NUR 1068 Health Assessment- Ch 1 - collecting and analyzing data

The primary aim of the Healthy People 2030 initiative is:

health promotion.

The nurse is caring for a client who ascribes to the theory of animism. When attempting to explain this theory to other staff members, the nurse should state:

"Everything in nature is alive with invisible forces."

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 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."

The registered nurse is teaching a community health class about illness prevention. Which statement reflects understanding of this concept?

"It is important to enroll in a smoking cessation class."

The nurse is attempting to provide anticipatory guidance for the parents of an 18-month-old child. Which statement would be best for the nurse to make?

"Keep all medications in a locked cabinet."

When the nurse is performing a physical examination on admission of a client to the medical unit, the client says the doctor already did an exam. The best response by the nurse would be

"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."

In what time period did nursing care as we now know it begin?

18th to 19th century

The nurse is evaluating client health. Which client should the nurse determine to be exhibiting the most signs of health?

A client with a leg amputation who performs activities of daily living with a prosthesis

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

physiologic status.

The nurse is completing an admission database entry and must include priority nursing diagnoses for the plan of care. Which statement describes a nursing diagnosis?

A clinical judgment about client responses to health difficulties.

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

A healthy environment

A nurse educator is discussing the criteria that define nursing as a profession. Which nursing actions are based on these criteria? Select all that apply.

A nurse uses diagnosis, interventions and evaluation to plan nursing care for clients. A nurse follows an established code of ethics when performing actions for clients who are in hospice. A nurse is committed to using ongoing research when planning nursing care for clients.

After hearing a presentation about the American Nurses Association (ANA), a nurse decides to join the organization based on the understanding that:

ANA aims at fostering high standards of nursing in the United States.

Which advancement in the nursing profession occurred immediately after World War II?

Advanced nursing education was established.

A client 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 client?

Airway

The first nursing journal owned, operated, and published by nurses was:

American Journal of Nursing

Which organization has established standards that help the nurse determine which clinical actions fall under the scope of nursing practice?

American Nurses Association

Diagnosis:

Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral)

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

Evaluation:

Assessing whether outcome criteria have been met and revising the plan as necessary

Which assessment finding should the nurse document as objective data?

Body functions

Implementation:

Carrying out the plan

A nurse is planning to pursue further education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which expanded career role is the nurse preparing?

Clinical nurse specialist

What occurs during the assessment phase of the nursing process?

Collect subjective and objective data.

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

Assessment:

Collecting subjective and objective data

Initial comprehensive assessment:

Collection of subjective data about the client's perception of health of all body parts or systems, past medical history, family history, and lifestyle and health practices.

Holistic nursing assessment

Collects holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment.

During the course of any given day of work in the acute care setting, the nurse may need to perform which roles? Select all that apply.

Communicator Counselor Teacher

Florence Nightingale introduced the concept of apprenticeship for nurses. Which statement is an example of this?

Completing clinical hours supervised by a nursing instructor

Which actions should a nurse perform before beginning the initial shift assessment of a client? Select all that apply.

Gather assessment tools. Review the client's record. Check the client's status with the nurse of the previous shift.

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

Ongoing or partial assessment:

Data collection that occurs after the comprehensive database is established.

Planning:

Determining outcome criteria and developing a plan

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

Diagnosis

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

The new nursing graduate is concerned about some of the critical changes that will be occurring in nursing. What changes does the nurse anticipate will impact nursing care?

Difficulty for nurses to remain current in a rapidly changing medical and technology environment

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

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

Which nursing actions are characteristic of the nurse's role as communicator?

Establishing and maintaining helping relationships with clients of all ages in a variety of

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

Physical medical assessment

Focuses primarily on the client's physiologic development status.

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

Functional

Is the following statement true or false? Physical medical assessment collects holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment.

False.

Is the following statement true or false? A partial assessment is done when the client first enters a health care facility.

False. A partial or ongoing assessment of the client consists of data collection that occurs after the comprehensive database is established. This takes place after the client is admitted to the health care facility.

The registered nurse is performing a nutritional assessment to ensure that the client's diet is optimal for wound healing. The nurse's intervention can be traced back to which key contributor to nursing?

Florence Nightingale

The nurse is performing a health assessment on a new client. While taking the detailed history, the nurse knows to include what?

Functional status

The 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

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 has completed assessment of a client with Alzheimer's disease and documentation of the information obtained from the client and now needs to analyze the data collected. Which nursing actions should be included in this phase of the nursing process? Select all that apply.

Identification of collaborative problems Identification of the need for referrals Formulation of nursing diagnosis(es)

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

The nurse discussing the importance of professional nursing organizations setting standards should include which statement?

It helps identify nursing as a profession.

A nurse educator is discussing the role of nursing based on the American Nurses Association (ANA). Which statement best describes this role?

It is the role of nursing to provide a caring relationship that facilitates health and healing.

The client's plan of care is created by the nurse using which guideline for nursing practice?

Nursing process

The nurse going back to school for nurse midwifery can trace education for nurse midwifery to which nursing leader?

Mary Breckinridge

How does a nurse decide what health-promotion activities are necessary for a particular client?

Nurses collaborate with clients to identify areas in which clients are willing to make changes

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 community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?

Nursing process

The client has a murmur. This is what type of data?

Objective

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?

Ongoing

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

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

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

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

Physical examination

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

Focused/problem-oriented assessment:

Thorough assessment of a particular client problem, which does not cover areas not related to the problem.

