Health Assessment Chapter 1: The Nurse's Role in Health Assessment
The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority? A) lives alone B) significantly impaired hearing C) widowed 2 years ago D) greatly concerned about cost of services
B) significantly impaired hearing Explanation: As a nurse, it is vital to sift through all the client information and make decisions on what information will impact client safety and quality of care. The ability to identify what is important on a daily basis for each individual client is paramount for nursing care. Of the data provided, the client's impaired hearing poses the greatest safety risk and has the greatest impact on the client's quality of life and so has priority. While the other options could be potential factors related to quality of life and safety, the nurse will need to assess them further.
What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain? A) Teaching the client to draw knees to chest to help minimize the pain B) Planning care to help minimize the client's pain C) Collecting data regarding the nature of the pain D) Identifying pain management interventions with input from the client
C) Collecting data regarding the nature of the pain Explanation: The nurse's initial role in health assessment is to collect data. Teaching would occur later in the process. Planning care and identifying interventions are parts of the nursing process and not the health assessment.
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? A) Functional B) Focused C) Head-to-toe D) Body system
C) Head-to-toe Explanation: A head-to-toe or comprehensive assessment is the most organized system for gathering comprehensive physical data.
The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply. A) "I feel so tired sometimes." B) Weight: 145 lbs C) Lungs clear to auscultation D) Client complains of a headache E) "My father died of a heart attack." F) Pupils equal, round, and reactive to light
A) "I feel so tired sometimes." D) Client complains of a headache E) "My father died of a heart attack." Explanation: Subjective data include information obtained from the client through interviewing and therapeutic communication skills and are sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Feeling tired, complaints of a headache, and the statement about the client's father dying of a heart attack reflect subjective information. Weight, lung sounds, and pupil reaction are examples of objective data.
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. A) Health history B) Wellness teaching C) Physical examination D) Outcome identification E) Medication administration
A) Health history C) Physical examination Explanation: A comprehensive health assessing includes a health history and physical examination. Wellness teaching cannot be done until the client's needs are identified. Outcome identification is a part of planning. Medication administration is a part of implementation.
During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is A) primary prevention B) secondary prevention C) tertiary prevention
A) primary prevention Explanation: Exercise and healthy eating improve wellness and help protect from disease and disability, which is primary prevention.
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. Explanation: 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.
Four broad goals describe the role of a professional nurse. What is one of these goals? A) To diagnose illness B) To counsel about human responses to health or illness C) To advocate for individuals, families, communities, and populations D) To prescribe medication
C) To advocate for individuals, families, communities, and populations Explanation: Four broad goals within nursing are (1) to promote health (state of optimal functioning or well-being with physical, social, and mental components); (2) to prevent illness; (3) to treat human responses to health or illness; and (4) to advocate for individuals, families, communities, and populations. Nursing goals do not include diagnosing illness, counseling about human responses to health or illness, or prescribing medications.
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) Healthy People 2020 B) the nursing process C) the Department of Health and Human Services D) the three levels of preventative care
A) Healthy People 2020 Explanation: Healthy People 2020 is a government project intended to increase the quality of life for people in the United States.
Which assessment finding should the nurse document as objective data? A) Biographical information B) Body functions C) Lifestyle practices D) Personal relationships
B) Body functions Explanation: Subjective data is what the client tells the nurse. Objective data is what the nurse assesses or observes when performing care of a client.
When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what? A) Assessment B) Diagnosis C) Planning D) Evaluation
B) Diagnosis Explanation: Diagnosis occurs when the data has been analyzed and a professional judgment occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan. Evaluation assesses whether the outcome criteria have been met.
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
C) Knowledge base and expertise Explanation: As the nurse becomes more proficient and comfortable in his or her role, the accountability does not decrease, but the knowledge base and expertise increase to foster confidence.
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 Explanation: An ongoing or client assessment occurs after the comprehensive database is established. It is a mini overview 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.
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment? A) Determine any changes from the baseline data B) Collect subjective data related to the client's overall health C) Perform a rapid assessment for prompt treatment D) Evaluate whether outcomes of treatment are met
A) Determine any changes from the baseline data Explanation: Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment. Evaluation is done after an intervention to determine if the outcomes have been achieved.
Nurses provide both direct and indirect care. What is an example of indirect care? A) Participating in a client care conference B) Adjusting an IV rate C) Calculating a medication dosage D) Completing a nursing assessment
A) Participating in a client care conference Explanation: Nurses provide direct care to help restore health for clients with illness in hospitals, clinics, long-term care facilities, and schools. Therefore, adjusting an IV rate, figuring out a medication dosage, and filling out a nursing assessment are all examples of direct client care. The only example of indirect client care is participating in a client care conference.
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 intervention B) Nursing goal C) Nursing evaluation D) Nursing assessment
A) Nursing intervention Explanation: 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 client's health status and current problems.
