NU273 Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data

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? "The health assessment will be more thorough if I wait until the client is pain free." "I'm going to assess the client now so that I can begin formulating the care plan." "I'll do the health assessment when the client's family leaves so that distractions will be minimal." "The client has been ordered a nutritional consult; I do the health assessment right after that is finished."

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

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? "Have you ever been dizzy enough to fall?" Can you remember when you first started to feel dizzy?" "Do you often feel dizzy?" "What do you mean by 'a little dizzy'?"

"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.

A student nurse is learning to document an initial assessment. What would theinstructor tell the student that accurate documentation of this specific assessment best provides? Data on the client's prognosis for recovery A baseline for comparison with future findings Information on the nurse's cultural competence Information on the effectiveness of interventions

A baseline for comparison with future findings

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? Identification of realistic, client-centered goals. To diagnose the condition and particular illness of the client. A clinical judgment about client responses to health difficulties. The collection of subjective and objective data.

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."

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? Circulation Breathing Airway Disability

Airway The emergency assessment involves a life-threatening or unstable situation, such as a client in an ED who has experienced a traumatic injury. Staff members at the ED use triage to determine the level of urgency by considering assessments based on the mnemonic A, B, C, D, E: A-Airway; B-Breathing; C-Circulation; D-Disability; and E-Exposure.

Question 12 of 20 How does a nurse best facilitate the nursing health assessment? Formulating a nursing diagnosis Creating a nursing care plan Asking the appropriate questions Maintaining privacy

Asking the appropriate questions

Using both verbal and nonverbal clues given by the client, what is the nurse constantly doing? Formulating a discharge plan Assessing Intervening where necessary Diagnosing

Assessing

What are the primary frameworks used in conducting a health assessment? Select all that apply. Functional systems Head to toe Gordon's Analytical Body systems

Body systems Functional Head to toe The three major frameworks for organizing assessment data are functional systems, head to toe, and body systems. Gordon's framework and an analytical framework are not primary frameworks for conducting a health assessment on a client.

A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse? Nursing care plan Physical assessment Critical thinking Diagnostic reasoning

Critical thinking Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems. Diagnostic reasoning is important in developing diagnostic statements, not in caring for multiple clients with complex care needs. Physical assessment is important in the building the foundation of the nursing care plan. The nursing care plan directs the care that will be provided for the individual client, but does not address the needs of caring for multiple clients.

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

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

A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use? Rationale American Nurses Association recommendations Diagnostic reasoning Physical assessment skills

Diagnostic reasoning Nurses use diagnostic reasoning and critical thinking to formulate diagnostic statements. Rationale, ANA recommendations, and physical assessment skills are not part of formulating diagnostic statements. Rationale supports the nursing interventions of the nursing care plan. The American Nurses Association does not have recommendations regarding formulation of diagnostic statements for the care plan. Physical assessment skills are important in the assessment step of the nursing process, not the formulation of the diagnostic statements.

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? Palpation Sympathy Empathy Inspection

Empathy Empathy is an intuitive awareness of what the client is going through; it helps the nurse to be effective in providing for the client's needs while remaining compassionately detached. Inspection and palpation are skills that help the nurse in collecting objective data of the client's physical characteristics. Sympathy is a feeling that would make the nurse as emotionally distraught as the client; this hampers the ability of the nurse to provide client care.

Revising the plan as needed occurs in what part of the nursing process? Assessment Diagnosis Planning Evaluation

Evaluation

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? Assessment Diagnosis Evaluation Implementation

Evaluation The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and the nursing care plan needs to be revised. The assessment stage involves collecting subjective and objective data. The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment. The implementation phase involves carrying out the plan to meet the determined outcome criteria.

An assessment that concentrates on patterns of role performance that all humans share is called what? Head-to-toe Body systems Focused 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.

The nurse is performing a health assessment on a new client. While taking the detailed history, the nurse knows to include what? Functional status Data focusing on the client complaint A focused assessment of the client complaint Family history for the past three generations

Functional status A detailed history includes data on all systems, psychosocial and mental health, and functional status. Data must be included information other than the client complaint. Family histories generally go back only to grandparents, not great-grandparents.

he 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? Body system Head-to-toe Functional Focused

Head-to-toe

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. Children younger than 13 years are some of the most common consumers of acute health care services. Children contract numerous communicable diseases in the school environment. Health promotion in a school setting can yield improved health outcomes for the student's siblings and parents.

Healthy child development is a critical health determinant because of its implications for lifelong health.

