Jensen Prep U: Ch. 1

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

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

A healthy environment

A patient 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 patient?

Airway

What is a required component of a health assessment?

Critical thinking

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

Evaluation

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

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

Knowledge base and expertise

35s The nurse notices a large number of positions available for employment in managed care. Which are reasons for the growth in nursing opportunities in this care environment? Select all that apply.

-Complex acute care - Aging of baby boomer generation -Expanding health service networks -Expanding health needs of single parents

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

Appearance

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.

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 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

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.

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

Which assessment finding should the nurse document as objective data?

Body functions

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

Knowledge deficit

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

Head-to-toe

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

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

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

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.

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

A nurse on the hospital's 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.

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

as a basis for the nursing process

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

primary prevention

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

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

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

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.

Data being collected during a health assessment causes the nurse to believe there may be additional issues that are possibly affecting the client's health and wellness. What action should the nurse take to best address the suggestion of additional health concerns?

Extend the time originally allotted for the completion of the initial health assessment.

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

Gathering forensic evidence for a legal proceeding

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.

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.

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.

For which client should a nurse perform a focused assessment?

Four-day history of sore throat and fever with enlarged lymph nodes

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.

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