Health Assessment, PrepUs Ch 1

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?"

What are the types of nursing assessments? (4)

- Initial - Focused - Time-lapsed - Emergency

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 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 are the 3 primary frameworks used in conducting a health assessment?

Functional systems, head to toe, and body 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 long term health.

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 (partial) assessment

The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions?

Use evidence-based techniques.

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: How will the client use her left arm? How will the client cook and eat? Who will be there to help the client with ADLs? How will the client get home from the hospital? How will the client drive?

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.

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.

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 hard of hearing.

What is the primary function of the health care team?

To decide the best overall care.