How does a nurse decide what health-promotion activities are necessary for a particular client? A) Nurses address areas associated with healthy behaviors only B) Nurses collaborate with clients to identify areas in which clients are willing to make changes C) Nurses assess areas in which clients are willing to make changes only D) Nurses construct their own theories to identify perceptions, barriers, and positive outcomes
B) Nurses collaborate with clients to identify areas in which clients are willing to make changes Explanation: 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.
The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data? A) Family history B) Occupation C) Appearance D) History of present health concern
C) Appearance Explanation: Appearance is something that can be directly observed by the nurse and is considered objective data. Present concern, family history, and occupation are considered subjective.
Revising the plan as needed occurs in what part of the nursing process? A) Assessment B) Diagnosis C) Planning D) Evaluation
D) Evaluation Explanation: Evaluation assesses whether the outcome criteria have been met and revising the plan as necessary. Diagnosis occurs when the data has been analyzed and a professional judgement occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan.
A nurse is conducting a health assessment. How will the information collected from the client be used? A) as a basis for the nursing process B) to illustrate nursing competence C) to facilitate nurse-client caring D) as one component of medical care
A) as a basis for the nursing process Explanation: 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 client's level of health.
The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which client 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 Explanation: 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.
The nurse is collecting data from a client. Which of the following best reflects objective data? A) Religion B) Occupation C) Appearance D) Age
C) Appearance Explanation: Appearance is something that can be directly observed by the nurse and is considered objective data. Religion and occupation are biographical data that are considered subjective. Age is considered to be subjective data because it is reported by the client. The nurse should assess whether the client appears to be their stated age.
What are nurses able to detect through the health assessment? A) Areas that need continuous care B) Areas that need in-hospital care C) Areas that need referral to a specialist D) Areas in need of health adjustments
D) Areas in need of health adjustments Explanation: Through the health assessment nurses are able to detect areas in need of health adjustments.
The nurse is exhibiting critical thinking in which client care situation? A) Transcribing medication orders onto the nurse's medication administration record. B) Notifying the healthcare provider of a critical lab result. C) Answering the client's call bell alarm while the nursing assistant is at lunch. D) Performing a focused assessment on a client who is complaining of shortness of breath.
D) Performing a focused assessment on a client who is complaining of shortness of breath. Explanation: The nurse investigating a client problem by performing a focused assessment is exhibiting critical thinking. Transcribing orders, calling a healthcare provider, and answering a call bell are not examples of critical thinking that entail outcome-directed thinking based on the nursing process.
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? A) "What do you mean by 'a little dizzy'?" B) "Do you often feel dizzy?" C) "Have you ever been dizzy enough to fall?" D) Can you remember when you first started to feel dizzy?"
A) "What do you mean by 'a little dizzy'?" Explanation: Listening and understanding a client is key to discovering a client's needs. As more details are acquired and collated, actual health risks emerge. The nurse should first clarify what the client means by the statement. If is only then that the nurse can determine is a health risk exists. While knowing the details of when the symptom started, how often it occurs, and if falling has occurred is important, clarification of what the client means is the initial focus of the nurse.
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment? A) Determine any changes from the baseline data B) Collect subjective data related to the client's overall health C) Perform a rapid assessment for prompt treatment E) Evaluate whether outcomes of treatment are met
A) Determine any changes from the baseline data Explanation: Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment. Evaluation is done after an intervention to determine if the outcomes have been achieved.
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
A) Open the client's airway Explanation: All life-threatening problems identified during the initial assessment require the initiation of critical interventions. The nurse opens the client's airway; assists the client's breathing; provides assistance with circulation (CPR if needed); if the client is injured, protects the cervical spine; ensures that the disoriented or suicidal client is safe; and provides pain management and sedation. The client has assessments and critical interventions performed simultaneously as life-threatening problems are treated.
A community health nurse is assessing an older adult client in their home. When the nurse is gathering subjective data, which of the following would the nurse identify? A) The client's feelings of happiness B) The client's posture C) The client's affect D) The client's behavior
A) The client's feelings of happiness Explanation: Subjective data are sensations, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client. Happiness is a feeling and therefore subjective. Posture, affect, and behavior are observable and are thus considered objective data.
A few nursing students revealed to a faculty advisor that they were concerned about the effects of their program demands on their personal health practices. Follow-up with other students indicated that this was a common concern among the student group. Further assessment showed that the students expressed their belief in the importance of maintaining good health practices, but that most students had discontinued weekday efforts because of their focus on school-related stress and limited economic resources. Faculty members supported the concept of integrated health programs and were prepared to develop a program as a project. To assess the need for health promotion among the group of students, which of the following assessment methods would be most useful? A) Physical assessment and health history B) Individual student interview and questionnaire C) Review of literature and consultation with faculty D) Walk-through of education facility and faculty questionnaire
B) Individual student interview and questionnaire Explanation: Key to any health promotion activity is a thorough assessment of the context and particular needs of the participants. This could be best determined by asking the students what would be more effective than a physical assessment, literature review, tour of the facility, or questionnaire of the faculty members.
