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

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.

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

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

A client admitted to the health care facility for new onset of abdominal pain expresses to nurse that they were treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

Past health history

The nurse would document driving with car seatbelt fastened, bicycling with properly-fitted helmet, and installing a smoke detector in a vacation home in the client's health history under which of the following?

Personal and social history

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

Primary

A comprehensive health history includes which components? Select all that apply.

Reason for seeking care History of present illness Past health history

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

The nurse asks a client "is there any time when you feel unsafe?" On which part of the comprehensive health history is the nurse focusing with this question?

family violence

A client has come to the physician's office several times in the last month with a black eye, bruises, and lacerations on the lower extremities. The client always explains having fallen and tripped. The nurse suspects abuse. The next step should be to:

Report the findings to a supervisor.

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.

The nurse is assessing an older adult client a hospice unit. The client cannot speak or communicate, but the client's daughter is there and answers all the questions as best as she can. What type of data source is the daughter?

Secondary

The nurse has completed a health history and assessment on a new client and is now documenting the findings. Which of the following would be considered objective data? Select all that apply.

Skin is pale and cool. Client appears disheveled. Client is emotionally labile, crying and laughing at times.

In interviewing a client about substance use, a nurse asks her whether she takes any herbal supplements. Which of the following is the best rationale for asking this question?

Some herbal supplements may interact with prescribed medications.

You are taking a health history on a new client. While performing your assessment, the client informs you that her mother has type 1 diabetes. What is the significance of this information to the health history?

The client may be at risk for developing diabetes

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?

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

The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next?

Validate that the client understands how to use the inhalers

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?

chief complaint

A client comes to the health care provider's office for a visit. The client has been seen in this office for the past five years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?

focued assesment

A client comes to the community clinic seeking help for acute low back pain. Which type of assessment should the nurse complete for this client?

focused

A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice?

health maintenance

A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?

health maintenance

A nurse working in a long-term care facility is performing a comprehensive assessment on an 84-year-old male resident.

last bowel movement was charted 7 days ago No urine output has been charted in the last 24 hours heart rate 120 beats/min and irregular oxygen saturations 88% on room air

An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?

last surgery date validated by adult daughter

A client says that food is not important and meals are not enjoyable. Where should the nurse document this information?

nutrition health pattern

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information?

past medical history

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

physiologic status.

A client comes to the emergency department with severe abdominal pain. When performing a complete assessment, the nurse would focus on which of the following areas when covering past health history?

previous medical and surgical problems

The nurse is conducting an initial health history with a client. The nurse asks about the client's history of neurological, respiratory, cardiovascular, and musculoskeletal problems. Which part of the subjective health assessment is the nurse performing?

review of the systems

Prior to meeting the new client, the nurse should first_______ and then ________

review the client's medical record explain the purpose of the interview speak to family members

An elderly client arrives in the Emergency Department with nonspecific symptoms. When the nurse attempts to take the health history, the client appears not to understand and does not answer the questions. The nurse realizes that this might be because of a common problem in the elderly, which is:

sensory deficits

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

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.

swelling redness around the site clear drainage on dressing

The nurse is completing an assessment on a new client at the community health clinic and would like to screen the client's cognitive ability. There are many resources that provide screening tools for nurses. Which agency would be most helpful in directing the nurse to a screening tool to assess the client's cognitive ability?

the Alzheimer's Association (AA)

The nurse conducts a health history with a client who reports having a dull headache over the past month. The client tells the nurse that using aromatherapy scents have helped manage the pain sometimes. This information is belongs to which attribute of a symptom?

treatment

The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to

use very basic lay terminology.

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?

value-belief

During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed

working.