chapter 1 - The Nurse's Role in Health Assessment
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?
Establish a baseline for the comparison of future health changes.
Revising the plan as needed occurs in what part of the nursing process?
Evaluation
When assisting a client with health promotion, what must the nurse also nurture?
A healthy environment In order to assist a client with health promotion, a healthy environment must also be nurtured.
The nurse is collecting data from a client. Which of the following best reflects objective data?
Appearance
A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?
Focused assessment
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 whether the client has achieved the outcome criteria of the treatment?
Evaluation
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?
Uses evidence-based techniques
A nurse is conducting a health assessment. How will the information collected from the client be used?
as a basis for the nursing process
What are nurses able to detect through the health assessment?
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?
Ask the client about the most recent experiences of pain.
A nurse on the hospital's subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice?
The focused assessment addresses a particular client problem.
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. Collaborative problems, such as changes in blood glucose, are certain physiologic complications that nurses monitor to detect onset or changes in status
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 motivation for change The Health Belief Model is based on three concepts: the existence of sufficient motivation, the belief that one is susceptible or vulnerable to a serious problem, and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. As a result, implementation of this model should begin with an appraisal of the client's motivation to change.
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.
The nurse is completing an admission database entry and must include priority nursing diagnoses for the plan of care. Which statement describes a nursing diagnosis?
A clinical judgment about client responses to health difficulties. Diagnosis is the clustering of data to make a judgment or statement about the client's difficulty or condition. NANDA International (NANDA-I, 2012) defines nursing diagnosis as "a clinical judgment about individual, family or community responses to actual or potential health difficulties/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable."
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 The emergency assessment involves a life-threatening or unstable situation, such as a client in an ED who has experienced a traumatic injury. 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.
