Chapter 1- Prep U (Weber)

Primary frameworks used in conducting a health assessment

-Head to toes -Body systems -Functional

A nurse has completed assessment of a patient with Alzheimer's disease and documentation of the information obtained from the client and now needs to analyze the data collected. Which nursing actions should be included in this phase of the nursing process? Select all that apply.

-Identification of collaborative problems -Identification of the need for referrals -Formulation of nursing diagnosis(es)

A patient is brought to the emergency department by ambulance after a motor cycle accident--- what is the highest priority by the staff triaging the patient

Airway

When making rounds, the RN should prioritize follow-up care for which client?

An oncology client with a cough but no fever

What are nurses able to detect through the health assessment

Areas in need of health adjustments

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

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

Continuous

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

Determine any changes from the baseline data

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 is performing a health assessment on a new client. While taking the detailed history, the nurse knows to include what?

Functional Status

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

Knowledge base and expertise

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 judgements or diagnoses

best example of holistic data collection by a nurse

Measuring blood pressure, inquiring about a clients nutritional intake, assessment for depression, asking client of how his condition affects family gatherings

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

Required component of heath assessment

critical thinking

required component of health assessment

critical thinking

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

functional

an assessment that concentrates on patterns of role performance that all humans share is...

functional

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 judgements or diagnoses

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?

on going or partial

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

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 judgements or diagnoses

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

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

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