NUR 210 - PrepU Ch 1

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

A healthy environment. In order to assist a patient with health promotion, a healthy environment must also be nurtured.

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 most important?

Assessment

What is the foundation of nursing practice?

Assessment is the foundation of nursing practice.

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

Appearance

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?

Body system

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

Knowledge deficit

Objective Data

Weight, lung sounds, and pupil reaction

Subjective Data

info obtained from the client through interviewing and therapeutic communication skills. Sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.

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 During the comprehensive assessment, the nurse identifies problems that require the assistance of other health care professionals. A client who is newly diagnosed with diabetes would benefit from a referral to a diabetes education program. Assistance from other health care professionals would not necessarily be required for the older adult client, the client wanting a vaccination, or the teenager seeking information.

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

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.

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."

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

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

Knowledge base and expertise. As the nurse becomes more proficient and comfortable in his or her role, the accountability does not decrease, but the knowledge base and expertise increase to foster confidence

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

Reassess previously detected problems. It consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on his or her health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes from the baseline data. In addition, a brief reassessment of the client's normal body system or holistic health patterns is performed whenever the nurse or another health care professional has an encounter with the client.

Assessment phase

The assessment stage involves collecting subjective and objective data.

Diagnosis phase

The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment.

Implementation phase

The implementation phase involves carrying out the plan to meet the determined outcome criteria.

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. 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.

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

Collect subjective data

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

continuous.

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

physiologic status. The physician focuses primarily on the client's physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.

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

It identifies risk factors, health issues, and diseases. It is a framework that identifies risk factors, health issues, and diseases in the US. The goals and objectives serve to improve the health of individuals and communities, targeting the next 10 years. Its overall goal is to increase quality of life by creating guidelines for a healthy lifestyle as well as educating people and cultivating an awareness that will assist in the elimination of health disparities.

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. The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment data.

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. Data are best validated by the client. Other sources are valid and useful, but the client is the ultimate source, especially in the case of subjective data.

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 is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the process.

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 The nurse is responsible for collecting subjective data related to the client's overall function. The physical therapist performs a musculoskeletal examination. A dietitian may take anthropometric measurements in addition to a subjective nutritional assessment.

What is a required component of a health assessment?

Critical thinking. It is a required component of health assessment and nursing care. Nurses do not use critical analysis, critical judgment, or critical decision making in providing nursing care to clients.

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. It involves assessing whether the outcome criteria have been met and the nursing care plan needs to be revised.