Health Assessment Chapter 1 Practice Questions

Why is the nurse always reassessing the client for changes?

To update the nursing diagnosis

What is paramount in health promotion? (Select all that apply.)

Working with the individual client Developing the nursing care plan

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

comprehensive

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

continuous

A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use?

diagnostic reasoning

What is one of the broad goals within nursing?

To treat human responses

Consider the nurse's role in the health assessment of a client. What action will the nurse perform initially when admitting a client to a long-term care facility?

collecting information regarding the client's health status

During a health assessment, a client shares, "I get a little dizzy when I get up from my chair too quickly." Which question will the nurse ask the client first when attempting to identify client needs and potential health risks?

"What do you mean by 'a little dizzy'?"

When the nurse is performing a physical examination on admission of a client to the medical unit, the client says the doctor already did an exam. The best response by the nurse would be

"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."

A client on the orthopedic unit is being discharged home. The client is elderly and has a broken right humerus; the client is right handed. The client's closest family member lives 50 miles away. What should the nurse consider before discharging the client? Select all the apply. (select all that apply.)

-Who will be there to help the client with ADLs? -How will the client get home from the hospital? -How will the client cook and eat?

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

An oncology client with a cough but no fever

What is the nurse's focus while conducting a health assessment with a client? (Select all that apply.)

Completing the health history. Conducting a physical examination.

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 exam room. Which type of assessment is most appropriate for a nurse perform for this client?

Comprehensive

Data being collected during a health assessment causes the nurse to believe there may be additional issues that are possibly affecting the client's health and wellness. What action should the nurse take to best address the suggestion of additional health concerns?

Extend the time originally allotted for the completion of the initial health assessment.

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 nurse prepared to complete a comprehensive health assessment on a client in the community. What should the nurse expect to complete when performing this assessment? Select all that apply.

Health history Physical examination

A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?

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?

Open the client's airway

A client admitted with reports of nausea and vomiting has not reported any vomiting in the last 6 hours. What initial response should the nurse have regarding this assessment information and its effect on the client's nursing plan of care?

Recognize the need to reevaluate the client's plan of care.

The nurse reviews information obtained from the admission's department about a client seeking medical care for a chronic problem. What should the nurse expect to complete when assessing this client? Select all that apply.

Validate data Document data Collect objective data Collect subjective data

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 which type of assessment?

body systems

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

functional

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

Functional status

The nurse prepares to analyze a list of a client's health problems. In which order will the nurse complete critical thinking of these problems? Drag statements into the proper order.

Identify abnormal data and strengths Cluster the data Draw inferences and identify problems Propose possible nursing diagnoses Check for defining characteristics of the diagnoses Confirm or rule out nursing diagnoses

The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?

The client's acuity

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be: a) Understanding the health problems that clients experience in everyday life b) Determining client stress levels related to lifestyle choices c) Ascertaining past and current use of health care services d) Using reputable health-education strategies to reduce risk behaviours

Using reputable health-education strategies to reduce risk behaviours Explanation: A central component of health promotion involves helping clients to develop personal health practices and to enhance coping skills, which are results of health education that emphasizes client knowledge for directing choices and actions. While the other given factors may hold significance for many individuals, they are not as salient as health education. Chapter 1: The Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 5.

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should

avoid premature judgments about the client.

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.

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

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?

Nursing diagnosis

A nurse has completed assessment of a client 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)

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to

arrive at conclusions about the client's health.

What are the areas of independent nursing practice? Select all that apply.

- Deciding when physical procedures should be performed on a client - Deciding what client teaching is necessary - Deciding when a client needs to be turned