NUR 230 chapter 1 PREPU

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 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

evaluation

Assessing whether outcome criteria have been met and revising the plan as necessary

Which assessment finding should the nurse document as objective data?

Body functions

assessment

Collecting subjective and objective data

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

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

Primary

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

To establish a database against which subsequent assessments can be measured

The nurse reviews information obtained from the admission's department about a client seeking medical care for a chronic problem. What should the nurse expect to complete when assessing this client? Select all that apply.

Validate data Document data Collect objective data Collect subjective data

objective data

actual testing of the patient- physical exam (inspection, percussion, palpation, auscultation)

diagnosis

analyzing subjective/objective data to make professional nursing judgement

implementation

carrying out the plan

planning

determine outcome criteria and developing a plan

The result of a nursing assessment is the

formulation of nursing diagnoses.

subjective data

health history-what you hear from the patient

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

physiologic status.

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

comprehensive health assessment

subjective/objective data patients records testing/other results

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."

Steps of the nursing process

1. Assessment 2. Diagnosis 3. Outcome Identification 4. Planning 5. Implementation 6. Evaluation

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 are nurses able to detect through the health assessment?

Areas in need of health adjustments

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

Evaluation

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

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

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

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

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 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

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

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

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.