HA PrepU Chapter 1

A nurse is conducting a health assessment. How will the information collected from the patient be used? a. as a basis for the nursing process b. to illustrate nursing competence c. to facilitate nurse-patient caring d. as one component of medical care

a. as a basis for the nursing process Health assessment is an integral component of nursing care and is the basis of the nursing process. Health assessments by nurses are used to plan, implement, and evaluate teaching and care. Nursing assessment is different from other types of healthcare provider assessments, as it is a holistic collection of information about a patient's level of health.

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral? a. An 80-year-old client who lives with her daughter b. A 50-year-old client newly diagnosed with diabetes c. An adult presenting for an influenza vaccination d. A teenager seeking information about contraception

b. A 50-year-old client newly diagnosed with diabetes During the comprehensive assessment, the nurse identifies problems that require the assistance of other health care professionals. A client who is newly diagnosed with diabetes would benefit from a referral to a diabetes education program. Assistance from other health care professionals would not necessarily be required for the older adult client, the client wanting a vaccination, or the teenager seeking information.

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) a. ongoing or partial assessment. b. focused or problem-oriented assessment. c. emergency assessment. d. initial comprehensive assessment.

b. focused or problem-oriented assessment. A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.

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? a. Comprehensive assessment b. Ongoing assessment c. Focused assessment d. Emergency assessment

c. Focused assessment The nurse would most likely perform a focused assessment, which is done when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A comprehensive assessment would have been done for this client when he or she first visited the office. An ongoing assessment would be done to evaluate problems identified earlier, to determine any changes. This might be the type of assessment done when the client returns after receiving treatment for the current complaints. An emergency assessment would be done if the client came in with a life-threatening complaint or problem.

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time? a. Initial b. Focused c. Ongoing d. Emergency

c. Ongoing An ongoing or patient assessment occurs after the comprehensive database is established. It is a minioverview of the client's body systems. The initial assessment was completed upon admission. A focused assessment is completed when the database for a client already exists and the client is experiencing a specific problem. An emergency assessment is completed in a life-threatening situation.

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason? a. Determine the need for crisis intervention b. Address areas previously omitted c. Reassess previously detected problems d. Provide information for the client's record

c. Reassess previously detected problems A periodic partial assessment consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes from the baseline data. In addition, a brief reassessment of the client's normal body system or holistic health patterns is performed whenever the nurse or another health care professional has an encounter with the client.

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? a. developmental level b. social well-being c. environmental d. physical

c. environmental The environment influences conditions to promote health. Physical health is the way the body works and adapts. Social well-being identifies relationships that support health. Developmental level focuses on thinking, problem solving, and decision making.

The nurse notices a large number of positions available for employment in managed care. Which are reasons for the growth in nursing opportunities in this care environment? Select all that apply. a. Expanding health needs of single parents b. Uncontrollable costs for health care c. Aging of baby boomer generation d. Complex acute care e. Expanding health service networks

d. Complex acute care c. Aging of baby boomer generation a. Expanding health service networks e. Expanding health needs of single parents The nursing role in managed care is growing. Factors that promote opportunities for nurses in this environment include increasing complexity of acute care; aging of the baby boomer generation; expanding health service networks, and expanding health care needs of single parents. Uncontrollable costs for health care is not identified as a factor for the growth of the nursing role in managed care.

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

d. Establish a baseline for the comparison of future health changes. An initial comprehensive assessment is needed when the client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared. It does not form the basis for medical treatment. The client's "ABCs" are included, but this is not the primary focus of an initial assessment.

How does a nurse decide what health-promotion activities are necessary for a particular client? a. Nurses construct their own theories to identify perceptions, barriers, and positive outcomes b. Nurses assess areas in which clients are willing to make changes only c. Nurses address areas associated with healthy behaviors only d. Nurses collaborate with clients to identify areas in which clients are willing to make changes

d. Nurses collaborate with clients to identify areas in which clients are willing to make changes Rather than addressing all areas associated with healthy behaviors and overwhelming clients, nurses collaborate with them to identify areas in which clients are willing to make changes. When caring for a client, a nurse does not address healthy behaviors only; nurses do not address only areas where clients are willing to make changes, nor do they construct their own theories to identify perceptions, barriers, and positive outcomes.

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? a. Nursing assessment b. Nursing evaluation c. Nursing goal d. Nursing intervention

d. Nursing intervention Nursing interventions are used to monitor health status; prevent, resolve, or control a problem; assist with ADLs; or promote optimum health and independence. Nursing goals are the client's desired outcomes. Nursing evaluation is deciding whether the nursing goals have been reached. Nursing assessment is an overview of the patient's health status and current problems.