HA: Nurse's Role
Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern? a. "What amount of cleaning have you been doing in the past?" b. "Have you tried to schedule a cleaning service?" c. "Do you have family who visit you regularly?" d. "Are you friendly with the neighbors?"
ANSWER: "Do you have family who visit you regularly?"
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? a. "Nurses focus on the diagnosis and treatment of diseases." b. "Both are the same and they serve to validate the information collected." c. "Nurses focus on the diagnosis of actual human responses to disease or life events." d. "The health care provider focuses on the treatment of human responses caused by diseases."
ANSWER: "The nurses focus on the diagnosis of actual human responses to disease or life events."
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: a. "the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease" b. "the doctor's and nurse's assessments are totally unrelated and are necessary so all forms are completed appropriately" c. "each assessment is important and the nurse and doctor will get together to determine what orders need to be written" d. "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"
ANSWER: "the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease"
For which of the following clients would the nurse perform a focused assessment? a. Client with elevated blood pressure with no previous history of heart problems b. Client with 4-day history of sore throat and fever with enlarged lymph nodes c. Client with right upper abdominal pain that radiates into the groin area d. Diabetic with elevated blood sugars for the past 2 weeks
ANSWER: Client with 4-day history of sore throat and fever with enlarged lymph nodes
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? a. Health People 2020 b. the client's family history c. organization standards of care d. the client's past medical history
ANSWER: Healthy People 2020
Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of: a. the nursing process b. Health People 2020 c. the Department of Health and Human Services d. the three levels of preventative care
ANSWER: Healthy People 2020
Which of the following statements best convey the rationale for health promotion in a school setting? a. Health promotion in a school setting can yield improved health outcomes for the student's siblings and parents. b. Children younger than 13 years of age are some of the most common consumers of acute health care services. c. Children contract numerous communicable diseases in the school environment. d. Healthy child development is a critical health determinant because of its implication of lifelong health.
ANSWER: Healthy child development is a critical health determinant because of its implications for lifelong health.
When making rounds, the RN should prioritize follow-up care for which client? a. an oncology client with a cough with no fever b. a client who is receiving intravenous antibiotics for pneumonia c. a client with strong, equal pedal pulses following catheterization. d. a client who is due for a routine shift assessment.
ANSWER: an oncology patient with a cough but no fever.
Before beginning a comprehensive health assessment for an adult client, the nurse should explain to the client that the purpose of the assessment is to... a. document any physical symptoms the client may have b. arrive at conclusions about the client's health c. contribute to the medical diagnosis d. validate the data collected
ANSWER: arrive at conclusions about the client's health
The nurse notes that an intervention provided to a client for a specific health problem was effective. Which action should the nurse take next? a. identify a new outcome b. implement a new action c. analyze the newly collected data d. assess the status of the health problem
ANSWER: assess the status of the health problem
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? a. guaranteeing a continual assessment process b. identifying abnormal data c. assuring valid conclusions from analyzed data d. allowing for drawing inferences and identifying problems
ANSWER: assuring valid conclusions from analyzed data
The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should: a.analyze data that have already been collected b. review any past collaborative problems c. avoid premature judgements about the client d. consult with the client's family members
ANSWER: avoid premature judgements about the client
A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about what type of assessment? a. body systems b. comprehensive c. head to toe d. emergency
ANSWER: body systems
The purpose of a health assessment includes what? Select all that apply a. identifying the client's major disease process b. collecting information about the health status of client c. clarifying the client's ability to pay for health care d. evaluating client outcomes e. synthesizing collected data
ANSWER: collecting information about the health status of the client, evaluating client outcomes, and synthesizing collected data
A client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed: a. entry b. exploratory c. focused d. comprehensive
ANSWER: comprehensive
A client presents to the health care facility with reports of new onset of chest pain of three days duration. Vital signs are stable and the chest pain has subsided since the client entered the room. Which types of assessment is most appropriate for a nurse perform for this client? a. emergency b. partial c. comprehensive d. focused
ANSWER: comprehensive
Although the assessment phase of the nursing process precedes the other phases, the assessment phase is... a. continuous b. completed on admission c. linear d. performed by only nurses
ANSWER: continuous
When planning a community program related to Health People 2020, the critical first step involves... a. defining the community b. assessing the community c. formulating questions to ask community leaders d. planning an introductory program for the community
ANSWER: defining the community
An adult client is being admitted to the hospital for cardiac catheterization related to chest pain and shortness of breath on exertion. What kind of assessment is the admitting nurse going to perform? a. focused b. comprehensive c. none, the cardiac catheterization will provide all needed information d. emergency
ANSWER: emergency
While assessing a patient, the nurse notes that the patient is more quiet after a visit from her sister. The nurse would note this under what facet of the assessment process? a. social b. mental c. spiritual d. emotional
ANSWER: emotional
The nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what? a. body systems b. functional c. focused d. head to toe
ANSWER: head to toe
As a nurse becomes more proficient and comfortable in his or her role, what increases? a. confidence and knowledge base b. time management and confidence c. knowledge base and expertise d. expertise and time management
ANSWER: knowledge base and expertise
An instructor is describing a comprehensive nursing health assessment to a group of students. The instructor determines that the teaching was successful when the students identify which of the following as the overall purpose? a. collect large quantities of data b. assist the physician c. make a clinical judgement d. validate previous data
ANSWER: make a clinical judgement
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? a. natural senses b. biomedical knowledge c. simple technology d. critical pathways
ANSWER: natural senses
After completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing? a. planning b. evaluation c. implementation d. nursing diagnosis
ANSWER: nursing diagnosis
A community health nurse is planning individualized care for a community. What does the nurse use as framework for this plan? a. nursing process b. diagnostic reasoning c. critical thinking d. community care map
ANSWER: nursing process
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? a. open the client's airway b. if the client is injured, protect the cervical spine c. begin CPR d. ensure that the client is safe
ANSWER: open the client's airway
The nurse prepares to collect objective data on a client new to a health clinic. What will the nurse use to collect this data? Select all that apply a. palpation b. inspection c. percussion d. auscultation e. the medical record
ANSWER: palpation, inspection, percussion, and auscultation
The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history? a. cluster the data b. document the findings c. determine the problem list d. perform a physical examination
ANSWER: perform a physical examination
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's... a. physiologic status b. holistic wellness status c. developmental history d. level of functioning
ANSWER: physiological status
What do nursing activities that promote health and prevent disease accomplish? Select all that apply a. reduce the risk of disease b. maintain optimal functioning c. optimize self-care abilities d. reinforce good habits e. create home care safety
ANSWER: reduce the risk of disease, maintain optimal functioning, and reinforce good habits
Program strategies consistent with a socioenvironmental approach to health and health promotion for nursing students would include: a. promoting personal health practices such a nutrition and fitness b. advocating policies that ensure adequate financial support for students c. screening for occupationally induced physiological risk factors of disease d. supporting lifestyle change to manage stress with exercise and time management
ANSWER: screening for occupationally induced physiological risk factors for disease
When describing the expansion of depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force? a. documentation b. informatics c. diversification d. technology
ANSWER: technology
Why is the nurse always reassessing for patient for changes? a. to never make a mistake when providing care b. to always have the best nursing care plan c. to achieve the best results d. to update the nursing process
ANSWER: to achieve the best results
To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be: a. ascertaining past and current use of health care services b. determining client stress levels related to lifestyles choices c. using reputable health-education strategies to reduce risk behaviors d. understanding the health problems that clients experience in everyday life
ANSWER: using reputable health-education strategies to reduce risk behaviors
