PrepU Chapter 1

What are the components of the SBAR? Select all that apply. A. Biophysical test results B. Assessment C. Referral D. Recommendation E. Situation

B. assessment D. recommendation E. situation

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

Primary Prevention

The nurse is collecting data from a client. Which of the following best reflects objective data? a. Religion b. Age c. Appearance d. Occupation

c. appearance

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

comprehensive.

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

physiologic status.

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 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 and treatment of diseases." "Both are the same and they serve to validate the information collected." "Nurses focus on the diagnosis of actual human responses to disease or life events." "The health care provider focuses on the treatment of human responses caused by diseases."

"Nurses focus on the diagnosis of actual human responses to disease or life events."

The nurse is analyzing the data obtained from the following clients. Which client would the nurse expect to facilitate a referral? An 80-year-old client who lives with her daughter A 3-year-old child with an acute ear infection A teenager seeking information about contraception A 50-year-old client newly diagnosed with diabetes

A 50-year-old client newly diagnosed with diabetes

What are nurses able to detect through the health assessment? Areas that need continuous care Areas that need referral to a specialist Areas in need of health adjustments Areas that need in-hospital care

Areas in need of health adjustments

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? Review the client's medication administration record for analgesic use. Meet with the client's spouse and daughter to discuss the client's pain. Collaborate with the physician who is treating the client. Ask the client about the most recent experiences of pain.

Ask the client about the most recent experiences of pain.

A nurse has documented the findings of a comprehensive assessment of a new client. What is the primary rationale that the nurse should identify for accurate and thorough documentation? Assuring valid conclusions from analyzed data Guaranteeing a continual assessment process Identifying abnormal data Allowing for drawing inferences and identifying problems

Assuring valid conclusions from analyzed data

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

Diagnosis

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

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.

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

Head to toe Functional systems Body systems

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 the client's family history organization standards of care the client's past medical history

Healthy People 2020

After assessment and documentation of the information obtained from the client, the nurse needs to analyze the data collected. Which nursing actions depend on accurate analysis of data during this phase of the nursing process? Select all that apply. Development of a nursing care plan Assessment of the outcome of the care plan Formulation of nursing diagnosis/es Identification of the need for referrals Identification of collaborative problems

Identification of collaborative problems Identification of the need for referrals Formulation of nursing diagnosis/es

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. Encourage the client to increase oral fluid intake. Assist the client with personal hygiene. Provide the client with a bedtime protein snack.

Measure the client's blood glucose four times daily

An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession? Biomedical knowledge Simple technology Natural senses Critical pathways

Natural senses

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? spiritual emotional social mental

emotional

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? Emergency Comprehensive Ongoing Focused

ongoing Ongoing, follow-up or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline.

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

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? Inspection Palpation Sympathy Empathy

Empathy

When assisting a patient with health promotion, what must the nurse also nurture? School/work attendance Knowledge of the Healthy People 2020 indicators A healthy environment Family communication

A healthy environment

When making rounds, the RN should prioritize follow-up care for which client? A client who is due for a routine shift assessment. An oncology client with a cough but no fever. A client who is receiving intravenous antibiotics for pneumonia. A client with strong, equal pedal pulses following catheterization.

An oncology client with a cough but no fever The nurse should prioritize care for the oncology client, because immunosuppression due to chemotherapy is a concern. The immunosuppressed client can still exhibit a respiratory infection without fever. The clients require routine assessments with no immediate concerns.

What are nurses able to detect through the health assessment? Areas in need of health adjustments Areas that need continuous care Areas that need referral to a specialist Areas that need in-hospital care

Areas in need of health adjustments

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

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

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? Determine the most likely prognosis for the client's health problem. Identify the status of the client's airway, breathing, and circulation. Identify the most appropriate forms of medical intervention for the client. Establish a baseline for the comparison of future health changes.

Establish a baseline for the comparison of future health changes.

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

Evaluation

Before beginning a health assessment with a patient, the nurse reviews Healthy People 2020 because: It serves as a guide for the health assessment. It lists specific interventions to address most patient health problems. It identifies risk factors, health issues, and diseases. It helps determine the patient's plan of care.

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 involves independent nursing actions. It is ongoing and continuous. Each step is independent of the others. It is used primarily in acute care settings.

It is ongoing and continuous.

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

Open the client's airway

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? Obtain basic biographic data. Validate information with the client. Consult clinical resources explaining the client's diagnosis. Review the client's medical record.

Review the client's medical record.

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

To decide the best overall care

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

as a basis for the nursing process

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 The client's posture The client's affect The client's behavior

The client's feelings of happiness

A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable? The client's acuity The nurse's potential for liability The unit's protocols The client's age

The client's acuity .

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." "I know it seems repetitive but the doctor is trying to treat the reason you were admitted and I will focus more on getting everything ready for you to go home." "each assessment is important and the nurse and doctor will get together to determine what orders need to be written." "the doctor's and nurse's assessments are totally unrelated and are necessary so all forms are completed appropriately."

"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."

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 It is ongoing and continuous.

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? Involves the client's musculoskeletal system and activities of daily living Focuses primarily on the client's physiologic development status Focuses only on the client's psychological, sociocultural, and spiritual well-being Physiologic, psychological, sociocultural, developmental, and spiritual data

Physiologic, psychological, sociocultural, developmental, and spiritual data

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 instruct the nurse how to assess for a cardiac event Standards of care tell the nurse how to get a good evaluation Standards of care dictate how to handle clients who have experienced trauma Standards of care often set the time frame for assessing the clients on the unit

Standards of care often set the time frame for assessing the clients on the unit

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 learning style The client's medical comorbidities The client's motivation for change The client's prognosis for recovery

The client's motivation for change

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

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

the rapport that exists between the nurse and the client

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

A patient has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this patient? Acute pain Knowledge deficit Ineffective coping Nutrition: less than body requirements

Knowledge deficit

Following completion of the comprehensive health assessment, the nurse periodically performs a partial assessment primarily for which reason? Address areas previously omitted Provide information for the client's record Determine the need for crisis intervention Reassess previously detected problems

Reassess previously detected problems

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 Uses evidence-based techniques Follows the ABC approach Focuses on the system that caused the hospitalization

Uses evidence-based techniques

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be: Ascertaining past and current use of health care services Using reputable health-education strategies to reduce risk behaviors Determining client stress levels related to lifestyle choices Understanding the health problems that clients experience in everyday life

Using reputable health-education strategies to reduce risk behaviors

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 second standard within the Nursing Scope and Standards of Practice states that the nurse analyzes assessment data to determine the diagnoses or issues. Which activities will the nurse perform when complying with the expectations of the second standard? Select all that apply. Documents the diagnoses Derives the diagnosis based on assessment data Validates the diagnoses with the client, family, and other health care providers Involves the client, family and other care providers when collecting data Prioritizes data collection activities based on the client's needs

Documents the diagnoses Derives the diagnosis based on assessment data Validates the diagnoses with the client, family, and other health care providers

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. Notify the primary health care provider of the change in the client's health status. Monitor the client frequently for other changes in health status. Request that the health care team revise the plan of care.

Recognize the need to reevaluate the client's plan of care.