Health Assessment in Nursing, chapter 1

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

Diagnosis

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

Empathy

As a nurse becomes more proficient and comfortable in his or her role, what

Knowledge base and expertise

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 patient 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 patient?

Airway

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

Which assessment finding should the nurse document as objective data?

Body functions

A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?

Critical thinking

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

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

Functional

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

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

Which of the following is the best example of assessment in everyday life?

Measuring the remaining tread on a car tire to determine whether it is time to replace it

The nurse is following a structured head-to-toe approach to identify changes in a patient's body systems. Which component of the health assessment is the nurse completing with the patient?

Physical examination

The result of a nursing assessment is the

formulation of nursing diagnoses.

When the client begins to cry, the nurse recognizes the need to focus the assessment on the client's emotional health. What factor will have the greatest effect on the nurse's ability to gather information concerning why the client is crying?

the rapport that exists between the nurse and the client

A young adult male 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 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 patient'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

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

The nurse is exhibiting critical thinking in which client care situation?

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

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?

Primary

A nurse is working with a client who has AIDS. Which of the following is an example of subjective data that might be gathered for this client?

The client's pain level

What is the primary function of the health care team?

To decide the best overall care

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

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

comprehensive.

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 nurse recognizes the value of the Healthy People 2020 guidelines when creating a plan of care that addresses which client-centered goals? Select all that apply

living a healthy lifestyle disease prevention improving one's quality of life

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

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

Body systems Functional Head to toe The three major frameworks for organizing assessment data are functional systems, head to toe, and body systems. Gordon's framework and an analytical framework are not primary frameworks for conducting a health assessment on a client.

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

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 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:Accurate documentation provides a baseline so that changes are noted between assessments.

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

A healthy environment:The physician performing a medical assessment focuses primarily on the client's physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility?

Collect subjective data related to overall function

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: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 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?

Individual student interview and questionnaire

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

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

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

An oncology client with a cough but no fever.:The nurse should prioritize care for the oncology client, because immunosuppression due to chemptherapy is a concern. The immunosuppressed client can still exhibit a respiratory infection without fever. The clients require routine assessments with no immediate concerns.

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

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

physiologic status.:The physician performing a medical assessment focuses primarily on the client's physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.

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

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

What is a required component of a health assessment?

Critical thinking

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.