Jensen's Health Assessment 3rd Ed. | Chapter 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?"

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 client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments?

"Nurses focus on the diagnosis of actual human responses to disease or life events."

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral?

A 50-year-old client newly diagnosed with diabetes

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

A healthy environment

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?

Ask the client about the most recent experiences of pain.

The nurse notes that an intervention provided to a client for a specific health problem was not effective. Which action should the nurse take next?

Assess the status of the health problem

For which of the following clients should a nurse perform a focused assessment?

Client with 4-day history of sore throat and fever with enlarged lymph nodes

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

Diagnosis

In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation?

Effect of health on functional status

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

Functional

When doing an overall assessment of a client, the nurse is able to utilize findings and do what?

Identify in what areas the client needs the most care

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

Knowledge deficit

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

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 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.

When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force?

Technology

A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable?

The client's acuity

What is the primary function of the health care team?

To decide the best overall care

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

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

emotional

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

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.