The diploma nurse is considering obtaining a baccalaureate degree. Which degree should the nurse investigate?

RN to BSN

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.

The nurse is performing care for a client in the end stage of cancer. How can the nurse best facilitate the client and family's ability to cope? Select all that apply.

Refer the client and family to hospice services. Assist the client and family with the preparation for end-of-life. Assist the client with activities of daily living (ADLs).

Which nursing intervention would be most appropriate for a new mother that calls the nursery for help with breastfeeding?

Refer the mother for a home care visit.

Preparing for the assessment:

Review client's record Review client's status with other health care team members Educate about client's diagnosis and tests performed

Florence Nightingale was a nursing pioneer who challenged prejudices against women and elevated the status of all nurses. Which statement accurately describes one of her accomplishments?

She promoted the publication of books about nursing and health care.

The nurse plans to follow the Health Belief Model when identifying a client's care needs. On what will the nurse focus when using this model? Select all that apply.

Sufficient motivation Making a change would be beneficial Belief of being susceptible to a health problem

The nurse conducts a home safety assessment for a client. Which statement best explains the standard of care being implemented?

The RN promotes a safe environment.

A nurse is providing care for clients in a long-term care facility. What should be the central focus of this care?

The client receiving the care

Which is the best example of a client-centered approach to care?

The nurse asks the client about health goals.

The American Nurses Association (ANA) Standards of Professional Nursing Practice provides standard of care for all nurses. Which statement on the assessment of the nursing process is accurate?

The nurse collects comprehensive data pertinent to the client's health or situation.

What is the primary function of the health care team?

To decide the best overall care

A group of nursing students has attended a presentation about the National Student Nurses' Association (NSNA). Which statement by the group indicates that they have understood the information presented?

The organization provides programs of current professional interest.

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

What is the primary purpose of health assessment?

To gather information about the health status of the client

A registered nurse wishes to work as a nurse researcher. Which is true regarding nurse researchers?

They are responsible for the continued development and advancement of nursing.

The registered nurse (RN) working with a licensed practical nurse (LPN) understands which about LPNs?

They must take a licensure exam.

The nurse is caring for a client after a stroke rendered the client's right side weaker than the left. The nurse coordinates the plan of care with the physical therapist. The nurse's interventions reflect which one of nursing's four broad goals?

To restore health

Is the following statement true or false? Subjective data are sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.

True. Subjective data are sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.

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?

Uses evidence-based techniques

Which practice by the nurse indicates that the nurse is a professional?

Using evidence-based practice interventions

The nurse reviews information obtained from the admission's department about a client seeking medical care for a chronic problem. What should the nurse expect to complete when assessing this client? Select all that apply.

Validate data Collect subjective data Collect objective data Document data

Emergency assessment:

Very rapid assessment performed in life-threatening situations.

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. (select all that apply.)

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?

The RN is working with hospital administrators to transform care at their facility. Which nursing competency will be critical for the nurse to utilize?

Work effectively in interdisciplinary teams

The need for university-based nursing education programs was brought to light during which important historical time?

World War II

A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)?

administering bedside blood glucose testing

A nurse must possess several characteristics to be successful in this profession. Secondary to critical thinking skills, which is of great value?

advocating for the client at all times

A nurse is considering relocating to another state to practice nursing. Which is the most appropriate action by the nurse to ensure ability to practice in the new state?

applying for a reciprocal license in the new state

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.

The nurse is caring for a client with a new diagnosis of cancer, and allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing?

art of nursing

The nurse is caring for a client who cannot meet health needs independently. Which action made by the nurse depicts concern and attachment?

asking the client, "How are you today? I am really worried about you."

A nurse mentoring second-year nursing students from a community college plans clinical experiences for them. These students will most likely graduate in which time frame?

at the end of the year

A client is very upset after being told by the health care provider that test results confirm a diagnosis of colon cancer. Which action should the nurse consider most important when answering questions from this client?

avoid offering personal opinion to which action to take next

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should

avoid premature judgments about the client.

The nurse is caring for a client who is on a ventilator. The nurse is bathing and talking to the client, including telling the client what is going to happen next. The nurse speaks to the client in a soothing manner. The nurse is acting in which role? Select all that apply.

caregiver educator communicator

The nurse is helping the unlicensed assistive personnel (UAP) bathe the client, who is experiencing a lot of pain when repositioned in bed. Which nursing responsibility is the nurse demonstrating?

client advocate

The primary aim of the Healthy People 2020 initiative is:

health promotion.

The nurse is caring for a postoperative client. The health care provider has written a prescription for a pain medication, and the prescription gives a dosage range for the amount the nurse may give depending on the severity of the client's pain. This type of functioning within the health care team is called:

collaborative functioning.

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

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

comprehensive.

Which nursing action best exemplifies the nurse's role in promoting health?

encouraging a group of junior high school students to engage in regular physical activity

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 result of a nursing assessment is the:

formulation of nursing diagnoses.

In the role of entrepreneur, the nurse's primary responsibility is:

managing a health-related business.

The nurse is utilizing knowledge about a blood pressure medication's actions and side effects to determine whether or not to give a client, whose blood pressure is low, the prescribed blood pressure medication. What best describes the aspect of nursing demonstrated?

science of nursing

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

All members of the health care team are encouraged to read and contribute to the individual plans of care for their clients. Which health care provider develops the plan of care?

the RN

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