NUR 201 - Jensen Ch. 1

A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?

"I'm sorry, but assessment is ongoing and continuous."

When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient 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 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 clients would the nurse most likely expect to facilitate a referral?

A 50-year-old client newly diagnosed with diabetes

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

A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides?

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?

A clinical judgment about client responses to health difficulties.

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

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

Appearance

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

Using both verbal and nonverbal clues given by the patient, what is the nurse constantly doing?

Assessing

After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases?

Assessment

Data collection occurs where in the nursing process?

Assessment

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

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 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

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

What is one way nurses use critical thinking in regard to the nursing process?

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

A nursing instructor is trying to convince the class of the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors should stressed that will promote opportunities for nurses with advanced assessment skills? Select all that apply.

Declining numbers of medical students due to rising costs and focus on primary care Increasing complexity of acute care Growing aging population with complex comorbidities Increasing impact of children and the homeless on communities

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?

Determine any changes from the baseline data

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

Diagnosis

A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment?

ED nurse

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

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

Empathy

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 To achieve the best results

A nurse is gathering subjective data. Which of the following would the nurse be most likely to assess?

Feelings of happiness

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?

Focused assessment

For which client should a nurse perform a focused assessment?

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

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

Functional

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

Gathering forensic evidence for a legal proceeding

What are the primary frameworks used in conducting a health assessment? Select all that apply.

Head to toe Body systems Functional systems

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

The nurse prepared to complete a comprehensive health assessment on a client in the community. What should the nurse expect to complete when performing this assessment? Select all that apply.

Health history Physical examination

After a health assessment the nurse determines that a client would benefit from health promotion interventions. Which item should the nurse refer to when determining the best actions for the client?

Healthy People 2020

Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of

Healthy People 2020

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

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?

Inspection

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.

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

It identifies risk factors, health issues, and diseases.

The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process?

It is ongoing and continuous.

When discussing the nursing process with a group of students, which of the following statements best describes it?

It is ongoing and continuous.

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

Knowledge base and expertise

An instructor is describing a comprehensive nursing health assessment to a group of students. The instructor determines that the teaching was successful when the students identify which of the following as the overall purpose?

Make a clinical judgment

A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?

Making incorrect nursing judgments or diagnoses

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

Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment?

Nurse

How does a nurse decide what health-promotion activities are necessary for a particular client?

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

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

The client has a murmur. This is what type of data?

Objective

The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable?

Objective

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

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?

Ongoing

The nurse is exhibiting critical thinking in which client care situation?

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

The nurse is following a structured head-to-toe approach to identify changes in a patient's body systems. Which component of the health assessment is the nurse completing with the patient?

Physical examination

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

Following completion of the comprehensive health assessment, the nurse periodically performs a partial assessment primarily for which reason?

Reassess previously detected problems

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

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 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

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

The client has a headache. What type of data is this?

Subjective

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 Making a change would be beneficial Belief of being susceptible to a health problem

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

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

A nurse is working with a client who has AIDS. Which of the following is an example of subjective data that might be gathered for this client?

The client's pain level

A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data?

The client's range of motion in her right arm

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.

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 2020 indicator of responsible sexual behavior?

The importance of using a condom when engaging in sexual activity

Why is the nurse always reassessing the patient for changes?

To achieve the best results

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

To advocate for individuals, families, communities, and populations

What is the primary function of the health care team?

To decide the best overall care

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 determine any changes from the baseline data

What is the primary purpose of health assessment?

To gather information about the health status of the client

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

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.

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

as a basis for the nursing process

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

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

comprehensive.

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is

continuous.

While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process?

emotional

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 home health nurse is visiting a patient who recently was hospitalized for repair of a fractured hip. The patient tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct?

focused

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

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

primary prevention

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first

review the client's health care record.

The nurse discusses ear plugs for a patient with low tone deafness when working in a noisy environment. The nurse is utilizing

tertiary prevention

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?"

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

The nurse reviews data collected while completing a comprehensive assessment with a client. Which information should the nurse identify as being subjective data?

Follows a Kosher diet

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 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 patient'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

Which assessment finding should the nurse document as objective data?

Participating in a client care conference

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.

A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify?

The client's feelings of happiness

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

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

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.

Nurses provide both direct and indirect care. What is an example of indirect care?

Participating in a client care conference

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

Primary prevention

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

Situation Assessment Recommendation

A client asks why a health assessment needs to be done. What should the nurse respond to this client?

"It determines your health status, risk factors and educational needs to develop a plan of care."

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.

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

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain?

Collecting data regarding the nature of the pain

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 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 whether the client has achieved the outcome criteria of the treatment?

Evaluation

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 patient 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 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

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 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

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

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

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

In which situation should a nurse perform an emergency assessment of a client?

Shortness of breath

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 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 nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply.

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

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

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.

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

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.

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

The nurse tells a newly admitted patient that she is going to do a health assessment to help in planning care and educational needs during the patient's hospital stay. Before the physical examination, the nurse should first

take a complete health history

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

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

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?

Collect subjective 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 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

When doing an overall assessment of a patient, the nurse is able to utilize findings and do what?

Identify in what areas the patient needs the most care

After completing a health history, the nurse determines that a patient would benefit from interventions to address the Healthy People 2020 indicator associated with the prevalence and mortality of chronic disease. What assessment data would related to this indicator? (Select all that apply.)

Prescribed medication for hypertension Diagnosed with heart disease three years ago Skin cancer lesion removed surgically four years ago

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

Primary