Health Assessment Exam 1 PrepU

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

A 45-year-old man with chest pain and diaphoresis for 1 hour

A patient has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this patient?

Knowledge deficit

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 to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas?

Physiologic, psychological, sociocultural, developmental, and spiritual data

What are the components of the SBAR? Select all that apply.

Situation Assessment Recommendation

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

An adult client is being admitted to the hospital for a cardiac catheterization related to chest pain and shortness of breath on exertion. What kind of assessment is the admitting nurse going to perform?

Emergency

Which skill does the nurse need to obtain subjective data during the initial comprehensive assessment?

Empathy

What are the primary frameworks used in conducting a health assessment? Select all that apply.

Head to toe Body systems Functional systems

Which of the following statements best conveys the rationale for health promotion in a school setting?

Healthy child development is a critical health determinant because of its implications for lifelong health.

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?

Making incorrect nursing judgments or diagnoses

A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing?

Ongoing Ongoing, follow-up or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline.

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.

What is the primary function of the health care team?

To decide the best overall care

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.

While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process?

emotional

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?

"Do you have family who visit you regularly?"

A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is "a bit sporadic." How should the nurse best respond to this assessment finding?

Identify a nursing diagnosis of Ineffective Health Maintenance.

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?

Natural senses

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

comprehensive

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

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?

significantly impaired hearing

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