NUR 230 FINAL EXAM

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 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."

objective data

-what you observe physical exam: -inspection -percussion -palpation -auscultation

steps of data analysis

1. Identify abnormal data and strengths. 2. Cluster the data. 3. Draw inferences and identify problems. 4. Propose possible nursing diagnoses. 5. Check for defining characteristics of those diagnoses. 6. Confirm or rule out nursing diagnoses. 7. Document conclusions.

Which assessment finding should the nurse document as objective data?

Body functions

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

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

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

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

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

Identify in what areas the client needs the most care

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

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

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

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

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

Objective

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

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

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

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

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be:

Using reputable health-education strategies to reduce risk behaviors

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?

airway

holistic approach

all levels of interventions but is not a "level" of intervention itself.

What is the foundation of nursing practice?

assessment

the nursing process (ADPIE)

assessment diagnosis planning implementation evaluation

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next

check for the presence of defining characteristics.

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

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.

tertiary prevention

focuses on preventing complications of an existing disease and promoting health to the highest level. Diet teaching for clients with diabetes, inhaler teaching for clients with lung disease, and exercise programs for those who have had myocardial infarction are examples

The result of a nursing assessment is the

formulation of nursing diagnoses

subjective data

health history what the patient says about him or herself

secondary prevention

includes the early diagnosis of health problems and prompts treatment to prevent complications. Vision screening, Pap smears, BP screening, hearing testing, scoliosis screening, and tuberculin skin testing are examples

primary prevention

involves strategies aimed at preventing problems. Immunizations, health teaching, safety precautions, and nutrition counseling are examples

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

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

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

primary

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

subjective