When doing an overall assessment of a client, the nurse is able to utilize findings and do what? Identify what level of prevention the client is at Identify in what areas the client can educate his or her family Identify in what areas the client needs the most care Identify the client's medical diagnosis

Identify in what areas the client needs the most care

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 Individual student interview and questionnaire Review of literature and consultation with faculty Walk-through of education facility and faculty questionnaire

Individual student interview and questionnaire

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 Validating information that is already correct Interjection of the nurse's thoughts or feelings into the data Relying on objective and subjective information

Making incorrect nursing judgments or diagnoses

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

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? Listening to a favorite song to relax in the evening Taking the dog for a walk in the park to get exercise Texting a friend to let her know that you made it home safely Measuring the remaining tread on a car tire to determine whether it is time to replace it

Measuring the remaining tread on a car tire to determine whether it is time to replace it As a professional nurse, you will constantly observe situations and collect information to make nursing judgments. This occurs no matter what the setting: hospital, clinic, home, community, or long-term care. You conduct many informal assessments every day. For example, when you get up in the morning, you check the weather and determine what would be the most appropriate clothing to wear. Measuring the remaining tread on a car tire to determine whether it is time to replace it is an example of assessment, as it involves gathering information (the height of the tire tread) to make a decision (whether to buy new tires). The other answers do not involve gathering information to make a decision.

How does a nurse decide what health-promotion activities are necessary for a particular client? Nurses assess areas in which clients are willing to make changes only Nurses construct their own theories to identify perceptions, barriers, and positive outcomes Nurses address areas associated with healthy behaviors only Nurses collaborate with clients to identify areas in which clients are willing to make changes

Nurses collaborate with clients to identify areas in which clients are willing to make changes

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 Implementation Planning Evaluation

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.

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 goal Nursing assessment Nursing intervention Nursing evaluation

Nursing intervention

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time? Focused Initial Emergency Ongoing

Ongoing An ongoing or client assessment occurs after the comprehensive database is established. It is a mini overview of the client's body systems. The initial assessment was completed upon admission. A focused assessment is completed when the database for a client already exists and the client is experiencing a specific problem. An emergency assessment is completed in a life-threatening situation.

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? Initial comprehensive Focused or problem-oriented Ongoing or partial Emergency

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? Ensure that the client is safe If the client is injured, protect the cervical spine Open the client's airway Begin CPR

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.

The nurse is exhibiting critical thinking in which client care situation? Transcribing medication orders onto the nurse's medication administration record. Notifying the healthcare provider of a critical lab result. Answering the client's call bell alarm while the nursing assistant is at lunch. Performing a focused assessment on a client who is complaining of shortness of breath.

Performing a focused assessment on a client who is complaining of shortness of breath.

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

Primary

The nurse plans to follow the Health Belief Model when identifying a client's care needs. On what will the nurse focus when using this model? Select all that apply. Sufficient motivation Belief of being susceptible to a health problem Making a change would be beneficial Individual characteristics Behavioral outcomes

Sufficient motivation Making a change would be beneficial Belief of being susceptible to a health problem The Health Belief Model is based on three concepts: the client has sufficient motivation; the client is susceptible to a health problem; and making a change will be beneficial to improve health. Behavioral outcomes and individual characteristics are focuses of the Health Promotion Model.

A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data? What type of work the client does Whether the client is caring for any dependents at home The client's range of motion in her right arm What types of foods the client typically eats

The client's range of motion in her right arm

What is the primary function of the health care team? To guide the client's care throughout times of crisis To work together to obtain maximum coverage To decide the best overall care To develop an individual focus for each member

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.

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment? To perform a rapid assessment for prompt treatment To collect subjective data related to the client's overall health To evaluate whether outcomes of treatment are met To determine any changes from the baseline data

To determine any changes from the baseline data

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? To quantify the degree of pain a client may be experiencing To gather information for specialists to whom the client might be referred To establish a database against which subsequent assessments can be measured To establish rapport with the client and family

To establish a database against which subsequent assessments can be measured

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 techniques

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

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should avoid premature judgments about the client. analyze data that have already been collected. review any past collaborative problems. consult with the client's family members.

avoid premature judgments about the client. After reviewing the record or discussing the client's status with others, remember to keep an open mind and to avoid premature judgments that may alter your ability to collect accurate data. Validate information with the client and be prepared to collect additional data.

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

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.

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) initial comprehensive assessment. emergency assessment. ongoing or partial assessment. focused or problem-oriented assessment.

focused or problem-oriented assessment. 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. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.

The result of a nursing assessment is the prescription of treatment. documentation of the need for a referral. formulation of nursing diagnoses. client's physiologic status.

formulation of nursing diagnoses.

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's level of functioning. holistic wellness status. developmental history. physiologic status.

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 nurse's ability to ask relevant questions the rapport that exists between the nurse and the client the type and degree of physical issues the client is experiencing

the rapport that exists between the nurse and the client