A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process? A) Interjection of the nurse's thoughts or feelings into the data B) Making incorrect nursing judgments or diagnoses C) Relying on objective and subjective information D) Validating information that is already correct
B) Making incorrect nursing judgments or diagnoses Explanation: Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate incorrect nursing judgments may be made that adversely affect the remaining phases of the nursing process. Injection of the nurse's thoughts or feeling may lead to bias or the withholding of information. Nursing judgments should rely on both objective and subjective information. Validating information that is correct makes more work for the nurse but will not lead to inaccurate judgments.
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? A) Interjection of the nurse's thoughts or feelings into the data B) Making incorrect nursing judgments or diagnoses C) Relying on objective and subjective information D) Validating information that is already correct
B) Making incorrect nursing judgments or diagnoses Explanation: Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgments may be made that adversely affect the remaining phases of the nursing process. Interjection of the nurse's thoughts or feelings may lead to bias or the withholding of information but would not necessarily result from a lack of a thorough and accurate assessment of a client. Nursing judgments should rely on both objective and subjective information; thus this is not an error. Validating information that is correct makes more work for the nurse but will not be prevented by a thorough and accurate assessment of a client.
A client comes to the health care provider's office for a visit. The client has been seen in this office for the past five 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 Explanation: The nurse would most likely perform a focused assessment, which is done when a comprehensive data base 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.
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 Explanation: 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 is completed for this client when he or she first visited the office. An ongoing assessment is completed to evaluate problems identified earlier, to determine any changes. This would be the type of assessment done when the client returns after receiving treatment for current complaints. An emergency assessment is done if the client presented with with a life-threatening complaint or problem.
When doing an overall assessment of a client, the nurse is able to utilize findings and do what? A) Identify what level of prevention the client is at B) Identify in what areas the client can educate his or her family C) Identify in what areas the client needs the most care D) Identify the client's medical diagnosis
C) Identify in what areas the client needs the most care Explanation: During the overall assessment of the client, the nurse is able to use the findings and decide in which areas the client is in need of the most care. The nurse should not identify conditions that the health care provider may have missed or identify the client's medical diagnosis, as making medical diagnoses are not within the nursing scope of practice. The nurse may provide education to the client's family throughout the client's care; however, the nurse should not delegate education of the family to the client, because this is the nurse's responsibility.
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? A) Request that the health care team revise the plan of care. B) Notify the primary health care provider of the change in the client's health status. C) Recognize the need to reevaluate the client's plan of care. D) Monitor the client frequently for other changes in health status.
C) Recognize the need to reevaluate the client's plan of care. Explanation: The health assessment allows data to be collected that is specific to the client and his or her nursing care needs. Initially, the nurse must be aware that any change to the client's health status may require an change to this plan of care. If changes are required, the health care team will be asked to consider and recommend them. Monitoring the client for changes is always considered a nursing responsibility. Notifying the primary health care provider is not directly related to the nursing plan of care.
A home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct? A) comprehensive B) ongoing partial C) focused D) emergency
C) focused Explanation: A focused assessment is conducted to assess a specific problem. In this case, the nurse would ask the client about urinary frequency, bowel movements, and diet, and then take vital signs and assess the abdomen. Comprehensive assessments include a detailed health history and physical assessment; ongoing partial assessments are conducted at regular intervals, and emergency assessments are carried out in emergency situations (such as prior to CPR).
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? A) "Fortunately, assessment only needs to be done at the beginning of your stay." B) "I'll just need to evaluate you once more, at the end of your stay." C) "Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end." D) "I'm sorry, but assessment is ongoing and continuous."
D) "I'm sorry, but assessment is ongoing and continuous." Explanation: Although the assessment phase of the nursing process precedes the other phases in the formal nursing process, be aware that assessment is ongoing and continuous throughout all the phases of the nursing process.
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. Explanation: 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.
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? A) Assessment B) Diagnosis C) Implementation D) Evaluation
D) Evaluation Explanation: The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and whether the nursing care plan needs to be revised. The assessment stage involves collecting subjective and objective data. The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment. The implementation phase involves carrying out the plan to meet the determined outcome criteria.
The result of a nursing assessment is the A) prescription of treatment. B) documentation of the need for a referral. C) client's physiologic status. D) formulation of nursing diagnoses.
D) formulation of nursing diagnoses. Explanation: Analysis of data (often called nursing diagnosis) is the second phase of the nursing process. Analysis of the collected data goes hand in hand with the rationale for performing a nursing assessment. The purpose of assessment is to arrive at conclusions about the client's health. To arrive at conclusions, the nurse must analyze the assessment data.
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 a problem list D) perform a physical examination
D) perform a physical examination Explanation: The health assessment includes a health history and physical examination. After completing the health history, the nurse should complete the physical examination. Clustering data and determining a problem list would occur after the physical examination is complete. Documentation of the findings would occur while conducting the health history and after completing the physical examination.