health assessement Ch 1: Analyzing Data to Make Accurate Clinical Judgments

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 nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?

"I'm sorry, but assessment is ongoing and continuous."

A nursing instructor is emphasizing the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors that will increase opportunities for nurses with advanced assessment skills should the instructor stress? Select all that apply.

-Declining numbers of medical students due to rising costs and focus on primary care -Increasing complexity of acute care -Growing population of older adults with complex comorbidities -Increasing impact of children and the homeless on communities

Which actions should a nurse perform before beginning the initial shift assessment of a client? Select all that apply.

-Gather assessment tools. -Review the client's record. -Check the client's status with the nurse of the previous shift.

A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides?

A baseline for comparison with future findings

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.

When assisting a client with health promotion, what must the nurse also nurture?

A healthy environment

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

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain?

Collecting data regarding the nature of the pain

A client presents to the health care facility with reports of new onset of chest pain of 3 days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse to perform for this client?

Comprehensive

When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?

Diagnosis

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

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

Revising the plan as needed occurs in what part of the nursing process?

Evaluation

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?

Head to toe

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

Head-to-toe

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?

Inspection

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 client'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 judgments or diagnoses

Which of the following is the best example of holistic data collection by a nurse?

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings

How does a nurse decide what health-promotion activities are necessary for a particular client?

Nurses collaborate with clients to identify areas in which clients are willing to make changes

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

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?

Ongoing

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 nurse is exhibiting critical thinking in which client care situation?

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

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

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

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?

environmental

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 result of a nursing assessment is the

formulation of nursing diagnoses.

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history?

perform a physical examination